How We Hurt
Featuring an interview and a book dive with Melina Sherman about the ongoing opioid epidemic
Melina Sherman is a communications scholar and author of How We Hurt: The Politics of Pain in the Opioid Epidemic, an in-depth examination of the proliferation of pain drugs and the harrowing side effects of opioid addiction. In this newsletter, we feature a Scholarly Sources interview with Dr. Sherman about her favorite books and an in-depth, written interview about her new book. Melina shows that when it comes to understanding addiction today, it is crucial that we also understand the logic of pain and pain management. How We Hurt is a tragic read, but it exemplifies the importance of probing and thoughtful scholarship, especially when it comes to making sense of difficult issues.
Scholarly Sources
Melina Sherman is a Researcher at Knology
Q: What are you reading right now?
A: A book in Portuguese called, A Dama do Bar Nevada: Cenas Urbanas. It’s a collection of short stories that capture the strange dynamics of urban life in different Brazilian cities.
Q: What is your favorite book or essay to give to people and why?
A: The first chapter of Foucault’s Discipline and Punish is something I often recommend to people who want to learn more about power– how it works, how it’s evolved, and why. Then, from a separate genre, I also really love Rebecca Solnit’s essay, “The Blue of Distance,” and I often suggest that people who love gorgeous writing read it. She finds beauty in uncertainty, in distance, and in places where you’d never expect it.
Q: Is there a book you read as a student that had a particularly profound impact on your trajectory as a scholar?
A: Yes. A Small Place by Jamaica Kincaid was the first book I read that truly helped me understand the effects of colonization, decolonization, and imperialism. When you read Kincaid, these processes are forced out of abstraction and come to life in seemingly small, but painfully concrete ways. I’ve probably read the book half a dozen times now, but it hits me just as hard with every read.
Q: Which deceased writer would you most like to meet and why?
A: There are so many. There are writer-scholars like Michel Foucault, who died before they could fully elaborate their most promising ideas. I have a million questions to ask Foucault if I could sit with him for an hour. Then there are writers I just think I’d vibe with, like Anne Carson, who wrote a perfect book of tangos called Beauty of the Husband that I identify with on a deep level. Or Hunter S. Thompson, who always makes me laugh and would definitely show me a good time!
Q: What's the best book you read in the past year?
A: This isn’t a book, but I recently read Camus’s essay “The Myth of Sisyphus” and was pretty stunned by his take on the absurd. I really agree with him about the disconnect between our human desire for happiness, love, and reason and the reality of living in a world that is “unreasonably silent.” I also like that this does not have to mean doom and gloom. Maybe we can learn to look at Sisyphus pushing his boulder up the mountain for eternity and imagine him happy.
Q: Have you seen any films, documentaries, or museum exhibitions that left an impression on you recently?
A: Does music count? Because I just became obsessed with everything Talking Heads has ever done. I can’t wait to see the new Stop Making Sense movie once it’s in theaters or available to stream.
Q: What do you plan on reading next?
A: I’d like to read Joan Didion’s new book of essays, Let Me Tell You What I Mean. I’m a big Didion fan, so I’m excited to see more of her work that I haven’t read before.
Deep Dive: How We Hurt
Question: Can you tell us a little bit about yourself and your background?
Melina Sherman: I’m a communication scholar focusing on the critical study of health. So, I’m interested in understanding how health and illness are constructed through communication in ways that have concrete impacts on individuals and society. I decided to write my dissertation about the opioid crisis, thinking that it would become a study of the social effects of opioid drugs themselves. But what I found through my research was that I couldn’t talk about opioids at all without running into a world of questions, problems, and debates that revolved around pain. The politics of pain are everywhere in the opioid crisis, and they’ve been shaping its trajectory at every step along the way. That’s how How We Hurt came about.
Q: You describe this book as a social autopsy of the opioid epidemic. What do you mean by “social autopsy”?
MS: Social autopsy is a method I borrow from Eric Klinenberg, who wrote a book using it to understand the Chicago heat wave of 1995 that killed over 700 people. In his book, social autopsy entails closely examining the “social organs” and conditions that resulted in widespread system failure and transformed a weather event into a deadly crisis. My book takes on the opioid crisis in a similar way.
I also take a close look at the failure of multiple social organs, and I do this by examining the logic and practices of key stakeholders that have been involved in decision-making around opioids and pain. Like Klinenberg, I try to shed light on how the working of those organs laid the groundwork for an ongoing disaster– in this case, an overdose crisis like none we’ve ever seen before.
Q: What research and methods did you use to write this book?
MS: I primarily relied on a method that is very common in communication studies called discourse analysis (DA). DA is a way of examining communication artifacts (texts, language, media) in context. For example, a discourse analysis of an FDA committee meeting would ask how the comments made are shaped by and give shape to the broader social landscape. It tries to reveal how language makes certain assumptions about its subject matter and how these assumptions either reinforce or disrupt broader social norms and structures.
My research, since it was mainly focused on critically examining the institutions and actors that contributed to the crisis, drew from a wide variety of sources. These included decades of FDA meeting transcripts, new drug applications, court cases, congressional hearings, opioid advertisements, articles in pain management and pain medicine, self-help books, and drug forum threads online, among other sources.
Taken together, all these different materials helped me gain a more comprehensive understanding of who and what was working behind the scenes when opioid prescriptions first started to rise. They’ve helped me understand the institutional and cultural dynamics that gave rise to the crisis.
Q: Can you give a brief overview of the history of pain and the development of pain management?
MS: Modern pain management was born, like many medical technologies, during wartime. While things like morphine and anesthesia have been used since the 19th century, the field really evolved during WWII, when Henry K. Beecher witnessed firsthand the subjective nature of pain. The story goes that Beecher treated wounded soldiers who remained on the field after a battle. When he asked them about their pain, they reported shockingly low levels of discomfort despite having egregious injuries. But then, once they were removed from the battlefield, their pain suddenly worsened, although their wounds had not. This led to the idea that pain is not necessarily always a proportionate response to a physical lesion but is, in fact, much more complex. Beecher’s argument after witnessing the soldiers was that pain must be assessed not only in terms of its physicality but also its subjectivity: what the patient thinks and feels about it.
Years later, this idea informed the work of another physician, John Bonica, who is now widely known as the leading pioneer of contemporary pain management. Bonica was frustrated by the lack of treatment options for pain that was lesionless – like phantom leg syndrome– and started a movement to make pain management a multidisciplinary practice that would involve not just physicians trained in biomedicine, but also psychologists (experts in the science of subjectivity). It was through Bonica’s efforts that pain medicine began to be seen as a field in its own right, and pain as a legitimate diagnosis, rather than just a symptom.
Q: Why did opioids for medical use become such a popular form of treatment in the 21st century?
MS: Opioids have been used in medicine since long before the 21st century. But the late 1990s into the early 2000s also seem to mark a turning point in terms of their ubiquity and the extent to which they became incorporated into medicine as routine treatment for different kinds of pain. Until the end of the 20th century, opioids were not routinely prescribed for chronic pain, for example. This began to change when pain advocates and cancer pain specialists began to champion the use of opioids as an ethical way to manage the chronic pain of cancer patients. Pharmaceutical companies then took the ethical argument for using opioids and leveraged it to market opioids for non-cancer-related chronic pain.
These processes were also at work around the same time that the U.S. Department of Veterans Affairs incorporated pain into its medical practice as the “fifth vital sign,” equal in importance to heart rate, blood pressure, and so on. The routine measurement of pain as a vital sign was quickly adopted by other organizations within the medical community. The same year that pain was introduced as a vital sign, OxyContin was introduced onto the medical market as a treatment for moderate to severe acute and chronic pain. That moment, for many, is when the opioid crisis crystallized and began to pick up speed. From 1999 to 2014, opioid prescribing quadrupled.
Q: How do we measure pain and is there any objective way to do it?
MS: In short, no. Pain can’t be objectively understood, because it can’t be separated from subjectivity. Pain experiences are as diverse as the people who experience them, and no one measurement technique will be sufficient to capture the complex realities of all people who live with pain. Attempts to universalize the measurement of pain - especially chronic pain - through the use of numerical scales sideline one of the most important lessons of modern pain management: understanding what pain is and how to manage it must be a multifaceted & multidisciplinary effort. Even more, pain isn’t just medical. It’s also social, which is to say that someone’s experience of pain is also shaped by their socio-economic status, level of social inclusion or exclusion, relationship to social institutions, and so on.
Q: What is the regulatory logic employed by the FDA when it comes to allowing drugs on the market like OxyContin?
MS: When it comes to opioids like OxyContin, the FDA has primarily relied on a regulatory approach that has been largely permissive, as opposed to precautionary. What that means is that the dominant approach to regulatory concerns like a new drug’s risks has been to assume that they do not exist until there is concrete and widespread evidence showing that they do. The FDA’s permissive approach has also been combined with a non-interventionist relationship to the opioid market, which has allowed opioid manufacturers to push new opioid products into circulation without the same level of oversight to which other kinds of narcotics are typically subject. Under these conditions, opioid manufacturers have been allowed to run the regulatory show.
Q: What role has pharmaceutical branding played in the proliferation of opioids?
MS: Branding has played a huge role in normalizing the use of opioids, which were not always seen as first-line treatments for pain. But even more, I think the success of opioid branding– especially Purdue Pharma’s branding of OxyContin– has been less due to the promotional claims made about the drugs and more due to the ways in which the company articulated a vision of pain relief to the American public. That is, Purdue successfully branded OxyContin as a path not just to relief, but to self-realization, productivity, and optimization– a sort of warped version of the American Dream. By connecting pain relief to an idealized vision of American identity, Purdue was able to convince physicians, patients, and others to accept opioids into their daily practices.
It’s also true that the company pursued an all-encompassing branding strategy that quickly implanted its products not just in households but also in hospitals across the country, binding opioids to medical practice. In the years Purdue was doing all of this, opioid sales skyrocketed, and the amount of opioid prescriptions in certain states outnumbered the people who lived there.
Q: You also discuss how the language surrounding pain management has impacted non-pharmaceutical industries, like self-help. Can you describe the influence you see?
MS: It’s interesting because pain self-management, or pain self-help, initially positioned itself as an alternative to pharmaceutical approaches to treating pain. But when you look at the ways in which pain self-help books and other self-management resources talked about the problem, you see that the industry was very much on the same page as the pharmaceutical companies when it came to selling the idea of pain relief. The themes of self-realization, self-optimization, and enhanced productivity are written all over the pain self-help industry and are the main discourses used to sell non-pharmaceutical treatments. Even more, pain self-help relies on an individualizing discourse that positions the pain patient as the sole person responsible for achieving relief.
I see this as highly problematic because pain is not an individual problem, but a highly social one. One’s social status, socio-economic position, level of social isolation, and social exclusion all play a huge role in one’s experience of pain. The pain self-help industry (just like the pharmaceutical industry) ignores the social dimension of pain. It looks instead to the person who lives with pain as the one who must take charge of the problem and cure themselves. As studies have shown, this approach is ineffective, and it misses the point that pain experiences do not exist in a bubble but are bound up with our experiences of the world.
Q: Chapter 5, “Pain’s New Faces,” examines how opioid users are portrayed in popular culture. What does this look like and what correctives would you offer?
MS: People who use opioids have long been figures in popular culture, from the dope fiends and junkies of old to today’s opioid patient turned opioid “addict.” But popular culture has treated people who use opioids differently at different moments in time, sometimes criminalizing them and sometimes offering them sympathy. This has depended in part on the shifting demographics of opioid use, as well as on medical theories of addiction that defined the problem as a character flaw or a moral failing.
In today’s crisis, people who use opioids are constructed differently than they were in the past. They are divided into sub-types: There is the opioid “addict” who is seen as an unethical consumer of drugs, the opioid “patient,” who has been consumed by a problematic health system, and the at-risk person who uses opioids, who is always in danger of sliding into the category of “addict.” Each of these types of people is treated differently in the opioid crisis, where the social construction of opioid use has exacerbated inequalities in treatment among people in pain.
As far as correctives, the first thing I can think of is that we need to rethink the concept of “addiction” and attempt to disassociate the physical process of drug habituation from the moral status of “addiction.” Addiction is not and has never been a moral problem (though it has often been treated that way). To stop seeing certain people as worthy of treatment and others as worthy of imprisonment or punishment, we have to remember that every single person’s pain matters, and that people in pain (regardless of where they get the drugs they use to treat it) all deserve to find relief.
Q: You offer suggestions at the end for new regulatory practices and future research. What new ground would you like to see broken?
MS: I would like to see ground broken in a number of different domains. I’d like to see changes in the regulatory domain, where pharmaceutical companies hold far too much sway over the regulatory process. Passing legislation to disempower the pharmaceutical industry and empower regulators instead would be a huge step toward rectifying mistakes of the past, where big pharma trumps regulators and takes near complete control of the process, especially once their drugs have gone to market.
The change I’d most like to see in the domain of research and regulation is the incorporation of new kinds of expertise at the decision-making table. We need to broaden the scope of expertise that is included in policy-making decisions beyond the traditional experts (pharmaceutical representatives, medical experts, pain specialists, etc.) and include experts of experience. By that I mean people who live with chronic pain and people who use drugs. Who better to speak to the complex realities of opioid use than people who use opioids themselves? Who better to correct misguided assumptions about the nature and experience of pain? In line with drug scholars like Jarrett Zigon and Nancy Campbell, I want to advocate for giving a seat at the drug policy table to those with lived experience. They have much to offer policymakers who wish to shrink the grey market and reduce the harms of a failed War on Drugs.
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