Table of contents(17 chapters)
So much has been written about addiction, one can reasonably ask why we need another volume on the subject now. The pieces gathered here take up a number of current trends that make this exactly the right time to take a fresh look at addiction. These include: debates over the nosology of addiction as part of the revision to the Diagnostic and Statistical Manual of Mental Disorders (DSM); the expansion of addiction's meaning and spheres of control beyond alcohol and illicit substances; the rise of neuroscience; the increasing ‘pharmaceuticalization’ of everyday life and new pharmaceutical treatments for addiction; growing awareness about the intersection of the drug war and the mass incarceration of people of color; and new theoretical frameworks for understanding the role of addiction as a fundamental technique of social control. These trends are reshaping addiction in both new and not-so-new ways that warrant the interrogation this volume provides.
Purpose – The chapter examines the historical pattern of interconnections between drug policy, research, and treatment in light of recent theoretical developments in the medicalization thesis advanced in the sociology of medicine.
Methodology/approach – The chapter uses interpretive methods to examine how the social construction of addiction as a “chronic, relapsing brain disorder” converges with or diverges from the conceptual framework offered by sociological theorists of medicalization and biomedicalization.
Findings – The approach adopted shows how the meanings of the bio/medicalization of addiction shifted and circulated within and beyond the institutions developed to respond to drug addiction as a hybrid social, medical, and biomedical condition during the 20th century.
Social implications – Bio/medical frameworks for addiction are the outcome of historical attempts to influence public attitudes and develop effective methods to treat and prevent this “disease” in ways that would positively affect the quality of life of people living with addictions.
Originality/value – This original contribution addresses both strengths and limitations of bio/medical models, assessing how their influence has changed over time.
Purpose – This chapter critically examines efforts to destigmatize addiction through the creation of a diagnostic category and medicalization. It further critiques “realist” accounts of neuro-scientific knowledge, proposing instead a “biocultural” framework that enables a more multifaceted understanding of drug problems that leads back to questions of biopolitics.
Methodology/approach – After showing that medicalization is not always associated with destigmatization, this chapter reviews evidence suggesting that the social class of drug users is central to questions of stigma. A literature review concerning social constructionist approaches to bodies is then offered, culminating in an exploration of “biocultural” frames and their implications for psychiatric knowledge.
Findings – The material world can only be grasped through a cultural frame, an understanding that challenges “realist” accounts of knowledge. While making reference to brain functioning, psychiatric “disorders” in fact identify violations of interpersonal or psychic norms. These violations cannot be linked in a linear way to patterns of brain activity, even at a theoretical level.
Social implications – This chapter points toward a way of analyzing psychiatric disorders that allows for and highlights their political effects. Without ruling out medical interventions, it suggests that clinical and social understandings are an essential component of psychiatric understanding.
Originality/value of chapter – While “biocultural” approaches have been proposed by other social theorists, this chapter applies the frame in new ways to the psychiatric endeavor. In the face of increasing medicalization within the field of psychiatry, this chapter makes a strong theoretical case concerning the value of clinical and social knowledge concerning psychiatric disorders.
Purpose – With reference to the long-term struggle to confirm cigarette smoking as a manifestation of nicotine addiction, this chapter explores the extent to which new understandings of addictions as ‘appetitive disorders’ rather than ‘dependence disorders’ derive from treatment technology development as well as advances in basic scientific research.
Approach – Through historical analysis it is discussed how cigarette smoking only became widely accepted as a real drug problem in the 1980s after it had been shown to be amenable to treatment as such through the use of novel nicotine replacement therapies.
Findings – These replacement therapies succeeded in showing that the same drug that drew users into addiction could be redeployed to help draw up them out of it. Nicorette® could serve as at least the partial antidote to nico-wrong (cigarettes). However, as relapse to smoking has remained the most likely outcome of any smoking cessation attempt, so medicinal nicotine has also served to demonstrate that nicotine addiction is ultimately a problem of an uncontrollable appetite for cigarettes in excess of drug dependence.
Implications – Pharmaceutical incursion on cigarette smoking commencing in the late 1970s pointed to the need for a new mental disease model of drug-related problems while also providing valuable new tools and insights for ensuing brain research.
Two Tiers of Biomedicalization: Methadone, Buprenorphine, and the Racial Politics of Addiction Treatment
Purpose – To compare the histories of two opioid medications that are pharmacologically similar but subject to contrasting regulations in their use in treatment of opiate dependence in the United States – methadone and buprenorphine – in order to analyze the role of racial imagery and racial politics in the legalization and clinical promotion of their use.
Methodology/approach – Historical methods of archival analysis of published articles and unpublished governmental records were used in researching methadone. Ethnographic methods of participant observation and semistructured interviews were used in researching buprenorphine.
Findings – Contrasting uses of racial imagery played a major role in shaping the current regulatory differences between the two treatments. The association of methadone with black and Latino heroin users has contributed to its increased federal regulation, while the association of buprenorphine with white, middle class prescription opioid users enabled its use in deregulated private physicians’ offices.
Originality/value of paper – Advocates of biomedicalization of behaviors and conditions thought of as social or moral, such as addiction, argue that biomedicalization reduces the stigma of the condition and imply that, in turn, it also reduces the racial inequalities associated with the condition. This study of the biomedicalization of treatment for opioid dependence indicates that the very process of biomedicalization depended on heightened racial imagery associated with each treatment and ultimately intensified, rather than reduced, the stigma of addiction for black and Latino low-income patients.
Purpose – Reality TV shows that feature embodied “transformations” are popular, including Intervention, a program that depicts therapeutic recovery from addiction to “health.” The purpose of this chapter is to address the ways whiteness constitutes narratives of addiction on Intervention.
Methodology – This analysis uses a mixed methodology. I conducted a systematic analysis of nine (9) seasons of one hundred and forty-seven (147) episodes featuring one hundred and fifty-seven individual “addicts” (157) and logged details, including race and gender. For the qualitative analysis, I watched each episode more than once (some, I watched several times) and took extensive notes on each episode.
Findings – The majority of characters (87%) are white, and the audience is invited to gaze through a white lens that tells a particular kind of story about addiction. The therapeutic model valorized by Intervention rests on neoliberal regimes of self-sufficient citizenship that compel us all toward “health” and becoming “productive” citizens. Such regimes presume whiteness. Failure to comply with an intervention becomes a “tragedy” of wasted whiteness. When talk of racism erupts, producers work to re-frame it in ways that erase systemic racism.
Social implications – The whiteness embedded in Intervention serves to justify and reinforce the punitive regimes of controlling African American and Latina/o drug users through the criminal justice system while controlling white drug users through self-disciplining therapeutic regimes of rehab.
Originality – Systematic studies of media content consistently find a connection between media representations of addiction and narratives about race, yet whiteness has rarely been the critical focus of addiction.
Drawing the Line at Drinking For Two: Governmentality, Biopolitics, and Risk in State Legislation on Fetal Alcohol Spectrum Disorders
Purpose – Using Foucault's concepts of biopolitics and governmentality along with sociological constructions of risk, this chapter asks, “What definitions and procedures have states used in their legislation about FAS to justify state intervention? What are the social and policy implications?”
Methodology/approach – Qualitative content analysis of state legislation enacted into law.
Findings – Against a backdrop of child abuse which justifies intervention, states use different techniques of biopolitics to secure governance over pregnant women and their developing fetuses, including (a) a social history of prenatal alcohol consumption; (b) a diagnosis of FAS in the child; and/or (c) a visible or measurable physiological characteristic of the newborn/child associated with FAS.
Social implications – This chapter extends the analysis of alcohol consumption by pregnant women to a policy level and examines central questions about the government's role in the biopolitical framing of prenatal alcohol use and the differential assignment of risk and responsibility.
Originality/value of chapter – This chapter contributes to work on maternal–fetal conflict, risk, and governmentality in women's reproductive health.
Purpose – Religious addiction treatment has experienced a rise both in its reach and exposure to attention from medical professionals. Largely autonomous conversion-based programs have received unprecedented support and legitimacy. We investigate “Victory Ministries,”11The organization ‘Victory Ministries’ is a pseudonym. Any resemblance to actual locales of this name or similar is entirely coincidental. All names have been change to protect the identity of the participants. a large Midwestern evangelical rehab facility, exploring the similarities and differences between formulations of addiction-as-disease found in “secular” rehab and the moral binaries that guide Victory's program.
Methodology/approach – Qualitative case study: Interviews and ethnography.
Findings – Working from in-depth interviews, we explore the inner workings of Victory's curriculum and program design, as it transmutes dominant therapeutic concepts and methods into its own Manichaean frame. Aided by superior financial resources and support of a tight-knit network of churches, it delivers its most successful clients into a new life “redeemed by Christ.”
Social implications – Proponents of conversion-based service provision position religious institutions as the primary agents of willing compassion and generosity beyond the family compass, stripping the rest of civil society of any claims to promote the greater good. In Victory's metaphor of “invisible war,” a Manichaean vision is quite explicit. Every definition of recovery and reintegration in terms of conversion and submission to religious authority inherently suggests that substance use stems largely from immorality and that the unsaved in general are sinful and dangerous. By funding a conversion-based shadow welfare apparatus, we argue, the US government is intensifying the criminalization of poverty, the steady downgrading of more inclusive institutions, and ultimately the materialization of Victory's Manichaean vision in a polarized nation.
Making Addicts of the Fat: Obesity, Psychiatry and the ‘Fatties Anonymous’ Model of Self-Help Weight Loss in the Post-War United States
Purpose – To reconsider the historical relationship between addiction and obesity, which current literature tends to treat as unrelated until the late twentieth century.
Approach – We describe the forms of sociality and therapeutic discourses manifested in the emerging weight loss group movement from the 1940s until 1970 in cultural and intellectual context, drawing mainly on popular media and medical literature. The histories of these ‘Fatties Anonymous’ groups serve as valuable lens for studying the mutable cultural linkage between drug addiction and obesity that was first forged in the golden age of psychoanalysis.
Findings – We show that medicine began interpreting obesity as addiction around 1940 and that this view achieved dominance in both medical and popular discourse by 1950. The theoretical framing of a psychoanalytical interpretation of obesity in the 1940s, combined with the simultaneous rise to prominence of obesity-related problems in public health and popular stigma around fatness, was translated in the Cold War United States into a popular mutual-aid weight loss movement modelled on Alcoholics Anonymous.
Originality value – Our account challenges the present received view that the stigmatised health conditions of obesity and addiction only came to be related in the late twentieth century. There is notable similarity between the 1950s ‘Fatties Anonymous’ type group and present public health campaigns in fostering the individual's sense of self-control and encouraging self-enterprising improvement. Neither historical and contemporary similarities nor differences should be elided. Further research in this area would be of value to current and future developments in public health.
“I Just Couldn’t Keep it in Control Anymore:” Weight Loss Surgery, Food Addiction, and Anti-Fat Stigma
Purpose – This chapter explores how discourses of obesity as addiction are taken up by weight loss surgery patients and medical and scientific professionals.
Methodology/approach – Based on 14 semistructured interviews, I discuss the ways in which bariatric patients partially account for their presurgical bodies and contemporary struggles with weight loss and regain by referencing food addiction. This work is part of a larger project involving 35 interviews and participant-observation work and therefore these results should thus be considered preliminary.
Findings – I argue that bariatric patients and bariatric professionals portray weight loss surgery as an extraordinary tool that allows the “out of control” to become controllable. However, bariatric patients also emphasize the hard work that is entailed in both losing weight and maintaining a weight loss even after surgery.
Social implications – I suggest that this portrayal, in addition to being an accurate assessment of the potential for regain following weight loss surgery, is a technology of stigma management.
Originality/value – This work contributes to the sociology of the body and medical sociology literatures by illustrating that, within a neoliberal and anti-fat social context, highlighting the hard work involved in weight loss and weight maintenance allows bariatric patients to demonstrate proper subjectivity and thereby reclaim “proper selves” as they work toward a “proper bodies.”
Purpose – To examine video gamers’ attitudes about and perspectives on the controversial topic of video game “addiction.”
Approach – Ethnographic interviews and participant observation with a group of 52 regular video gamers, most also reporting considerable experience with substance use and/or dependence.
Findings – Gamers tended to endorse one of two explanations for video game addiction, either arguing that games operate on the same reward centers in the brain as drugs or that gamers who do become addicted are weak, unintelligent, or actively pursue an addictive state. Several rejected the category of addiction as applied to video gaming due to the lack of withdrawal symptomatology or the confusion of pleasure-seeking with pathology. None offered sociostructural explanations for the phenomenon, despite the relative oversampling of poor and minority participants with low degrees of education.
Research implications – Future research should attend to ideologies of causality and agency among populations affected by behavioral “addictions.”
Practical implications – The perspectives of video gamers themselves are critical to research and advocacy that departs from a position of slightly greater sensitivity, both to the formal dimensions of those games held to be most habit-forming and to the ideological dimensions of video gamers’ thinking about what constitutes “addiction.”