Life in Pain: Affective Economy and the Demand for Pain Relief [1st ed. 2020] 978-981-10-5639-0, 978-981-10-5640-6

Table of contents :
Front Matter ....Pages i-xiii
Introduction (John L. Fitzgerald)....Pages 1-21
Extending the Neuromatrix (John L. Fitzgerald)....Pages 23-43
The North American Opioid Epidemic (John L. Fitzgerald)....Pages 45-75
Pain and Cannabis Markets (John L. Fitzgerald)....Pages 77-106
Over the Counter (OTC) Pain Relief and the Self-treatment of Pain (John L. Fitzgerald)....Pages 107-137
Etched in the Skin: Pain, Methamphetamine Violence and Affect (John L. Fitzgerald)....Pages 139-169
Regulating the Cultural Pain Neuromatrix (John L. Fitzgerald)....Pages 171-192
Conclusion (John L. Fitzgerald)....Pages 193-195

Citation preview

John L. Fitzgerald

Life in Pain Affective Economy and the Demand for Pain Relief

Life in Pain

John L. Fitzgerald

Life in Pain Affective Economy and the Demand for Pain Relief

123

John L. Fitzgerald School of Social and Political Sciences University of Melbourne Parkville, VIC, Australia

ISBN 978-981-10-5639-0 ISBN 978-981-10-5640-6 https://doi.org/10.1007/978-981-10-5640-6

(eBook)

© Springer Nature Singapore Pte Ltd. 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Preface

Ronnie is a walk-in cannabis dealer in Melbourne, Australia. He deals in small bags of around $20–$50. He used to be a speed dealer, but there is a more aggressive speed dealer living at the end of the street now, and he can’t afford to compete with him, purely on the risk of violence. Instead, he mostly moves small quantities of cannabis for friends, family members and acquaintances, who come to his house every couple of days and buy small bags of leaf and head. He has a glass bong on the living room coffee table amidst all the magazines and cutup cigarettes. The room is dark and moist; it is public housing. It is a Thursday afternoon in winter, and the sun only just peeks over the treeline in the backyard barely visible through the kitchen window. The sunlight doesn’t go all the way from the kitchen into the living room. Instead, the pale oven globe gives off a faint glow which guides the way between the two main rooms in this two bedroom units. “There’s some dinner in the oven if you want it”, he offers. A couple of fish fingers, bubbling with fat, cast a pungent oily vapour trail though the other stale smells. This is Ronnie’s dinner. “It’s all I got, Mel’s in hospital again” he looks away, embarrassed. His girlfriend usually shops, cooks and looks after the house. His job is to try and keep the cash coming in from the steady cannabis trade, and occasionally from selling small quantities of heroin and speed when he can get his hands on it, without the dealer up the street finding out. Things aren’t going so well. The small cannabis trade provides enough money for food and buses, but not enough to pay rent and bills. With Mel in hospital, he tends not to manage the house very well and he loses track of things. He recently got some attention from the local police. He refused to let them in the front door, so the senior constable hit him in the face. The blood spray pattern on the wall above the doorway entrance re-enacts the approximate trajectory of his one remaining front tooth as it left his face and ricocheted around the walls of the unit to be lost somewhere under the coffee table. There is a lot of pain in Ronnie’s life. The pain of not having enough food, the pain of the recently departed front tooth, of not being able to find work, and the pain of knowing that he is trapped in the cul-de-sac, with little prospect of making

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enough money to go to the movies, because Rick, the dealer at the top of the street, has him under a constant watch. If Ronnie does come into money, it will have to go back to Rick anyway because he still owes him from the last drug deal that fell through. Tom and Shauna have just moved to Portland, Oregon. Tom is a fly-in-fly-out worker. He is one of the digital natives who has a mobile workplace. He flies between Europe, the USA and China, delivering his specialist IT services. On his return from a particularly gruelling ten-day, three-country work trip, he finds he is not sleeping. His sleep patterns are disturbed, and he has a continuous headache for four days. He is fifty-three years old, with a wife and two children. He is slim, athletic, rarely drinks alcohol, doesn’t smoke and eats mostly vegetarian food. He is at the peak of his professional career and is in fine physical condition. So, there is not much that can explain his headache and sleep disturbance. He goes to Marijuana Paradise, a cannabis dispensary in Multnomah County in Portland, buys some pomegranate CBD 1:1 marijuana gummies and takes one after dinner on Wednesday. Tom sleeps well that night, and the next day his headache has gone. Tom did not get a prescription, nor did he see a doctor, but he is using cannabis for medicinal purposes. It helps in a number of ways. Drugs relieve pain. Drugs can also cause pain. The relationship between pain and drugs is entirely context dependent. This book explores the disparate contexts through which life in pain is mediated by drugs. Unusually, we now live in a world where cannabis in one context is a legal medicine, and in another is an illegal recreational drug of dependence. The ambivalence of psychoactive drugs, where they can be both remedy and poison, is not new. However, we are at a moment in the drug policy arena when we have never experienced a level of pain caused so clearly by a legally prescribed group of pain relievers. The North American opioid epidemic has had a profound effect on North American life, health and culture. Also profound is the market confidence in cannabis as a potential replacement for those opioid plain relievers. Life in Pain explores these perversities and provides a way of thinking about the place of pain-relieving drugs in our society. This is a profoundly social and economic framework for understanding the contradictions and perverse social and material outcomes from drug use. This work floats across a number of disciplines. On the one hand, it can be read as a piece of medical anthropology. It can also be read as criminology, sociology, philosophy or cultural studies. Rather than try and pitch the written text to a particular discipline, I have written this work for the interested reader. As I alternated between different rhetorical styles and textual forms, I tried to resist writing for a specific kind of academic reader. Instead, Life in Pain is written for the motivated reader. It is written to engage with a reader who is prepared to read outside their comfort zone, and is prepared to not understand some sections, and to read a technical or analytical style that they haven’t encountered before. I have written his book with four actual readers in mind. The first is Rae, a clinical counsellor with a master’s degree who works with war veterans and young mums. She uses a mix of narrative, psychodynamic and family therapies. She knows that pain is a subjective and importantly, a collective

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experience. She tries to use tools from her clinical psychology toolbox to relieve what might be lifelong pain brought about through trauma or relationship tensions. It is the interdependencies in pain that fascinate her. The second is my brother Mike. He is a General Practitioner (GP) who has worked for many years with ageing and complex clients. He is the practitioner who seeks an extra diagnostic test to make sure he has all the alternative diagnoses covered. Mike knows that opioid pain relievers don’t work the way that orthodox science suggests they should. He knows that alternative therapies like pilates and yoga do more than just stretch musculature. For him, pain is a complex experience, although as a GP in a rural setting he rarely gets access to the specialist pain physicians who can offer the complex solutions that are required. Mike is the clinician who wants to know more about contemporary pain theory and has direct experience of the limitations of older medical pain frameworks. The third reader I have in mind is Cameron Duff, a social scientist who works in interdisciplinary academic arenas. He has travelled down an academic path similar to my own. I think he will find this interesting. This is a piece of interdisciplinary research that stretches across the humanities, social sciences, medicine and neuroscience. I have taken a neuroscience metaphor (the pain neuromatrix) and deployed it in a cultural setting to see what happens. Cameron knows that it is only by rubbing knowledge structures up against each other, turning them upside down, and inside out that you get a chance to think about problems differently. Like me, he has worked to apply post-structuralist thinking to health. This is a working extension of this shared line of thought. The final reader is my sister Cathy who is a business woman and could have been a scientist. She is also a carer for her daughter and a cancer survivor. After years of struggling to navigate pathways through an incoherent health system, Cathy knows all too well the impact that narrow scientific frameworks can have on accessing appropriate care. Although she has no formal training in neuroscience, public health, criminology or cultural studies, Cathy engages with the philosophical aspects of this work. She looks for energetic models of collective human action. She goes outside individualist frameworks and looks to the matter/energy of the world for ways to improve health. Each of these readers will find something in this work. They will also not engage with other elements, either because they are too abstract or outside their frame of reference. The important message when the reader encounters a section that is beyond their own focus is to skip ahead. This is written on the assumption that you don’t have to understand the whole book, you just need to be open to being challenged. The two scenarios I described earlier, in Ronnie and Tom, are there to illustrate the ambivalence and banality of pain and its relief with drugs. Life in Pain provides an alternative way of engaging with this ambivalence and banality. It provides a cultural window into human experience that is both entirely subjective and

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thoroughly universal. Pain is all around us, until we grapple with the cultural significance of pain and its economic centrality to modern capital, we will forever be turning to the pharmacy to find relief and left wanting more. John L. Fitzgerald University of Melbourne Parkville, Australia

Acknowledgements

This work emerged in 2016 when my publisher approached me and asked the usual question, “What are you working on”. It forced me to put in action what I had been ruminating over since reading Merrill Singer’s influential work back as a post-doctoral fellow on a NHMRC Fellowship. Since 1997, I have been living with pain under the watchful eye and amazing clinical hands of Dr. Steve Jensen. He continues the tradition of the humble intellectual, a musculo-skeletal pain clinician who is more interested in the functional quality of people’s lives, rather than what the diagnostic tests suggest. Thank you Steve for getting me this far. My funders who have supported me, the Australian Research Council, National Health and Medical Research Council, VicHealth and Victoria Police, have all contributed to this work. To Prof. Karen Farquarson who reminded me that the circling wolves of academia are not the heart of academic life, I thank you for providing some much-needed support. Thanks to my many brothers and sisters who continue to reach out and support me, even when the curmudgeon growls in his cave. Also, thanks to my running mates Steve and Lisa who were a testing ground for many of these ideas. My amazing girls inspire me everyday and though they may not know it now, but in the course of expanding their inquiring minds through their inquisition of the world they have brought me through some of my most profound pain. Thanks so much Tilda and Harriet. Finally, for someone who carries the worlds of those around her with selfless grace, and deserves more love than the world can give, I thank you Mary. Someday the world will realise just how much it owes you.

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Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 Economic Setting, Substance Use and Pain . . . . . . . . . . . . 1.3 Pain as a Cause of Illicit Drug Use . . . . . . . . . . . . . . . . . . 1.4 On Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5 Pain as a Shapeshifting Quality . . . . . . . . . . . . . . . . . . . . . 1.6 A Changing World: The Centrality of Affective Capitalism . 1.7 Pain, Neurosignatures, Refrain and the Body . . . . . . . . . . . 1.8 Key Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9 Structure of This Book . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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2 Extending the Neuromatrix . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Melzack’s Pain Neuromatrix . . . . . . . . . . . . . . . . . . . . . 2.2 Conscious and Less-than-Conscious Neurosignatures . . . 2.3 Central Sensitization . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4 Paradigmatic Change and Keeping it Simple . . . . . . . . . 2.5 Organising Principles of the Neuromatrix . . . . . . . . . . . . 2.6 Pain as Social and Cultural: A Cultural Phenomenology of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7 Medicalisation Pain Neuromatrix . . . . . . . . . . . . . . . . . . 2.8 Faces of Methamphetamine Use and the Cultural Pain Neuromatrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.9 Pain as a Shapeshifting Commodity . . . . . . . . . . . . . . . . 2.10 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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3 The North American Opioid Epidemic . . . . . . . . . . . . . . . . . . . 3.1 The Opioid Epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 The Early Stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Political Change and Liberal Pain Theory . . . . . . . . . . . . . 3.4 Marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5 Unleashing the Pain Tiger—Pain as the Fifth Vital Sign . . . 3.6 A Drug Epidemic or Pain Epidemic . . . . . . . . . . . . . . . . . . 3.7 The Pharmaceutical Machine in the Body-Economy Milieu . 3.8 Pain as a Shapeshifter . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.9 Affective Economy and Pain . . . . . . . . . . . . . . . . . . . . . . . 3.10 Emotional Labour and Drugs . . . . . . . . . . . . . . . . . . . . . . . 3.11 Contracting for Difference . . . . . . . . . . . . . . . . . . . . . . . . . 3.12 The Pharmaceutical Machine as Derivative Trader . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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4 Pain and Cannabis Markets . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Cannabis as a Pain Reliever . . . . . . . . . . . . . . . . . . . . . . 4.2 Replacing Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 Temptation Goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 Public Opinion of Cannabis . . . . . . . . . . . . . . . . . . . . . . . 4.5 Broad-Based Opinion Polls . . . . . . . . . . . . . . . . . . . . . . . 4.6 A Shapeshifting Commodity . . . . . . . . . . . . . . . . . . . . . . 4.7 Cannabis as a Pain Reliever in Australia . . . . . . . . . . . . . 4.8 Modulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.9 Neurochemical Selves . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.10 Affect in the Field of Potential . . . . . . . . . . . . . . . . . . . . 4.11 Derivative Logic or How Much Is Cramer’s Affect Worth 4.12 Capitalism and the Field of Potential . . . . . . . . . . . . . . . . 4.13 How Cannabis Is Working Culturally . . . . . . . . . . . . . . . 4.14 Cultural Pain Sensitization, and Cannabis . . . . . . . . . . . . . 4.15 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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5 Over the Counter (OTC) Pain Relief and the Self-treatment of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 The Therapeutic Goods Administration (TGA) Decision to Up-Schedule Codeine . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Everyday Life Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 The Contagious Pain of Opioid Addiction . . . . . . . . . . . . . 5.4 Semiotics and Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 Neurosignature Analysis: “When Pain Is Gone, Life Takes Its Place” (LTIP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6 The Panadol Campaign—The Contemporary Life Headache

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Signature, Self-hood and Territory . . . . . . . . . . . . . . . Machines and Milieu . . . . . . . . . . . . . . . . . . . . . . . . Leaving Everyday Pain Sufferers Behind: The Many Wolves of the Market . . . . . . . . . . . . . . . . . . . . . . . . 5.10 Leaving Ordinary Pain Sufferers Behind . . . . . . . . . . 5.11 When Regulation Is Gone, the Market Takes Its Place 5.12 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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6 Etched in the Skin: Pain, Methamphetamine Violence and Affect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 Faces of Meth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 Faces of Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.3 Faces and Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4 Pain and Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.5 Cultural Pain of Addiction . . . . . . . . . . . . . . . . . . . . . 6.6 Iteration of Suffering and Pain in Treatment Modalities 6.7 The Meth Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.8 Your Face on Meth . . . . . . . . . . . . . . . . . . . . . . . . . . 6.9 Meth Epidemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.10 The Australian Ice Epidemic . . . . . . . . . . . . . . . . . . . . 6.11 Ice—Related Violence . . . . . . . . . . . . . . . . . . . . . . . . 6.12 The Ice-Violence Cultural Pain Neurosignature . . . . . . . 6.13 Cultural Pain Sensitization . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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7 Regulating the Cultural Pain Neuromatrix . . . . . . . . . . . . . . . . . . . . 7.1 Pain: Applying the Cultural Neuromatrix Theory . . . . . . . . . . . . 7.2 Pain: Signifying and a-Signifying Semiotics . . . . . . . . . . . . . . . . 7.3 The Face of Pain Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4 The Deployment of Biopower . . . . . . . . . . . . . . . . . . . . . . . . . . 7.5 The Role of the State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.6 Guardians (Methamphetamine) . . . . . . . . . . . . . . . . . . . . . . . . . 7.7 Wolves of the Marketplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.8 A Normal Commodity Market . . . . . . . . . . . . . . . . . . . . . . . . . . 7.9 Disparity of Opportunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.10 The State as Spectator (The North American Opioid Epidemic) . . . 7.11 The Gardener . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.12 Markets Cannot Control Access to Life . . . . . . . . . . . . . . . . . . . 7.13 Leaving No One Behind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

Chapter 1

Introduction

Pain is not injury; the quality of pain experiences must not be confused with the physical event of breaking skin or bone. Warmth and cold are not “out there”; temperature changes occur “out there,” but the qualities of experience must be generated by structures in the brain. There are no external equivalents to stinging, smarting, tickling, itch; the qualities are produced by built-in neuromodules whose neurosignatures innately produce the qualities. Melzack (2005: p. 87) Pain does not emerge naturally from physiological processes, but in negotiation with social worlds. Bourke (2014: p. 300) Derivatives are the dominant mode of capital in the neoliberal epoch, both in terms of their dynamism and in terms of the magnitude of the value they ferry. Massumi (2018: p. 86)

1.1 Introduction This book emerges from my continuing interest in the intersections between bodies, culture, markets, politico-economic forces and illicit drugs (Fitzgerald 2015). The focus of this book is however more specific than previous excursions. The focus is on pain and how it relates to drug use. This focus emerges from both a historical perspective and a personal experience with pain. Back in the mid 1990s I believed that the drug and alcohol research discourse was overly preoccupied with the pathology of illicit drug users. Research samples drawn from treatment cohorts and prison populations dominated research, painting a picture of damaged individuals living in pathological social, economic and institutional settings. Pain was everywhere. Through the 2000s the research perspective shifted, mainly from the efforts of harm reduction-oriented researchers internationally, away from pain and onto pleasure (Bjerg 2008). Shifting the focus onto a larger population of illicit drug users who use the drug for the purposes of pleasure (thought to © Springer Nature Singapore Pte Ltd. 2020 J. L. Fitzgerald, Life in Pain, https://doi.org/10.1007/978-981-10-5640-6_1

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1 Introduction

be around 80% of those who use illicit substances) was intended to create a more representative empirical picture and perhaps a new impact on drug policy in a more humane and compassionate direction. The strategy did not work as well as planned. In recent times, we have seen illicit drug strategies in different parts of the world (e.g. Philippines, Thailand, Bangladesh) that aim to inflict hardship, pain and indeed in some instances, death on drug users (Yusay and Canoy 2019; https://www.hrw.org/news/2018/06/06/bangladeshsuspend-deadly-war-drugs). We have also seen an epidemic of prescribed pain relievers in North America that bears no historical comparison. From 2001 to 2013, there was a three-fold increase in overdose deaths involving prescription pain relievers and a five-fold increase in overdose deaths involving heroin (NIDA 2015). The rise in morbidity and mortality caused by oxycodone and fentanyl in North America since 2012 is extraordinary. Prescription pain relief is a rapidly changing arena (Karanges et al. 2016). Pain is back on the agenda. Now, closing in on 2020, I believe it is important to bring a focus back onto pain and how it relates to illicit drug use. Not because the focus on pleasure was wrong, but because we need a better account of how pain relates to illicit drug consumption. From a personal perspective, I am living with pain. In the course of the writing of this work, a spinal injury that I had managed for 20 years started producing uncontrollable neuropathic pain. I experienced and learned to manage a central sensitization from an originary injury in my cervical spine (neck). Decades of physical therapy, surgical interventions, opioid analgesia and finally neuro-physio-therapeutic pain management, have left me with a deepened experience of living with and travelling through life in pain. Pain is a central experience for people who are dependent on drugs. Whether as a cause of drug use or as an outcome from substance use. There are reports that between 55 and 61% of patients receiving pharmacotherapy experience chronic pain (Eyler 2013; Voon et al. 2015a, 2018). A cohort study of people who use drugs in Canada reported that up to 66% of the sample had been refused access to pain management medication (Voon et al. 2015b). Some take the view that illicit drug strategies are designed to inflict pain and hardship on those who use illicit drugs. Making it risky to use drugs, sending a tough message, for some is a preventative strategy. These same drug strategies are thought to cause pain. According to Voon’s review of the literature, drug users report the accentuation of psychosocial harm related to inadequately managed pain, economic vulnerability, and “perceptions of “inhumane” and “cruel and unusual” treatment from health care providers (Voon et al. 2018). Pain and suffering are part of life, however the pain caused by the stigma of drug use (Chang et al. 2017) is substantial. According to Chang et al. (2017) this pain is related to a lack of “cultural health capital”. Pain for illicit drug users is at the intersection between corporeal experience, health, sociality and ultimately capital.

1.2 Economic Setting, Substance Use and Pain

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1.2 Economic Setting, Substance Use and Pain It is reasonably intuitive to understand the relationship between pain and economic downturns/financial strain. Not so intuitive is the relationship between economic hardship and illicit drug use and drug problems. Carpenter et al. (2017) have performed the most extensive economic evaluation of this relationship in the Northern American context of the prescribed analgesic epidemic over the period 2003–2013. There is a statistically significant procyclical relationship (i.e. drug use goes up as economic growth goes up) for stimulants and LSD (Carpenter et al. 2017: p. 14). Ecstasy use however is strongly countercyclical (Carpenter et al. 2017: p. 16). A 1% increase in unemployment results in a 5% increase in ecstasy use. There were no cyclical relationships between economic conditions (as indexed through unemployment rates) and the use of analgesics, sedative or tranquilisers. Substance use disorders however paint a different picture. Substance use disorders for most major drug classes (marijuana, cocaine, stimulants, heroin, sedatives and tranquilizers, and inhalants) are not related to economic conditions (p. 17). However, disorders involving the use of analgesics and hallucinogens are significantly countercyclical. A 1% rise in unemployment produces a 6% rise in analgesic substance use disorders and an 11% rise in hallucinogen disorders (Carpenter et al. 2017: p. 17). In a subsequent analysis to examine the segmentation of the relation between economic conditions and substance use disorders, Carpenter et al. (2017) report that state unemployment rates are significantly positively related to analgesics and hallucinogen disorders for men, whites, less educated individuals, and 18–64 year old’s (Carpenter et al. 2017: p. 20). The countercyclical relationship for substance use disorders involving analgesics mostly affects people in sales/service occupations. Substance use disorders involving heroin were strongly countercyclical among blue collar workers (construction, maintenance, machine operators, transportation workers, and the armed forces). When economic conditions deteriorate, analgesic problems rise in service occupations, whereas heroin use problems rise in blue collar occupations. Interestingly, Arkes (2011) suggests that a one-percentage-point rise in the state unemployment rate increases teenage cannabis past-year use by 4.1% points, increases past month use by 1.9% points, increases heavy use by 0.9% points, and leads to approximately 0.3 more days used, on average, in the past month. In Australia, the results are similar (Costa-Sorti et al. 2011). Economic downturns boost both the number of young cannabis users and the frequency of its use (Chalmers and Ritter 2011). Changes in cannabis use differ according to different age groups with older people (aged 35–49 years) using cannabis less frequently during downturns, whilst younger people (25–34 years) tend to use it a little more frequently (Chalmers and Ritter 2011). Economic downturns have market impacts. Through increased competition, recessions tend to reduce profit margins. Downturns also increase the number of those who participate in the illicit drug market, increasing the number of cocaine, heroin and amphetamine users in response to declining drug prices (Caulkins 2011).

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1 Introduction

The pain of economic life has direct and indirect impacts on illicit drug use and illicit drug markets. The relations are however not structured simply by the forces of supply and demand. There are added complexities by virtue that drugs are not ordinary commodities: the substances themselves are ambivalent, they can both cause and relieve pain.

1.3 Pain as a Cause of Illicit Drug Use Historically, pain has always been known as a cause of the non-medical use of drugs, in particular the over-use of opioid pain-relievers. Whether the pain originates from economic downturns (Carpenter et al. 2017), forced migration (Horyniak et al. 2016), chronic mental health problems (Compton et al. 2005), sporting injury (Denham 2012), workplace injury (National Safety Council 2015), post-war PTSD (Teeters et al. 2017); or family violence (Rakovec-Felser 2014), the connection between pain and illicit drug use is all too apparent. In the 1990s with the shift to risk factor research, the search for “causes” of drug use switched to identifying risk factors for illicit drug use. The WHO has for some time identified risk factors that predict drug use. Interestingly pain is not specifically listed. Instead there are a variety of individual factors (that produce pain) that predict non-medical drug use (Table 1.1). Confirming this interpretation is a finding from an analysis of a national sample (n = 14,784) of opioid misusers. Over and above any other known risk factors, experiencing chronic pain during adolescence was an independent risk factor for opioid misuse in adulthood (Groenewald et al. 2019). Pain is the common element underpinning a wide range of factors that predict illicit drug use. However, for some reason pain is not a target for intervention. Is it because the pain from one cause is not the same as the pain from another? It is because some pain is avoidable, but other pain is not? Is it because pain is an inherently personal Table 1.1 Factors predicting non-medical drug use (WHO Alcohol and Public Policy Group 2004: p. 23)

Individual factors

Environmental factors

Genetic predisposition

Poverty

Being a victim of child abuse

Social change

Personality disorder

Peer culture

Family disruption and dependence problems

Occupation

Poor performance at school

Cultural norms, attitudes

Social deprivation

Drug policies

Depression and suicidal behaviour

1.3 Pain as a Cause of Illicit Drug Use

5

and individual experience, thus making it difficult to manage through public policy? Is it because pain is commonly thought of as a medical condition and rarely defined in social or cultural terms? Similarly, the premise of the international movement to reduce harm, commonly referred to as “Harm Reduction”, does not focus on pain. Its focus is on harm. Although implicit to harm is pain, pain is the silent partner in policy. It is the elephant in the room in drug policy. Everyone knows it is there, but we dare not speak its name. A key question that has yet to be comprehensively answered is why some USA states had an epidemic of pain relievers and others did not? Was there an epidemic of pain before an epidemic of pain relief? Why did some states have so much pain. How is it possible that pain relief is stratified so starkly among those states and not others? Alternatively, how could non-medical consumption of pain relievers be so sharply segmented among those states that have poor regional communities. Surely the outbreak of pain relief was not solely due to unscrupulous pharmaceutical companies, pain doctors and “pill mills”, that duped the population into consuming pain relievers at a scale never before seen in the United States. Surely there cannot be that many people who are prepared to fraudulently misrepresent their pain in order to experience the effects of oxycodone and fentanyl? Even if there were that many people who were fraudulently misrepresenting their pain, why are they so specifically stratified in the way they are? A picture emerges in other jurisdictions about the stratification of pain relief. In the United Kingdom, the rates of opioid prescription are higher in more socially deprived neighbourhoods. Patients more likely to receive prescribed opioids are aged more than 65 years, female, smoke, and are at risk of obesity and depression (Chen et al. 2019). Both in the US and Australia lower socio economic status has been associated with higher rates of prescribed opioid consumption (McDonald et al. 2012; Degenhardt et al. 2016). A medical basis for this variation is often used, with higher rates of chronic pain conditions, “persistent opioid utilization and aberrant medication-taking behaviors” in lower SES communities (Chen et al. 2019). It is however, hard to believe that the extraordinary variation is explained by sick and “aberrant” drug users. Chen et al. (2019) also reported that prescribed opioid consumption is associated with lower levels of income, employment, education and skills, health and disability and crime. Opioid use was also significantly associated with poor living environments (Chen et al. 2019). These findings are reminiscent of an earlier theory posited by Merrill Singer of “Oppression illness”. Where drug use was a response to socioeconomic suffering and “structural violence” (Singer 2001, 2004, 2008). Oppression illness provided a link between structural discrimination experienced through social processes and poor individual health: [Oppression illness] is the chronic, traumatic effects of experiencing social bigotry over long periods of time (especially during critical developmental periods of identity formation) combined with the negative emotional effects of internalizing prejudice… [Oppression illness] is a product of the impact of suffering from social mistreatment based on bigotry and, at some level, accepting blame for one’s suffering as just retribution for someone who does not deserve better treatment. (Singer 2004)

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1 Introduction

Bourgois provided an expanded version when he situated illicit drug use within the pain of structural violence of illicit drug markets experienced by inner city drug users and dealers in North America and their version of seeking out the American dream (Bourgois 1996). From a broader health perspective, it is well-recognised now that it is the composite of material, infrastructural and economic forces, the neo-material matrix of contemporary life, that shapes inequalities in health outcomes: A neo-material interpretation says that health inequalities result from the differential accumulation of exposures and experiences that have their sources in the material world. Under a neo-material interpretation, the effect of income inequality on health reflects a combination of negative exposures and lack of resources held by individuals, along with systematic underinvestment across a wide range of human, physical, health, and social infrastructure. An unequal income distribution is one result of historical, cultural, and political-economic processes. These processes influence the private resources available to individuals and shape the nature of public infrastructure - education, health services, transportation, environmental controls, availability of food, quality of housing, occupational health regulations - that form the “neo- material” matrix of contemporary life. (Lynch et al. 2000)

These questions elevate the interrogation of pain and drugs beyond the experience of the individual and into a wider examination of the social, cultural and economic forces that make pain relief epidemics possible.

1.4 On Theory A branch of illicit drug researchers has developed a theoretical position that reassesses the stability of key terms in drug research, such as “addiction” (Malins 2004; Duff 2014; Mcleod 2017; Farrugia 2014; Oksanen 2014; Herschinger 2015; Fraser et al. 2014; Ghiabi 2018). Broadly referenced as poststructuralist (Bachhi 2018), this theory tends to focus on language and meaning-making. It enables an analysis of how key structures of knowledge “work”. These authors also tend to develop their ideas around the work of the philosopher Gilles Deleuze. Foundational terms are now understood not as necessary, natural, or ‘true’. Terms such as addiction are not the product of scientific progress, rather they are historical, technical, political and social achievements. Rather than just reflecting institutional or ideological hegemony, ideas such as “addiction” are seen to be unstable social and technical categories. Fraser et al. (2014) assert “addiction” is an assemblage, “an ad hoc cluster of knowledges, technologies, bodies and practices that contingently gather to form a temporary phenomenon” (Fraser et al. (2014). Although these assemblages are contingent, they can, nonetheless, be resilient and resistant to power. A feature of this type of orientation is to refocus empirical work on both the macro and micropolitical workings of power. As Ghiabi notes in an analysis of drug treatment camps in Iran: The camps operate as a rhizome of the state, which instead of reproducing vertical lines of control and discipline, becomes diffused and horizontal – similar to the grassroots (rhizomes) of a tree. When societal control is practiced, this is cropped out through the rhizomes that

1.4 On Theory

7

stem from the horizontal roots of the state itself, camouflaged as other forms of intervention, the illegal world of treatment dealing with the illegal life of drugs users. This forms what I define as maintaining disorder. Ghiabi (2018)

One keen feature of a Deleuzian approach is the capacity to implicate a wide range of actors, institutions and forces into complex phenomena. The analytic framework encourages experimentation with ideas; a bringing together of objects with different ontology into a mixity of forces that produce material outcomes. It is the acknowledgement of how both the virtual and the material are related that is an attractive feature of this form of analysis. Having previously explored this terrain, I will not develop how Deleuze assists when examining illicit drugs (Fitzgerald 2015). I will however now outline how a Deleuzian approach is of particular salience when it comes to thinking about pain and drugs.

1.5 Pain as a Shapeshifting Quality Robert Melzack opens this book as the pioneer of an influential framework for thinking about chronic pain, the pain neuromatrix. His framework suggests that pain is best understood as a multidimensional experience. He rejects the Cartesian concept of pain simply as a sensation produced directly by “injury, inflammation or other tissue pathology” (Melzack 2005). The quality of pain experience is both inscribed in the brain and also dynamically responsive to neural triggers. Pain is mobile, it can change shape and character (Bourke 2013, 2014). There are infinite variations both within and across individuals. There are multiple processes involved in the translation of pain as a brain impulse and the resultant autonomic (corporeal) or even behavioural outcome. Pain is subjective, but also organically felt. Pain in this framework has many dimensions. Whilst this book is not about the biological basis of chronic pain, it will draw on the metaphors used by Melzack and his colleagues. The central reason for this is that the foundation of Melzack’s framework is a diffuse model that implicates multiple pathways, structures and functional components. This biological model is a micro version of what I believe is happening at an individual, social, cultural and economic level. This book is concerned with how pain fits into, what could be called a broader affective economy. Pain is not just an individual experience, it is a cultural and economic experience, and as such, needs a cultural phenomenology. What comes with an expansion of the scope of pain and its intermediaries, is the problematisation of the ontology of pain: to what extent can pain be an object in its own right. To what extent is it a “thing”, if it is product of culture, or even an imagined entity. Moving beyond Melzack’s neuromatrix is not just a change in scale, there are deeper questions as to how pain is a thing-in-itself when deploying metaphors such as the neuromatrix.

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In her historical account of pain, Bourke (2014: pp. 5–12) deals elegantly with the tensions between pain as an ontological object and pain as constructed. The ontological instability of pain is managed by focussing on pain as something named, performed and constructed within discourse as a “pain-event”. This rendering allows pain to have the narrative property of “mine-ness” (Bourke 2014: p. 5). A person becomes or makes herself as a person-in-pain through a productive discursive act. Productivity is not however purely a property of a speaking individual. Productivity can also be thought of in Foucauldian terms as productive discourse, it creates that of which it speaks (Foucault 1977: p. 119). As discussed by Bourke, in Wittgensteinian terms, a pain event is never private, it is always already formed through language, it is socially and publicly formed (Bourke 2014: p. 6). The reasons for extending an understanding of pain beyond the individual and to implicate economic, social and cultural systems are both philosophical and empirical. From a philosophical point of view, it seems inadequate to isolate a discussion of pain down to the individual when it is clearly evident that pain and its management involves a wide set of forces ranging from government, to the pharmaceutical industry and social formations. From an empirical point of view, pain affects vast and increasing numbers of people across the globe. Over a hundred million people in the United states suffer chronic pain (Institute of Medicine 2011). Gaskin and Richard (2011) report that the annual cost of pain in the USA (in 2010 dollars) was between $560 and $635 billion. Pain costs more than the annual costs of heart disease, cancer and diabetes. Chronic pain affects one in five adults in Europe (Breivik et al. 2006). National population-based surveys in Spain, Portugal, Ireland, Denmark, Norway and Iceland estimate that between 25 and 35% of adults report chronic pain (Breivik et al. 2013). In the United States, estimates of the prevalence of chronic pain vary. A 2010 cross sectional web-based survey (Johannes et al. 2013) reported a prevalence of chronic pain of 30%. Prevalence was higher for females (34.3%) than males (26.7%) and increased with age. Half of those reporting chronic pain experienced daily pain, with 32% reporting severe pain intensity. Low-income households and unemployment were significant predictors of chronic pain. An annual national household survey reports that over 50 million American adults have significant chronic pain or severe pain (American Pain Society 2015). Estimates in the Netherlands of 19% of the Dutch total population experiencing chronic pain suggest the prevalence of opioid use among chronic pain patients is 31.6% (van Amsterdam and van den Brink 2015). According to the USA Centre for Disease Control (CDC), 20% of patients presenting with non-cancer pain symptoms receive an opioid prescription (Daubresse et al. 2013; and https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm). According to the U.S. CDC, in 2012, health care providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills. Over the period 2007–2012 opioid prescriptions increased 7.3%, with opioid prescribing increasing the most among local general practitioners. The rates of opioid prescribing in different states are not related to the health problems of the population (Paulozzi et al. 2015).

1.5 Pain as a Shapeshifting Quality

9

In 2015 it was reported that in the European Union 1.9 million (0.7% of the population) people were dependent on opioid pain relievers (van Amsterdam and van den Brink 2015). Prescribed opioids are the second most widely-used drug (4.5 million users) after marijuana (8 million users). In approximately 40% of cases, pain relief was the most common reason for non-medical use, Around half of nonmedical prescribed opioid users reported non-pain relief reasons for use including to get high or to relax. In Germany from 2000 to 2010, the proportion of insured persons with at least one opioid prescription increased from 3.3 to 4.5%. The use of oxycodone increased ten-fold. Over the same period in the United Kingdom, the total annual number of non-cancer patient prescriptions of opioids (buprenorphine, fentanyl, morphine and oxycodone) increased by 58% (Zin et al. 2014). Van Amsterdam and van den Brink (2015) suggest some significant cultural bases for the high level of use of prescribed opioid use in the United States compared to Europe. In contrast to the EU, a “culture of consumerism” in medicine is driven by direct-to-consumer advertising, and advertisements containing “subjective information”. Weisberg and Stannard (2013) suggests that both a relatively low price of heroin and the relatively easier access to opioid pharmacotherapy in the UK may have restricted the growth in the illicit market for and misuse of prescribed opioids in the UK. In the UK and in the Netherlands the treatment rate for dependent opioid users is about double that of the dependent opioid users in the USA. After many decades of focus on the health of the individual (Lupton 1995), contemporary social health analysts are noting that health is no longer the responsibility or the achievement of individuals (McLeod 2017). Duff (2014) and others have led the charge in applying the philosophy of Deleuze to the fields of health and drug use. A cornerstone of this work is the observation that health is an achievement of both human and non-human forces, and that the apparent ontological distinctions between different forces at play is breaking down (Duff 2014: p. 183). More than ever scholars are able, using these kinds of tools, to demonstrate how the interplay between economies, bodies, spaces and discourses can produce health outcomes (Fitzgerald 2015; McLeod 2017). This focus on health beyond the individual has specific consequences. In particular, the observation that health is intimately associated with the way people connect to the world. According to Duff connectedness is a vital part of the “affective labour of maintaining one’s mental health” (Duff 2014: p. 186). Affective labour in this sense is not about emotion, it is in references to being open to the flow of affect, open to contingency and the roll of the dice (Fitzgerald 2015). Connectedness here too is not limited to being socially connected. Connectedness refers to the capacity to engage with the world in a broader, deeper sense. Although Melzack was focussed on the neurobiology of pain, his diffuse model of pain, distributed across different elements and structures informs a broader model through which we can understand health and pain that extends beyond the individual. We do not learn to feel qualities of experience: our brains are built to produce them (Melzack 2005: p. 87). With a parallel logic, we do not learn to feel the qualities of wellbeing, our assemblages with the world around us are built to produce them.

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1 Introduction

In this way, wellbeing and pain arise collectively from the assemblages of bodies, individuals, institutions and machines that bind us to the world (McLeod 2017). There are few objects that have the capacity to possess so many qualities. As I will argue throughout this book, pain is the ultimate shapeshifting commodity. As a consequence, a commodity with such mobile qualities, is amenable to rampant capitalisation. In fact, this shapeshifting quality is just the kind of commodity upon which modern capitalism thrives. Other than value itself, there are few commodities that can be valued, revalued and valued again in such a variety of ways. Pain as a commodity can assume different values by virtue of its value never being reliably fixed at any point in time. From this perspective, pain is infinitely amenable to being “derivatised” or made derivative. It is for this reason that I will make recourse to Massumi’s (2018) recently published treatise on post-capitalist logic and the logic of the derivative. The logic of the derivative is at the heart of understanding the value of pain, and ultimately understanding the political economy of pain. This framework sets the stage now for an exploration of life in pain. This exploration will shuttle from the specific coordinates of pain—felt, imagined, and communicated—to the broader cultural, economic and social machines that enable pain to exert force; to shape shift from a subjective feeling, to an idea, and into a commodity form. This work will outline how pain drives drug consumption writ large. Arising from this appreciation of the economic and social force of pain will be a range of criminological concerns in the form of regulatory, legislative and policy problems. When the pain neuromatrix extends the culpability for pain beyond the individual, onto government, industry, law enforcement and cultural institutions, it is no longer the individual who shoulders the responsibility for relieving pain, we all become implicated in finding solutions. Figure 1.1 provides the basic outline for the theory of pain to be explored in this book.

Fig. 1.1 Theoretical terrain for life in pain

1.6 A Changing World: The Centrality of Affective Capitalism

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1.6 A Changing World: The Centrality of Affective Capitalism Global capitalism has changed (LiPuma 2017; Zuboff 2019). Advanced western economies have witnessed a number of broad changes: deregulation, privatisation, capital mobilisation, the dismantling of trade unions, the state as purchaser of welfare, the shrinking of the manufacturing sector and the expansion of the service sector have all created a range of health and social impacts (Harvey 2005; Navarro 2007). Forms of production have changed, as have modes of consumption. Emergent from the financial crisis is a greater awareness of the fluidity of capital, and the contradictions in the distribution of different types of labor across the social and class structures (Prins et al. 2015). More importantly, as the logic of capitalism changes, so too are changes in the social world (LiPuma 2017). With the diminution of manufacturing in advanced western economies there has been increased focus on the information and service sectors. Focus has turned to the forms of labor that add emotion or affect to the service provided. Increasingly, analysts now focus on affective components of capitalist production. Reference is now made to two forms of “immaterial labor” prevalent in fast capitalism (Peters 2018). Immaterial labor that supports the “informational content” of a commodity and that which supports the “cultural content” of the commodity. The second element of immaterial labor involves that which establishes cultural and artistic standards, fashions, tastes, consumer norms, and public opinion (Peters 2018). Immaterial labour, is “that which creates immaterial products, such as knowledge, information, communication, a relationship or an emotional response” (Hardt and Negri 2004: p. 108). Affective labor is especially important in the service occupations such as personal care workers, hospitality and support workers. Affective labor is often “invisible labour” where part of the job is to both produce and change the emotions (Oksala 2016). Affective capitalism however is not just concerned with the production of emotion. It is concerned with the trafficking of “affect” or “movement/energy” in a broader sense. Affective capitalism is a broad infrastructure in which the emotional culture and its classed and gendered history merge with value production and everyday life (Karppi et al. 2016). As Bourke (2014: p. 71) notes, “the physiological body is constituted by the figurative languages that bring the body into the world. Figurative languages “disclose” our beings-in-the-world”. Bringing the body into the world—or the worlding of bodies (Stewart 2010) though cultural discourses is of primary concern in the “affective turn” in anthropology and cultural studies (Grossberg 2010; Hardt 1999). At the heart of the worlding of bodies is the role of affect. Developed from Spinozian philosophy, affect connects passions, actions and bodies. Not just emotion, affect is a relational field of causality. It connects thought, practices, the power to act and the power to be affected (Hardt 2011). Affects can be actions caused by internal forces, or passions caused by external forces. Affects straddle the divides

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1 Introduction

between the mind’s power to think, the body’s power to act and the power to act and be affected. Affect is an uncertain field of relations (Massumi 2002). Affect theory examines those forces beneath conscious knowing that can serve to drive us toward movement, thought, “… [to] illuminate the intertwined realms of the aesthetic, the ethical, and the political as they play out across bodies (human and non-human)” (Gregg and Seigworth 2010). Affective capitalism operates: where resonances between bodies – both human and non-human alike – enter systems of value and value production. Affective capitalism appeals to our desires, it needs social relationships, and organises and establishes them. Our capacities to affect and become affected are transformed into assets, goods, services, and managerial strategies.(Karppi et al. 2016)

Massumi (2002: p. 45) suggests that affect is a key infrastructural element in modern capitalism, Affect has the potential to activate subjects beyond rationality and conscious action. For Deleuze and Guattari (1987: p. 265) “Affect is not a personal feeling, nor is it a characteristic; it is the effectuation of a power of the pack that throws the self into upheaval and makes it reel”. Sampson (2016b) suggests the operations of affective capitalism in everyday life can be seen in the manipulation of emotions in Facebook. The brain is a space for the folding of subjectivity with capitalism, and in this case the networked relations fold the collective through the individual (Sampson 2016a). It is vulnerable to manipulation through neuroeconomics and neuromarketing, which stimulate the brain in less-than-conscious registers. Thrift calls these autonomic vulnerabilities. Affect for Sampson operates between the brain and social relationality and is manifested in the moods and movements of the crowd. It connects individuals to the sentiment and movement of the crowd. Samson’s main contribution is the illustration of the extent to which affect is contagious and is transmitted through networked pathways, and as such opens up a series of deeper questions about network sociality, social media and affect in contemporary society. I will return to these questions in a later chapter about pain, methamphetamine use and the media. Affects are not just emotions. According to Massumi, distinctions need to be made between affects and emotions: An emotion is a subjective content, the sociolinguistic fixing of the quality of an experience, which is from that point onward defined as personal. Emotion is qualified intensity, the conventional consensual point of insertion into intensity into semantically and semiotically formed progressions, into narrativizable action-reaction circuits, into function and meaning. It is owned and recognized. It is crucial to theorize the difference between affect and emotion. (Massumi 2002: p. 28)

Affects act as points of transformation whereas emotions are recognised structures of feeling. Emotions instantiate sovereign subjects, whereas it is through affects that change occurs, “not just the change of passing from one emotion to another, but becoming, the transformations that disrupt and undo the existing emotional order” (Read 2016). In the Spinozian-rooted notion of affect as bodily capacities, bodies are not seen as entities, but rather as assemblages that extend beyond clearly defined boundaries (e.g. Massumi 2002; Gregg and Seigworth 2010; Blackman 2012). Moreover, this account

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“moves away from a distinctive focus on the human body to bodies as assemblages of human and non-human processes” (Blackman 2012: p. 1), which further accentuates the dynamic nature of affect.

1.7 Pain, Neurosignatures, Refrain and the Body People’s primary experience of pain is through the body. The body however is not just a collection of tissues. Melzack’s neuromatrix model of pain extends the previous linear Cartesian pain models that once dominated medicine, to a more diffuse set of relations across an adaptive body. Even the US Institutes of Medicine (IOM) have adopted the neuromatrix model of pain (Institute of Medicine 2011). Pain is now better appreciated as originating from a wide set of diffuse locations, most importantly from the brain itself. This relational picture of pain as both a cause of drug use and effect of drug use is complicated. It is however now recognised that suffering and indeed pain is not just a medical phenomenon. It is the product of a network of forces (Bourgois and Schonberg 2009; Fraser et al. 2018) of different scales, intensities and complexities. The metaphor of the “assemblage” has emerged as a contemporary model for complexity even for the brain itself (Sampson 2016a). The brain as assemblage becomes a site through which the affectual economy acts. Affects become attached to objects and create relations between objects and bodies. As much as affects indicate zones of indeterminacy, they are also captured. Bodies, subjectivities institutions, machines—pain itself—get territorialised. Pain gets lodged on and into resilient and resistant objects. Refrains or repetitions achieve this task. The refrain is a philosophical trope as well as a musical term. It is used to provide a mechanism through which matter and form emerge from a repetitive application of forces. Having a mechanism through which the world is made, is crucial as otherwise the philosophical conversation would be located in energies, forces and the abstract, rather than in the materiality of bodies and forms. The refrain is a trope used by Deleuze and Guattari to help explain their philosophy of how forces move between states and create things in the world. Kathleen Stewart has the best articulation of a refrain in her reflections on making worlds or “worlding” (Stewart 2010: p. 339): What is, is a refrain. A scoring over a world’s repetitions. A scratching over a world’s repetitions. A scratching on the surface of rhythms, sensory habits, gathering materialities, intervals and durations. A gangly accrual of slow or sudden accretions. A rutting by scoring over. Refrains are a worlding. Nascent forms quicken. Rinding up like the skin of an orange. Pre-personal intensities lodge in bodies. Events, relations and impacts accumulate as the capacities to affect and be affected. Public feelings “world up” as lived circuits of action and reaction.

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The basic elements from which refrains assemble are milieus and rhythms. From chaos, “milieus and rhythms are born” (Deleuze and Guattari 1987: p. 313). A milieu forms a “block of space-time constituted by the periodic repetition of the component”. As can be seen in Fig. 1.1, the milieu gives rise to the refrain, which then makes things in the world. One type of refrain I will develop later in this book is the concept of the neurosignature. Melzack’s abstract neuronal firing pattern that directs nociceptive responses can be thought of as a refrain. It is the basic mechanism through which matters and forms emerge from the repetitive application of force, to establish the pain message in response to nociceptive input. This is the crucial starting point in the extension of Melzack’s metaphor from brain circuitry into an expanded analytical sphere.

1.8 Key Questions This book will examine pain and its relationship to illicit drug use. The focus will extend beyond individual models of pain and utilise Melzack’s neuromatrix model of pain both as a model to understand individual pain, but also as a metaphor to understand how pain is culturally and economically mediated. Specifically the book will examine the follow questions: • How can pain be a common element underpinning illicit drug use? • Why is pain such a valuable commodity? • What is the relationship between pain and new forms of capitalism? Ultimately, by exploring these questions, the book will open up new ways of thinking about pain and why it is so central to illicit drug use.

1.9 Structure of This Book 1. Introduction This chapter introduces the need for a new way to account for the unprecedented demand for pharmaceutical pain relief. The recent epidemic of prescribed oxycodone in the United States, the continuing segmentation of problematic illicit drug use among marginal populations, the extraordinary rise in the consumption of over-thecounter opioids across the globe and the emergence of a legal medicinal cannabis industry has raised a new set of questions about the relationship between pain and drug use. On the one hand, it does seem like people are trying to manage pain. However, it also seems unlikely that there has been a global explosion of pain. There is a need to formulate a new way to understand the relationship between drug use and pain in its many dimensions. Getting the framework right is essential in finding the right set of solutions.

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2. Extending the neuromatrix Early in this chapter I introduce Melzack’s concept of the neuromatrix and then extend it beyond the human brain into a wider metaphor for a cultural neuromatrix. I will extract what I believe are the functional principles underpinning this matrix metaphor (such as organisation, modulation, signature ghosts and interoceptive modelling) and apply these in more abstract terms. The chapter then will progress to the more social and cultural dimensions of the pain neuromatrix. Two articulations of the social dimensions to pain will be described. A key element of the cultural neuromatrix are cultural neurosignatures, the refrains that capture pain and fashion it into specific forms and relationships. In the final section I will introduce the idea that pain is a commodity and underpinning its value as a commodity is its capacity to shapeshift. It is this shapeshifting capacity that reveals the derivative logic to commodity pain. 3. Oxycodone epidemic In this chapter I tell a story about the opioid epidemic in North America. The cultural neuromatrix framework implicates a wider set of actors in the propagation of the epidemic. Rather than just blame bad pharma and its compliant regulators, this chapter offers an alternative explanation for the epidemic. In this chapter it is the shapeshifting quality of pain as a commodity that enables a networked affective economy to thrive. Affective capitalism is at the heart of the oxycodone epidemic in North America. Although oxycodone was the reliever that was consumed, it actually only covaried with pain, the real commodity in this economy. When regulators began to reduce access to oxycodone, the third wave of the epidemic began with a range of other synthetic opiates. Once North America unleashed the pain tiger, it has been hard to put back in the box. Cannabis has been primed as the next substance in line to mitigate the pain epidemic that has swept North America. The problem is that the epidemic has been misdiagnosed. It is affective capitalism that is at the heart of pain. 4. Pain and Cannabis Markets On 14 March 2014 CNBC stock market TV commentator Jim Cramer was crazily excited about a rapid rise in the stock price of GW Pharmaceuticals after positive phase III test results for cannabinoid drug Epidiolex (cannabidiol). He observed that the stock price rise was not due to the potential for its use in child epilepsy (what the phase III trials were for), but due to the potential introduction of GW Pharmaceuticals into the pain relief market as a preplacement for oxycodone. The market response was clear, pain management was a growth industry. In 2015 the global pain management market for pharmaceuticals was estimated at $36.6bn. Growth is noted particularly in the ageing population (cancer pain), increased incidence in obesity (driving musculoskeletal problems) and in changing attitudes to pain management after the oxycodone epidemic. This chapter maps out the rising fortunes of the cannabis pain relief market. Through looking at the rise of cannabis industries and the various ways governments across the globe are trying to extract capital through licensing and taxation, the neuromatrix extends from the individual into a discussion of how the state can extract economic value from pain. Through modulations in the

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perceived value of pain, private companies, governments and financial systems are readying themselves for a new commodification of pain. 5. Over the counter (OTC) pain relief and the self-treatment of pain The use of over-the-counter (OTC) analgesics reflects the degree to which the population is allowed to engage in the self-treatment of pain. Regulation of the advertising practices for OTC analgesics is usually the remit of a government agency tasked to assess the efficacy and safety of medicines, and to respond to complaints about false or misleading advertising. Following the opioid epidemic in the United States, greater attention has been placed on reducing access to OTC opioid analgesics such as codeine. In 2018, the Australian Therapeutic Goods Administration (TGA) “upscheduled” codeine, such that it is now only available by prescription. Reducing access to codeine was argued to be necessary because of the addictive qualities of codeine and the risk it poses for both codeine mortality and the development of demand for stronger opioid analgesics such as oxycodone. This regulatory move was seen as a necessary preventive intervention to avoid a North American-style opioid epidemic in Australia. The pain of the North American opioid epidemic was somehow contagious. In this chapter the consequences of contagious pain are explored in terms of what happens when the self-management of pain is curtailed, for fear that a segment of the population will abuse pain relievers. The impacts are mapped, not in terms of alternative analgesic consumption (both legal or illegal), but in terms of the vulnerability of this segment of pain sufferers to cultural pain neurosignatures created by big pharma through market mechanisms. The chapter will begin with an analysis of the rationale for codeine up-scheduling, and then develop through an analysis of a cultural pain neurosignature—a marketing campaign for paracetamol—and conclude with an explication of the deployment of biopower through leaving this segment of pain sufferers to the mercy of some of the world’s most powerful marketing forces. This chapter illustrates the deeper problems caused by codifying pain in narrow objectivist terms. Regulation of OTC opioid analgesics is not an evidencebased rational process. This chapter reveals how affective contagion produces an evidential ellipsis, leaving the door open for the cannabis markets to emerge as the big winners from pain. 6. Etched in the skin: pain, methamphetamine violence and affect Very powerful in constructing the image of drug user suffering is a genre of websites that “demonstrate” the impact of drug addiction through the physical transformation of drug user faces. Websites such as “faces of meth” and “faces of addiction”, emerging either from police or the drug rehabilitation industry, trace the changes in drug user faces over time, usually showing the pain of extreme degeneration. Whilst there is an obvious critique of these strategies in terms of mobilising fear and the construction of horror, there is a deeper question as to how we read pain in people faces and what sort of pain do we recognise when we see the faces of drug users in these types of images. The technique of reading pain in faces has an ancient history, however 20th century medicine, re-recognised the face of pain through the 1934 work

1.9 Structure of This Book

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of German physician and photographer Hans Killian. The title of his work “Facies Dolorosa” assumed a clinical meaning. In recent times, reading pain from faces has been applied to a wide range of applications. In the case of drug users, reading faces is a primary mechanism to culturally inscribe pain. There are now algorithms for reading facial musculature, to provide an “objective” account of this subjective state. In this chapter I explore the rendering of the pain of drug user faces in “face-ofdrugs” websites and how the reading of pain and violence in drug user faces has material impacts on how we read the faces of methamphetamine users and construct methamphetamine epidemics. I will then explore how this transformation of pain into a corporeal state creates affects. This rendering has significant implications for the cultural pain neuromatrix and how we communicate the pain of drug use. There are material consequences from etching the pain of drugs into faces. 7. Regulating pain In this chapter I discuss pain as a cultural phenomenon. Those in the clinical space may wish to reflect on reversing the logic in this chapter and examining the degree to which the observations from the cultural world can be reversed into the clinical space in a productive and helpful way. The mechanisms through which pain is encountered are fundamentally semiotic. But it is a mixed semiotics that structures our encounters with pain. The significatory encounter with pain is orthodox, knowable and infinitely manageable. Less manageable however is pain encountered through a-signifying processes. This is the pain that is chronic in nature. Pain produced through sensitization. This pain that is produced through automated, less-than-conscious processes, is seemingly independent of the original stimulus that initiated the pain response from the cultural pain neuromatrix. Pain is inherently productive. There is no getting outside of this. It will continue to be at the centre of life as it is at the centre of Being in the world. At the heart of a better regulatory approach to pain are a set of principles derived from the acknowledgement of the cultural basis for pain through the cultural pain neuromatrix: diffuse, autonomous, identifiable through neurosignatures and the recruitment of machines across different milieu. Regulation of pain needs to extend beyond the regulation of pharmaceuticals through therapeutic goods bureaucracies. Implicit in this is a codification of pain that goes beyond linear causal pathways and an acknowledgement of the a-signifying processes that automate cultural responses to pain. The pain of drug epidemics, moral panics and the pain of addiction, are three obvious examples where an a-signifying semiotics has driven the propagation of cultural pain from drugs. 8. Conclusion This book goes beyond “social context” and suggests that pain, one of the most central of human affects and body experiences, is a commodity trafficked across a bio-cultural complex extending beyond the human into the realm of abstract market forces. Pain is a perfect commodity for the affective economy. It is at once organic,

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subjective, neurochemical, abstract and infinitely malleable. The neuromatrix offers a new framework through which to conceptualise and implicate disparate elements of life in the propagation of the demand for pain relief, and to help us understand life in pain.

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Degenhardt, L., Gisev, N., Cama, E., Nielsen, S., Larance, B., & Bruno, R. (2016). The extent and correlates of community-based pharmaceutical opioid utilisation in Australia. Pharmacoepidemiology and Drug Safety, 25, 521–538. Deleuze, G., & Guattari, F. (1987/1980). A thousand plateaus: Capitalism and schizophrenia (B. Massumi, Trans.). Minneapolis: University of Minnesota Press. Denham, B. (2012). High school sports participation and substance use: Differences by sport, race, and gender. Journal of Child & Adolescent Substance Abuse, 23(3), 145–154. Duff, C. (2014). Assemblages of health: Deleuze’s empiricism and the ethology of life. Dordrecht: Springer. Eyler, E. C. (2013). Chronic and acute pain and pain management for patients in methadone maintenance treatment. The American Journal on Addictions, 22(1), 75–83. Farrugia, A. (2014). Assembling the dominant accounts of youth drug use in Australian harm reduction drug education. International Journal of Drug Policy, 25(4), 663–672. Fitzgerald, J. L. (2015). Framing drug use: Bodies, space, economy and crime. Oxford: Palgrave McMillan. Foucault, M. (1977). Power/knowledge: Selected interviews and other writings 1972–1977 (C. Gordon, L. Marshall, J. Mepham, & K. Soper, Trans.). New York: Pantheon Books. Fraser, S., Moore, D., & Keane, H. (2014). Habits: Remaking addiction. London: Palgrave Macmillan. Fraser, S., valentine, k, & Ekendahl, M. (2018). Drugs, brains and other subalterns: Public debate and the new materialist politics of addiction. Body and Society, 24(4), 58–86. Gaskin, D. J., Richard, P. D. (2011). Appendix C: The economic costs of pain in the United States. In: Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Institute of Medicine (IOM) committee on advancing pain research, care, and education. Washington, DC: The National Academies Press. Ghiabi, M. (2018). Maintaining disorder: The micropolitics of drugs policy in Iran. Third World Quaterly, 39(2), 277–297. Gregg, M., & Seigworth, G. J. (Eds.). (2010). The affect theory reader. Durham, NC: Duke University Press. Groenewald, C. B., Law, E. F., Fisher, E., Beals-Erickson, S. E., & Palermo, T. M. (2019). Associations between adolescent chronic pain and prescription opioid misuse in adulthood. The Journal of Pain, 20(1), 28–37. Grossberg, L. (2010). Affect’s future: Rediscovering the virtual in the actual. In M. Gregg & G. J. Seigworth (Eds.), The affect theory reader. Durham, NC: Duke University Press. Hardt, M. (1999). Affective labor. Boundary 2, 26(2), 89–100. Hardt, M. (2011). For love or money. Cultural Anthropology, 26(4), 676–682. Hardt, M., & Negri, A. (2004). Multitude: War and democracy in the age of empire. New York, NY: Penguin Press. Harvey, D. (2005). A brief history of neoliberalism. New York: Oxford University Press. Herschinger, E. (2015). The drug dispositif: Ambivalent materiality and the addiction of the global drug prohibition regime. Security Dialogue, 46(2), 183–201. Horyniak, D., Melo, J. S., Farrell, R. M., Ojeda, V. D., & Strathdee, S. A. (2016). Epidemiology of substance use among forced migrants: A global systematic review. PLoS ONE, 11(7), e0159134. Institute of Medicine (IOM). (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, DC: The National Academies Press. Johannes, C. B., Le, T. K., Zhou, X., Johnston, J. A., & Dworkin, R. H. (2013). The prevalence of chronic pain in United States adults: Results of an Internet-based survey. The Journal of Pain, 11(11), 1230–1239. Karanges, E. A., Blanch, B., Buckley, N. A., & Pearson, S.-A. (2016). Twenty-five years of prescription opioid use in Australia: A whole-of-population analysis using pharmaceutical claims. British Journal of Clinical Pharmacology, 82(1), 255–267. Karppi, T., Kähkönen, L., Mannevuo, M., Pajala, M., & Sihvonen, T. (2016). Affective capitalism: Investments and investigations. Ephemera: Theory and Politics in Organisation, 16(4), 1–13.

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LiPuma, E. (2017). The social life of financial derivatives: Markets, risk and time. Durham: Duke University Press. Lupton, D. (1995). The imperative of health: Public health and the regulated body. London: Sage. Lynch, J., Smith, G. D., Kaplan, G. A., & House, J. S. (2000). Income inequality and mortality: Importance to health of individual income, psychosocial environment, or material conditions. British Medical Journal, 320(7243), 1200–1204. Malins, P. (2004). Machinic assemblages: Deleuze, Guattari and an ethico-aesthetics of drug use. Janus Head, 7(1), 84–104. Massumi, B. (2002). Parables for the virtual: Movement, affect, sensation. Durham: Duke University Press. Massumi, B. (2018). 99 Theses on the revaluation of value. A Postcapitalist Manifesto. Minneapolis: University of Minnesota Press. McDonald, D. C., Carlson, K., & Izrael, D. (2012). Geographic variation in opioid prescribing in the U.S. The Journal of Pain, 13(10), 988–996. McLeod, K. (2017). Wellbeing machine: How health emerges from the assemblages of everyday life. Durham: Carolina Academic Press. Melzack, R. (2005). Evolution of the neuromatrix theory of pain. The Prithvi Raj lecture. Presented at the third World Congress of World Institute of pain, Barcelona 2004. Pain Practice, 5(2), 85–94. National Institute on Drug Abuse (NIDA). (2015). Overdose death rates. Available at: http://www. drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. National Safety Council. (2015). Prescription pain medications: A fatal cure for injured workers. How employers can protect injured workers while decreasing their liability. Washington: National Safety Council. Navarro, V. (2007). Neoliberalism, globalization, and inequalities: Consequences for health and quality of life (1st ed.). Amityville, NY: Baywood Pub. Oksala, J. (2016). Affective labor and feminist politics. Signs: Journal of Women in Culture and Society, 41(2), 281–303. Oksanen, A. (2014). Deleuze and the theory of addiction. Journal of Psychoactive Drugs, 45(1), 57–67. Paulozzi, L. B., Mack, K. A., & Jones, C. M. (2015). Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007–2012. American Journal of Preventive Medicine, 49, 409–413. Peters, M. A. (2018). Affective capitalism, higher education and the constitution of the social body Althusser, Deleuze, and Negri on Spinoza and Marxism. Educational Philosophy and Theory. https://doi.org/10.1080/00131857.2018.1439720. Prins, S. J., Bates, L. M., Keyes, K. M., & Muntaner, C. (2015). Anxious? Depressed? You might be suffering from capitalism: Contradictory class locations and the prevalence of depression and anxiety in the United States. Sociology of Health & Illness, 37(8), 1352–1372. Rakovec-Felser, Z. (2014). Domestic violence and abuse in intimate relationship from public health perspective. Health Psychology Research, 2(3), 62–67. Read, J. (2016). The affective economy: Producing and consuming affects in Deleuze and Guattari. In: C. Meiborg & S. van Tuinen (Eds.), Deleuze and the passions. Chapter 5 (pp. 103–124). Goleta, CA: Punctum Books. Samson, T. D. (2016a). The assemblage brain: Sense making in neuroculture. Minneapolis: University of Minnesota Press. Samson, T. D. (2016b). Various joyful encounters with the dystopias of affective capitalism. Ephemera: Theory and Politics in Organisation, 16(4), 51–74. Singer, M. (2001). Toward a bio-cultural and political economic integration of alcohol, tobacco and drug studies in the coming century. Social Science and Medicine, 53, 199–213. Singer, M. (2004). The social origins and expressions of illness. British Medical Bulletin, 69(1), 9–16. Singer, M. (2008). Drugging the poor: Legal and Illegal drug industries and the structuring of social inequality, prospect heights. IL: Waveland Press.

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Chapter 2

Extending the Neuromatrix

Make me fully understand that the ills of the body are nothing else than the punishment and the encompassing symbol for the ills of the soul… let me feel this pain sharply so that I can make whatever is left of my life a continual penance to wash away the offences I have committed. (Blaise Pascal, c1659, Prayer to ask God for the good use of sickness: cited in Morris 1991: p. 44).

As Pascal has done in his prayer to extend his pain from a bodily sensation into a spiritual remedy, I will be moving pain understood through one register into another. In this chapter I extend a neurological model for pain into the cultural realm.

2.1 Melzack’s Pain Neuromatrix Previously the co-author of the gate-control theory of pain (Melzack and Wall 1965), Ronald Melzack in 1989 advanced the neuromatrix theory in an attempt to explain phantom limb pain (Melzack and Loeser 1978; Melzack 1990, 1999, 2005). The neuromatrix is a neural network that integrates information from a number of systems. Different brain regions contribute different qualities to the pain experience. The emotional aspects of pain associated with the limbic and insular systems (Uddin 2015), the meaning of pain is associated with the prefrontal cortex (Simons et al. 2014), and pain location is associated with the somatosensory cortex (Haggard et al. 2013). Emerging from this matrix of neuronal processing is a sense of pain (Fig. 2.1). In its simplest form Melzack’s “body-self neuromatrix” was an extension of body schema theory (Head and Holmes 1912), whereby an abstract map of the body resided in a distributed form in the brain. It was however also revolutionary as it implicated a wider set of biological participants in the experience of pain, beyond a linear set of connected neurons. According to the neuromatrix theory, pain is a multidimensional experience produced by specific patterns of nerve impulses generated by a widelydistributed neural network. © Springer Nature Singapore Pte Ltd. 2020 J. L. Fitzgerald, Life in Pain, https://doi.org/10.1007/978-981-10-5640-6_2

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Fig. 2.1 Schematic of the body-self neuromatrix (adapted from Melzack 2001). Factors that contribute to the patterns of activity generated by the body-self neuromatrix, which is comprised of sensory, affective, and cognitive neuromodules

Melzack (2005) notes several key attributes of the neuromatrix. The pain neuromatrix can produce the experience of pain without any sensory or nociceptive inputs. Stimuli can trigger the neural processes that produce the experience of pain, but the stimuli themselves do not produce pain. The body-brain neuromatrix also provides a sense of a unified self, which whilst genetically formed, is modified by the environment (Melzack 2005). Pain is not proportional to the extent of tissue damage. Pain levels are affected by the degree of focus on pain (Bantick et al. 2002), prior learning about pain (Weich et al. 2014); the social context in which pain occurs (Montoya et al. 2004) and emotional state (Villemure and Bushnell 2009). There are multiple inputs to the neuromatrix (Melzack 1999): (1) (2) (3) (4) (5)

sensory (cutaneous, visceral and other somatic receptors); visual and other sense information; cognitive and emotional messages (phasic and tonic) from different brain areas; intrinsic neural inhibitory modulation; the activity of the body’s stress-regulation systems (e.g. the endocrine, autonomic, immune and opioid systems).

The output from these inputs are neural patterns (Fig. 2.1). Melzack referred to these patterns as “neurosignatures”, or by others also sometimes called “neurotags” (Butler and Moseley 2003). Melzack suggested that phantom limb pain arises when the deletion of a limb causes an abnormal neurosignature. Acute pain tends to follow the pathways of connected neurons. However, a feature of the neurosignature is the capacity to recruit non-related neural pathways into the pain neurosignature. In the chronic pain condition, (i.e. in the absence of acute pain stimuli), pain is produced by the neuromatrix. In a normal state, the pain signatures respond to the

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variations in stimuli to it from different sources. In chronic pain, neurosignatures are recycled from one event to another, and newly recruited non-related neural pathways can widen the experience of pain.

2.2 Conscious and Less-than-Conscious Neurosignatures An important distinction for Melzack’s diffuse pain neuromatrix is that it is not under direct conscious control. The body-self neuromatrix receives input from cognitive, sensory and emotion-related brain areas (Fig. 2.1). The capacity to cognitively intervene in the neurosignature is limited. Cognitive-behavioural techniques to intervene in chronic pain neurosignatures are not very successful (Eccleston et al. 2009). Moseley (2012) gives the example of the neurosignatures involved in smelling bread. The experience of smelling bread emerges from receptors in the nose sending stimuli to the brain, which activates a neurosignature. The neurosignature combines signal processing between memories, visual representations of bread, sounds, the desire for bread, and future plans for buying bread. When a neurosignature is activated, it produces an output. In this case, it is the experience of smelling bread. In the circumstance of nociceptive receptors being stimulated in someone with a chronic neck injury, the neurosignature that is activated produces the experience of neck pain. The criteria for neurosignature activation are specificity, (i.e. there are specific neural paths that are activated), and that there is a dynamic activation threshold. Not all stimuli can activate a neurosignature. The dynamic activation threshold is important, as it creates a point at which neurons are recruited into the neurosignature. Non-neurosignature-member brain cells provide an inhibitory or dampening influence on the neurosignature (Moseley 2012: p. 25). The discussion of conscious and less than conscious force is crucial to the kinds of interventions that are likely to be successful using the neuromatrix framework. If people have conscious control of pain, then they should be able to talk themselves out of pain. This however is rarely the case, and the neuromatrix model does not suggest that normal cognitive behavioural strategies will work in reducing pain. Interestingly, Moseley (2012) approaches the issue of conscious and less-thanconscious force through a discussion of the processes underpinning the sensitization and the disinhibition of neurosignatures that occurs in chronic pain. Barker extends the Moseley position well to incorporate a sense of Being-in-the-world, with preconscious action: Prior to the immanent experience of pain, we make an appraisal of danger, and of the possibilities understood as available for negotiating that danger. This intertwined appraisal is grounded, at least partially, in vastly complex conceptual categories that necessarily emerge through language. This appraisal relates body to lifeworld in a way that is richly holistic and future-orientated, even as it occurs instantaneously, without volition, and outside of

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2 Extending the Neuromatrix conscious experience and its words. But, this implicit, preconscious interpretation of beingin-danger is not pain. Pain is the translation of this understanding of being-in-danger. It is in this way that pain, as I suggested at the outset, is always already a translation. (Barker 2015: p. 10)

2.3 Central Sensitization When pain persists, the pain neurosignature becomes “sensitised and disinhibited” (Moseley 2012). Neurosignature member brain cells are more easily activated and there is a decrease in the disinhibition by non-participant brain cells. Neurosignatures lose specificity and their activation threshold is reduced. Specific areas of the cortex that once reflected the sensory processing of discrete body segments, now become reorganised, or “smudged”, and a wider set of body areas are included in the pain neurosignature. The neurosignature and the pain, become less specific. The lack of precision in a chronic pain situation, can be explored by examining the degree to which a body part is overtly recognised. Chronic pain sufferers often lack sensory discriminability in the area, the region or in the side of the body of the original injury. For example, people with arthritis, chronic lower back pain, and complex regional pain syndrome perform poorly on two-point discrimination threshold tests (Catley et al. 2014). Being able to discriminate whether the skin is being touched at one or two points simultaneously is not an error in skin sensitivity but in brain processing. This deficit in tactile acuity is not under conscious control in the sense that a person can use a cognitive therapy to improve their acuity. Rather tactile acuity training can be used to improve brain processing of sensory information and to reduce the “smudging” that occurs in neurosignatures (Catley et al. 2014). The neuromatrix incorporates interoceptive (or interiorised) images of the status of the body from different parts of the brain. Interoception is the sense of the physiological condition of the entire body (Craig 2002). Some of these interoceptive inputs are from receptors reporting on muscle movements which enable the brain to determine localised sensations. Some inputs convey information about temperature, pain, cardiorespiratory function, hunger and thirst (DiLernia 2016a). Some inputs are from nociceptors that report on pain sensations external to the brain. These inputs come together in the anterior cingulate cortex to form a meta-representation of the interoceptive activity in the body which leads directly to a sense of self-awareness (DiLernia et al. 2016a). Neurosignatures of the body are disrupted in chronic pain (Moseley 2012). According to neuroanatomical studies, the anterior insula cortex represents the interoceptive system, whereas the anterior cingulate cortex represents the integration of “motivational” input. Together they generate an emergent “emotional feature” made up of both sensation and motivation (DiLernia et al. 2016a). This is the key component of the neurosignature. Chronic pain causes deficits in interoceptive awareness, through alterations in the representation of the body at this level. Parts of the body are misrecognised through a lack of specificity in the location of sensory information

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and changes to the recognition of different parts of the body. The brain’s maps of space are disrupted. Deficits in interoceptive awareness are common among those with chronic pain. These deficits can be expressed in poor acuity in visual left/right discrimination and in tactile tests. When visual left/right discrimination training is successful, those who improve their left/right discrimination also report a reduction in pain (Moseley 2012: p. 36). Moseley (2012) explains how the neurology of the brain offers an opportunity for intervention. When we think about moving a part of the body, implicit motor activity results in activation of neurons in the premotor cortex (DiLernia et al. 2016a). Neurons in the premotor cortex can cause changes in the motor cortex without activating them. Thus interventions that focus on left/right discriminability primarily do not focus on pain, they are focussed on decluttering the less-than-conscious disruptions to interoceptive awareness. Much of the “training” in intervention studies is focussed on enhancing interoceptive awareness activity. However, there are a number of complications with this approach. Depression, eating disorders and somatoform disorders are all conditions that can co-exist with chronic pain and which themselves can alter interoceptive awareness (DiLernia et al. 2016a).

2.4 Paradigmatic Change and Keeping it Simple Using cinematic metaphors, DiLernia et al. (2016b) suggest that snapshots of painful neurosignatures reside in the neuromatrix. The interoceptive matrix (inside the neuromatrix) situates an image of body, in the past, present and future. Painful “ghost” signatures can be modified through “external symbolic interoceptive information to compensate the interoceptive dysfunctional patterns”. For Dilernia et al. (2016a) a wide array of pain treatment options emerge from this model of chronic pain, structured around the metaphor of wave-like nerurosignatures. According to Dilernia et al. (2016b), the representation of waveform neurosignatures in pain-free individuals constantly changes. For individuals with chronic pain the pain neurosignature dominates, blocking access to other neurosignatures. Interoceptive modelling/training introduces interoceptive inputs, resulting in amended pain neurosignatures. DiLernia et al. (2016b) compare this intervention to the modulation of sound waves, where two waves cancel each other out (DiLernia et al. 2016b). Whilst waveform representation of neurosignatures is appealing, it is perhaps a little too simplistic. However, making this pain paradigm understandable is a challenge (Butler and Moseley 2003). By its implicit challenge to linear causal models of pain this paradigm of pain management is hard for the layperson to understand. For those operating in the older model of pain, the temptation is to say that when pain is all in the head, it is imagined and therefore not real. A second complication arising from the paradigmatic change in the model of pain, is how distal interventions can be to the site of pain. Interventions that work to enhance the discriminability of interoceptive cues are physically and logically some

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distance away from where it hurts. Similarly, the “training” can logically appear to be a quite disconnected from the experience of pain. Training in left-right visual discrimination tasks seem a long way from solving the neck pain arising from arthritic changes in C3–C4 neck joints.

2.5 Organising Principles of the Neuromatrix Melzack asserted that there were four functional components to the nervous system in his framework: (1) the body-self neuromatrix; (2) cyclical processing and synthesis; (3) conversion of the flow of neurosignatures into the flow of awareness; and (4) activation of neurosignatures into a pattern of movements (Melzack 2005). In 2005 Melzack and his followers have asserted a set of functional principles for the organisation of the neuromatrix. Organised and distributed Although the neuromatrix is adaptive, dynamic and distributed, it is organised. It has sensory, affective, and cognitive neuromodules. As the neuromatrix produces a neurosiognature, a neural hub needs to convert that into a stream of awareness. Ghosts in the machine Resilient pain signatures are like ghosts in the machine (DiLernia 2016b). These ghosts enable the painful signature to dominate a vision of the present and future self and cause the signatures of the past healthy self to fade. Modulation of the interoceptive landscape In people with chronic pain, the usual wave-like neurosignatures are dominated by a resilient pain signature. This disruption blocks access to other interoceptive inputs. All this is happening subconsciously. Whilst there is evidence of exteroceptive modulation of some interoceptive processing (Marshall et al. 2017) this is occurring subconsciously. Immersive virtual reality experiences have been reported to treat chronic pain (Harvie et al. 2017). Kinematic training of pain-free range of motion performed in a virtual setting has been shown to change the real-world range of motion in patients with chronic neck pain (Sarig Bahat et al. 2015, 2018; Harvie et al. 2015, 2016, 2017). Here modulation of the neck pain neurosignature is achieved through modulation of the visual register of interoceptive cues. Interoceptive modelling Resilient pain signatures influence interoceptive predictions, i.e. what the body will be like. By introducing external symbolic stimuli to the neuromatrix it is possible to nullify the painful signature and alter the prediction of pain of future movements. There are tensions and definitional issues in this arena. Interoceptive sensitivity and accuracy in relation to pain are complex. Some research suggests that heightened

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interoceptive sensitivity may predict higher pain sensitivity. Other research suggests that greater sensitivity to interoceptive cues may provide opportunities for greater control. When Harvie et al. (2015) recalibrated the visual field using VR goggles, the anticipated range of motion produced by bogus visual clues predicted changes in the actual range of motion: When vision overstated the amount of rotation, pain occurred at 7% less rotation than under conditions of accurate visual feedback, and when vision understated rotation, pain occurred at 6% greater rotation than under conditions of accurate visual feedback. (Harvie et al. 2015)

Stimuli that become connected with pain can themselves trigger pain. Altering the modelling of pain in the neurosignature offers opportunities to alter the processing of less-than-conscious interoceptive messaging. These principles will be used to extend the body-self-neuromatrix to a culturalneuromatrix. Importantly, the real challenge posed by this framework, when extended into the cultural arena, is the distinction (and grey area) between interventions that are meant to operate at a less-than-conscious level. In the cultural arena, this poses significant challenges and opportunities when trying to understand how pain is produced, communicated and enabled through culture, politics and capital in both conscious and less-than-conscious ways.

2.6 Pain as Social and Cultural: A Cultural Phenomenology of Pain In an analysis of the rise of pain clinics in the United States, Morris (1991) asserted that pain was a social experience, not reducible to nervous system processes. Rather than just a modulator of the pain experience, pain is intersubjective. Indeed Morris asserts that pain emerges only at the intersection of bodies, minds and cultures (Morris 1991: p. 3). Pain has historical specificity and cultural meanings: “when we fall into pain we fall into a net of already constructed meanings” (Morris 1991: p. 18). Pain is deeply social, “the pain we feel has in large part been constructed or shaped by the culture from which we now feel excluded” (Morris 1991: p. 37). The body as something inherently social has been explored by social theorists and philosophers for some time. Merleau-Ponty (2012/1962), Satre (1965), Foucault (1973), Bourdieu (1977, 1984) and Deleuze and Guattari (1987) to name a few, have all engaged with the body on different terms from traditional medical science. A reconciliation between individualist accounts of the body and the body as ontologically social, was found in studies of embodiment, where the social is embodied. It is only because I have a “body-for-others”, where the body becomes a social object, that enables some knowledge about my body to become available to me. It is only because my body can be measured, read and compared to other bodies that my body can be confirmed as classified with a disease or not: “[Disease] on principle

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escapes me” (Sartre 1956: p. 467). This intertwining of body and world is most readily captured in the term “embodiment”. The pain embodiment literature is vast. At its heart is the premise that world and body are not separate, but that the world is in the body. Thus, pain is not just a sensation but a change or rupture to the self’s connection with the world, through the body. Bullington (2009) notes that a painful body experiences a loss of identity through a retreat from the world, through the incapacity of the body. An extension of this embodiment literature has been the understanding of pain through the lens of a cultural phenomenology, as touted by Csordas (1997, 2002). Although it emerges from medical anthropology, it is a broad suite of sensitivities rather than a strict analytic method. The emphasis is on how world and body intertwine. In this research, which peaked in the 1990s, often language, sign systems or narrative provide the media through which the forces of the world and the experience of body are connected (Kleinman 1988a, b; Delvecchio-Good et al. 1994; Frank 1995; Das 1997). In his study of charismatic Christian healers, Csordas (1997) located pain in signs and symbols that were felt in the body. He used a semiotic framework for connecting signs to the forces that cause spiritual and ultimately, embodied pain (Csordas 1997). In one example, a woman undergoing marital difficulties relates her family troubles back to a difficult relationship with her own mother. The spiritual healer focusses on releasing the burden of guilt that she had been carrying. On releasing the burden the patient felt physical pain in her heart and a tingling. As Csordas explains: This can be understood as a kind of synesthetic metaphor based on the conventional metaphor of the heart as seat of the emotions. As physical and emotional pain are merged in the bodily synthesis, the image is presented simultaneously in the proprioceptive and affective modalities. Finally, the image is further enriched by tingling, which, as we know, is for Charismatic typically an indexical sign of divine power. Csordas (1997: p. 117)

Csordas demonstrates how, through narrative and indexical signs, the world and body can intertwine through pain. The pain in the patient’s heart was real. The tingling was an identifiable sensation, yet they came from spiritual forces external to the woman. The sense made of the external spiritual force, organised through structured disciplinary knowledge about how pain should be recognised and interpreted, is provided by the patient’s Charismatic doctrine. The principle here is important, rather than the focus on charismatic Christianity. Religion is only one of the many institutions that organises and structures the intelligibility of pain. Religion, the State, corporate branding, education, class habitus, gender, language and even specific cultural logics (e.g. sporting codes, ethnic codes) are all institutions that can organise a pain neurosignature at a cultural level. This is the primary mechanism for how we can extend the neuromatrix metaphor from the individual to the cultural. This is where the value of extending the metaphor gets played out. The embodiment of strong disciplinary worlds can shape the experience of pain in different directions. For example, in research on young dancers, their experience

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of pain is highly embedded in their elite dance training (McKewan and Young 2011; Singh 2011). The focus is on “brain-body-world entanglements” (Blackman 2012), where bodies are in processes of continual change and “becoming-other” (Dragojlovic and Broom 2018). In their study of care and healing in aged care settings, Dragojlovic and Broom (2018: p. 197) noted that suffering works across individuals. In their analysis of group work therapy, they noted: Negative feelings can be approached intracorporeally; as processes that have the ability to lead towards desired self-transformation. Thus, the affective atmosphere of suffering, the intensity of the intersubjective exchanges and the sense of mutual healing were understood to have a reintegrating, focalising capacity and a sense of bringing the fragmented self into a “state of wholeness”. Dragojlovic and Broom (2018: p. 199)

They also noted that when suffering is individualised, affective suffering can become a form a suffering in and of itself. Suffering, especially affective suffering, when approached as a collective and social phenomenon can transform the pain of individuals (Kleinman and Kleinman 1997: p. 3). More recently, pain as an intrinsically social phenomenon has been deeply explored (Karos 2018). Pain and social stress share overlapping neural pathways (Eisenberger 2012). Pain tolerance is also positively related to social network size (Johnson and Dunbar 2016). There are now examples of studies that find evidence of how the social world becomes represented in the brain through fMRI imagery of neural signatures of social nonconformity and conformity (Wu et al. 2016). No longer can it be said that the self is separate from the world. The world is present in the self through neurosignatures, and these are measurable. One of the most comprehensive examinations of the intersections between the social world, institutions of care, and the bodily experience of chronic pain is the recent qualitative meta-review by Toye et al. (2013) of patient pain narratives. In this extensive report for the UK National Health Service (2013), Toyes et al. reviewed a wide range of qualitative studies of patient pain narratives. An adaptation of the metareview results is visually portrayed in Fig. 2.2 Patient experiences of the health care system, family, work, conceptions of the old self and the new self; sense of legitimation and ultimately the altered construction of time itself, are all at stake when the present and future become unpredictable because of pain. At an individual level, we could break this figure down into a series of pain neurosignatures. At a cultural level we can also develop up a taxonomy of cultural neurosignatures beyond the individual. The health care system has a pain neurosignature for chronic pain sufferers. The workplace has a cultural neurosignature for managing people with fibromyalgia. Sporting codes have a neurosignature for managing ex-NFL footballers with acquired brain disease from a career of head clashes. The logic of cultural pain neurosignatures follows the logic of the elements of the principles of the narrative pain neurosignature that Toye et al. (2013) articulate in their metareview. Although Toye et al. (2013) use this figure to summarise the narrative that patients with chronic pain use to “move forward with pain”, these

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Fig. 2.2 The web of relations that contribute to narratives of the chronic pain experience. Adapted from Toye et al. (2013)

elements actually reveal the narrative principles underpinning a refrain that organises all the modular neurosignatures comprising their pain narrative environment. Their narratives summarise how the embodiment of pain is achieved in relation to the world of the patient. This is not theoretical, it is an empirical finding from a qualitative synthesis of patient narratives. It tells a story of how a chronic pain patient comes to “be-in-the-world” with pain. It reveals a narrative strategy, but it also reveals something about the “worlding” of pain in narrative (Stewart 2010; Bourke 2014). It tells us something about the world of the chronic pain sufferer. I am using this metanarrative as an analytic template for mapping out the elements of cultural neurosignatures. As the refrain indicates, a cultural pain neurosignature will in some way have some or all of the following principles. A cultural neurosignature will show: • • • • • •

How normal is re/defined How the various parts of a painful body are integrated How pain is communicated socially Positioning pain beyond time—pain is ongoing How the owner of the neurosignature is an expert about this particular pain How the pain sufferer becomes part of the community.

Just as individual neurosignatures produce pain, cultural neurosignatures produce pain. Just as individual neurosignatures are diffuse, so too cultural neurosignatures are diffuse. Just as individual neurosignatures can exist as “Ghosts in the machine”, old resilient cultural neurosignatures cause painful signatures to dominate the understanding of pain in culture. Subsequent chapters will examine how cultural neurosignatures about various drugs, construct and produce the pain of these substances. Cultural neurosignatures

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implicate everyone. In the same way that a neurosignature under chronic pain conditions becomes less specific (it smudges across neural pathways) and disinhibits other elements of the brain (and thus recruits other elements into the neurosignature), cultural neurosignatures can grow and spread beyond their original cultural site, akin to moral panics and drug scares. Cultural neurosignatures like brain neurosignatures are organised functionally. That is, one neurone can be involved in the neurosignature of elbow flexion and wrist deviation because it is in the neurosignature of drinking a beer (Moseley 2012: p. 45). Similarly, the local pharmacist can be involved in the cultural neuromatrix of addiction and pharmacotherapy, because the pharmacist is also involved in the cultural neuromatrix of medicalisation of drug users as they shame and marginalise pharmacotherapy patients when they collect methadone each day in the community pharmacy (Patil et al. 2018). Bourgois (2000), Gomart (2004), Fraser (2006) and Fraser et al. (2009, 2014) have provided extensive analysis of medicalisation and the medical control of drug users through pharmacotherapy. Medicalisation is a cultural pain neurosignature that produces pain. Cultural pain neurosignatures do not mediate or communicate, they cause pain. Here is another way of analysing the practice of community dispensed pharmacotherapy using the neuromatrix framework.

2.7 Medicalisation Pain Neuromatrix There are numerous participants recruited into the cultural pain neuromatrix. The cultural pain neuromatrix normalises and redefines that having people on a daily dose of methadone is a normal practice. Policy and dispensing practices organise the various bodies that participate in the neuromatrix. Pharmacists allocate a space in the pharmacy (usually to the side of the dispensary). Recipients are often asked to wait until other customers have been seen. Methadone recipients are closely monitored when they receive their daily dose of methadone syrup. Because very few methadone clients are allowed “take away” methadone for self-administration, this effectively binds the patient to a daily routine with their methadone provider, thus physically controlling the daily movements of the body of the drug user (Patil et al. 2018). Because methadone clients are not defined as “in pain” (even though methadone is actually an analgesic), pain is rarely part of the social definition of these patients. Although pain is known to be a central part of the life of many drug users, the conventional wisdom is that methadone patients are not in physical pain because they are on methadone. The pain however that the cultural neurosignature inscribes and communicates socially is the pain of medicalisation and addiction. People on methadone are “addicts”, and they suffer because of their addiction. This is a different kind of pain, one that is on-going, lifelong and untreatable, except through maintaining the drug addict on a pharmacotherapy. In fact, the ongoing nature of this pain is profound (Bourgois 2000). In broader terms, the success on the methadone program is not defined through getting people off methadone, it is defined primarily by how well it keeps drug addicts on the program, rather than buying heroin illegally

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on the streets. Thus, the interminability of the pain of addiction is transcendent and deeply inscribed. The medicalisation cultural neurosignature also proscribes that the methadone provider and dispensers are experts in this neurosignature. So much so that the client has no say in the management of dose levels. The addict, by virtue of their addictive pain can never be expert in medicalisation, because it, by definition requires the patient to be controlled by a medical authority. Finally, the neurosignature defines how the pain sufferer (the drug addict) can become part of the community. Only through being compliant to medical control can the drug user be a part of the community. This neurosignature ensures the medical control over drug users. It guarantees the pain is produced through repetition of the addiction neurosignature, and ensures the drug user continues to be subject to the will of the state through the deployment of state power (Bourgois 2000) and disciplinary power (Fraser et al. 2014). The process of cultural pain neurosignature production is a deployment of what Massumi (2015) calls “ontopower”. All these elements could also have the quality of indexical makers of cultural virtue (Throop 2010: p. 237). The utterances, signs and narrative techniques of the actors in the practice of a pharmacotherapy program point to broader systems of value (Summerson-Carr 2010). Markers connect seemingly disparate events, intentions and objects into a narrative with a temporal frame that make pain and emotional suffering meaningful and intelligible. They link past events and future outcomes, such that acute moments of pain are experienced through a proto narrative that makes cultural sense. Often it is the repetition of these indexical markers that reinforces the temporal framing. Pain, experienced in the moment can be connected to cultural values and inscribed, redirected, ignored, resisted or amplified, via indexical markers. Indexical markers provide a cultural scaffold for pain (Throop 2010: p. 255). A chronic pain cultural neurosignature will emphasise the continuity of pain across time and the inevitability of its presence. In the case of the medicalisation of drug addicts, the addiction narrative is one such “refrain” or neurosignature. As much as it is an individual narrative (Summerson-Carr 2010), it is also a cultural narrative where the disease of addiction is codified through the 12-step “speech genre” (O’Brien 1998; Morris 1997) and embodied through the physical practices of the narcotics anonymous social field (O’Brien 1998). This brings us back to the diagram of this extended theory of the neuromatrix (Fig. 2.3). From each milieu emerges a range of neurosignatures, from the body, culture or the politico-economic arena. Whilst the neurosignatures emerge from a specific set of relations, their extent is not delimited to each milieu. A neurosignature can extend beyond the milieu from which it emerged and “smudge” the edges of the milieu as it grows and recruits other elements into its neuromatrix. For the body pain neuromatrix, a refrain will primarily organise subjectivities, bodies and sensitisations. For the cultural pain neuromatrix, refrains organise relations between institutions, machines and materials. For the politico-economic neuromatrix, refrains organise flows of capital, machines and materials. Passing through all the milieux is pain, but it is not delimited to one form. Pain is a shapeshifting commodity that takes

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Fig. 2.3 The cultural pain neuromatrix framework

on different forms in different milieu. Working through all milieu also is affective capitalism. As described in Chap. 1, the neurosignatures/refrains organise and connect up these different elements. In the next section I will briefly illustrate the cultural pain neuromatrix in terms of how we understand methamphetamine use.

2.8 Faces of Methamphetamine Use and the Cultural Pain Neuromatrix There is strong evidence that visualising pain at the level of the individual can create pain for that individual. Phantom limb experiments demonstrate the primacy of visual recognition in the generation of pain. Visual perception of the external world alters our internal systems. That presentation of pain, need not just be limited to the recognition of painful body parts. The visual presentation of angry faces, alters an individual body’s capacity to know its own interoceptive signals (Marshall et al. 2017). It is unclear however the extent to which, as a culture, we become aware of pain when indexical makers of pain trigger pain at a cultural level. Although at an individual level we can test the degree to which exposure to an image of pain can promote an experience of pain, it is not so easy at a cultural level. One example can be found in the “condensation” images used in public antidrug campaigns, in the responses to methamphetamine use in the United States. The Meth Project (http://foundation.methproject.org/about/), the Montana meth project (https://www.montanameth.org/) and the online “faces of meth” program (http:// www.mcso.us/facesofmeth/index.htm) are prime examples of how images of drug pain are used to affect cultural change.

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Faces of drug pain (in this case purportedly of meth pain) evoke a cultural neurosignature. Each time we see a “meth face”, it does something. Does it evoke an image of pain, suffering or threat of the “pain of drugs”? It is unclear what impact the meth face has at the level of an individual body, but also at a cultural level, to provide a cultural neurosignature, a cultural mechanism for producing pain, in the absence of a painful stimulus itself. Some prevention specialists would perhaps respond by saying that using images of pain to warn against dangerous drug use is an established and successful method. In fact, the Meth Project has won 50 awards, including 11 Gold ADDY Awards, 19 Silver ADDY Awards, 2 Gold Effie Awards, and the Cannes Lions Award at the Cannes International Advertising Festival (https://www.montanameth.org/about-us/ #mission). Advocates claim that the preventive message of popularising images of pain is central to successful public campaigns to reduce drug use. Certainly, the advocates for the 2005 Meth Project, attest to the success of this method (https:// www.montanameth.org/). Detailed evaluations of the Meth Project however say that the “success” of the campaign was very limited (Anderson and Elsea 2015). This lack of a generalisable effect is subject to a more detailed analysis in Chap. 6. In Chap. 6 the “ghost” cultural neurosignature of the Montana Meth Project will be examined to see how these images from 2005 were reproduced as documentary evidence of the harm of methamphetamine in an Australian TV News item. Fictive images from Montana in 2005 were inserted into a visual TV news package to mobilise affect in Australia during a purported “methamphetamine epidemic” in 2016. Importantly, extending the neuromatrix to a cultural arena does more than just acknowledge the cultural context for pain. There are numerous frameworks that account for cultural and social context by visually presenting them as context for individual pain (Karos 2018). The extension of the neuromatrix into a cultural neuromatrix does something more. In this metaphorical extension, the claim is that cultural pain neurosignatures produce pain. The attributes of the body-mind neuromatrix, are applied to the cultural neuromatrix. The system is diffuse, yet organised, it is modulated by forces both internal and external to culture, there are images that model pain internal to the culture and some of these images persist over time as “ghosts” in the machine. The faces of meth cultural pain neurosignature will be analysed in terms of the elements of pain narratives. As is most clear, the faces-of-meth cultural pain neurosignature evokes a feeling, it evokes affect. Cultural pain neurosignatures connect the individual experience of pain to affect and the affective economy. Importantly, this is not just for the pain sufferer, but also for those witnessing pain. Empathy for pain involves the affective but not sensory components of pain (Singer et al. 2004). A final part of the analysis in Chap. 6 will focus on how these indexical marks in the faces-of-meth cultural pain neurosignature mobilise affect in the affective economy. They create pain which in turn mobilises affect and which then, in turn, mobilises capital.

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The sponsor list of the Meth project reveals a direct connection between the meth project, Nexafed® (a tamperproof pseudoephedrine tablet) and the affective economy. A scientific publication by Acura Pharmaceuticals (Brzeczko et al. 2013), the Texas drug company that produces pseudoephedrine, suggests that a tamperproof reformulation of pseudoephedrine manufactured by Acura Pharmaceuticals can reduce misuse of pseudoephedrine, a methamphetamine precursor used in clandestine laboratories. No doubt the sponsorship of the Meth Project by Acura was meant to facilitate the perception of Nexafed® (and Acura) as a solution to the problem of illicit methamphetamine manufacture. Sponsorship is a hedge strategy to protect the financial standing of Acura. Here the affective economy meets the financial economy directly. Unfortunately, the evaluations of the tamper-resistant formulations showed that reformulation is no solution to the illicit economy. Only slight modifications to the “one-pot” clandestine methamphetamine cook method were needed to replicate extraction yields of non-tamper proof formulations (Presley et al. 2018). Nevertheless, the links between economy, affect and pain connect the cultural neurosignature to pain. Karos (2018) was more explicit in linking the cultural environment with the pain experience through the need to belong, the need for autonomy and the need for justice. These elements of the pain experience locate pain in the social and cultural arena, beyond the direct medical model of pain. What perhaps is less obvious is how pain may persist through different cultural neurosignatures as an economic object. In an introduction, and in turn, a perversion of some economic theory, I will extend the neuromatrix metaphor even further into a discussion of now the cultural neurosignatures rely on pain being a shapeshifting commodity within the context of affective capitalism.

2.9 Pain as a Shapeshifting Commodity Scholarship on the affective economy is extensive (Gregg and Seigworth 2010; Peters 2018) and focuses on how affect and emotion as sources of labour power are drivers of modern flows of capital. Neo-marxian commentators have also revised work on immaterial labour and how this relates to the affective economy (Lazzarato 1997). Immaterial labour produces two dimensions to a commodity, the “informational content” of the commodity and the “cultural content” of the commodity. The cultural content of the commodity involves those activities that define cultural and artistic standards, fashions, tastes, consumer norms and public opinion. The affective economy traffics in pain as a commodity. Immaterial labour in the cultural and politico-economic milieux enables the sloughing of value from commodity exchange. Cultural neurosignatures direct the flows of immaterial labour in the affective economy. Pain as a commodity is both vastly different from other commodities and common to all commodities. The commonality between pain and other commodities in this regime is that the pain-commodity is not defined by its use value, but by its “surplus value of flow”. The difference between commodity-pain and other

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commodities is that value is extracted from the processes of capturing the potential for germinal life. It is here in this text that some readers will find this a departure point from the usual lexicon of social science and medical scientific reading. This section provides a very specific and contemporary link between affects, emotions, pain and capital, and has its origins in the theoretical humanities, philosophy and cultural studies. In order to make the connections between what is felt and what is exchanged, I will make recourse to a paradigm of thought that revises how we think about the relations between the world, the body and capital. As noted in Chap. 1, wellbeing and pain arise not just individually though being-inthe-world, but collectively from the assemblages of bodies, individuals, institutions and machines that bind us in the world (McLeod 2017). This extends beyond both phenomenological accounts of pain and social constructivist accounts of pain. In this account pain is not just social, it has its origins in the matter/energy of the world. This account puts us into the zone of post-humanist scholarship (Braidotti 2008). Pain is the ultimate shapeshifter. On the one hand, some scholars believe pain to be ineffable, where pain “may seem to have…no reality because it has not yet manifested itself on the visible surface of the earth” (Scarry 1985). On the other hand, pain can be felt, it is organic and material. It can be measured, albeit with some debate about the stability of the measures. Pain is felt, it is subjective. For pain scientists such as Lorimer Moseley, pain neurosignatures are neural patterns that have neurochemical properties. From the traditional scientific point of view, pain is composed of electrochemical movements. For pain clinicians, using the Chronic Pain Grade there are four grades of pain. For health economists, the taxonomy is based on temporality, it can be acute or chronic (Access Economics 2007). In tort law, pain is codified in the visual evidence of morphological change (MRIs and X-rays) and in the doctrines of excess pain, reasonable pain, and chronic pain as a psychiatric illness (Pustilnik 2015). Pain assumes many shapes. It may be a discursive effect or it may be because of the unstable ontological quality of pain. I believe both are true. Rather than leave pain as ineffable, (Scarry 1985) or as performative act (Bourke 2014: p. 6), I have decided to produce an account of its ontological properties based on a philosophical model of the body with its origins in Bergson, Spinoza, Neitzsche, Deleuze, Ansell-Pearson and Massumi. There is a reason that pain is ineffable if we look for it in the “visible surface of the earth”. In the post-humanist paradigm, the focus is on potentials in fields of relations. Bodies-in-the-world emerge from these fields of relations. All objects in the world emerge from an “infra-corporeal level”. A field of potential from which forms of life emerge. Pain is one such object. This tradition also accounts for how objects enter into systems of capital. In fact according to Massumi (2017: p. 58) the field of relations from which life is extracted overlaps entirely with the capitalist field—they have a mutual belonging. According to Massumi this has consequences for how we consider the category of pain: … it is necessary to call radically into question the “hedonic” categories of pleasure and pain, in favor of notions of intensity of activation and the fullness of that activation with potentials. (Massumi 2017: p. 58)

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Drawing on Massumi (2017), pain is an object that is named and enacted, and thus formed from an energetic debt at an “infra-corporeal level”. This infra-corporeal level is immanent to existence, it is “the well-spring from which streams of life emerge” (Massumi 2017: p. 12). Pain is an energetic debt caused by the movement of force through an affective field of intermodulation. Pain is what is named. It is the object, a perceptible sign of what is stirring in the relational field. Pain is an indexical marker, it points to movement. Pain is a product of ontopower (Massumi 2015). Capital, through biotechnology creates the conditions for life and pain to emerge from this field of potential. Capital produces the conditions through which pain, as an object, emerges into life. The body with chronic pain is a “capital life form” produced by ontopower. Pain etched into the assemblage of bits and pieces that constitute a body, is a commodity. As the assemblages change so too does the shape of commodity-pain. For neuroscientists neuropathic pain is different from phantom limb pain. For social scientists, existential pain is different from physical pain. Cancer-pain is treated as different to non-cancer pain. Pain is a shapeshifter, primarily because the varied conditions of its emergence define its quality.

2.10 Discussion I started the chapter with an extended quote from Pascal, on the transformation of pain from a physical register into a spiritual register. This transformation could be read as an individual accomplishment. This could be a simple matter of changing the meaning of pain. In this formulation pain is an object upon which meaning is inscribed. Pain is a positivist object, it exists, it can be measured, but we can change its meaning. This is all very conscious. The neuromatrix model of pain devised by Melzack however develops an architecture of pain that relies on non-conscious messaging. The interoceptive signals that form the core of the patterns of messages that communicate pain in the body, are however not subject to subjective control. There is a degree of conscious engagement with the conditions under which we experience pain and the context and meaning of pain, however pain is for the most part occurring at a less than conscious level. Pain is also collective. It is not just an individual activity. It is contagious, it can be shared and it has a social life (Morris 1991; Bourke 2014). Pain is a shapeshifter. There are numerous taxonomies for pain. The ubiquity and transferability of pain may be because we have not assembled a sensible account of pain. Or, as has been discussed in this chapter, we have not been abstract enough in exploring its ontology. Rather than treating pain as ineffable, pain can have more germinal origins. The ambivalence and shapeshifting quality is better understood, when pain is configured as emerging from the matter/energy of the world. This also enables the connection of pain to a literature about affective capitalism. Extending the neuromatrix brings us into a deeper understanding of Fig. 2.3. Dominant pain neurosignatures experienced in the mind-body-neuromatrix are connected

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to the cultural milieu by the affective economy. Affect connects up the force of pain in one milieu and repackages it as a commodity into different forms through cultural pain neurosignatures. Different institutional machines then combine into new assemblages to produce new affects at the level of the population. Then, affective capitalism again transforms pain into more commodities, indexed to the exchange value of the previous commodity-forms, rather than to any intrinsic use value. This is how pain then gets transformed into a politico-economic milieu. Here again new machines, apparatuses of capture and institutions then slough off a surplus value of flow from pain. In fact, according to Massumi the objective is to slough off surplus value of life, in the same way that derivatives slough off value in the financial economy. Foregrounded in these first two chapters, this sets the stage now for a series of case studies that explicate life in pain. The case studies will provide the specific transformations that show the material consequences of the affective economy and the place of drugs in the demand for pain relief.

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Chapter 3

The North American Opioid Epidemic

In this chapter I tell a story about the opioid epidemic in North America. The cultural neuromatrix framework implicates a wider set of actors in the propagation of the epidemic. Rather than just blame bad pharma and its compliant regulators, this chapter offers an alternative explanation for the epidemic. In this chapter it is the shapeshifting quality of pain as a commodity that enables a networked affective economy to thrive. Affective capitalism is at the heart of the oxycodone epidemic in North America. Although oxycodone was the reliever that was consumed, it actually only covaried with pain, the real commodity in this economy. When regulators began to reduce access to oxycodone, the third wave of the epidemic began with a range of other synthetic opiates. Once North America unleashed the pain tiger, it has been hard to put back in the box. Cannabis has been primed as the next substance in line to mitigate the pain epidemic that has swept North America. The problem is that the epidemic has been misdiagnosed. It is affective capitalism that is at the heart of pain.

I started seeing the first signs of new attitudes toward pain, and an overeagerness to treat it with opioids, as a physician in the 1990s. The concept of pain as a fifth vital sign struck me and many other doctors as nonsensical. A symptom of disease is not a vital sign. But there was, and still is, a pervasive sense that doctors would be judged in part based on how well patients were satisfied with the pain treatment they got—an issue that patients were being encouraged to make a central medical concern. Sadly, this coupled with a poor appreciation of the risks of opioids led many to prescribe them when they weren’t even needed. There is no question that this overreach helped create the problem we have today, and that ending this epidemic requires going back to its roots. (Tom Price, Secretary Health and Human Services 2017)

© Springer Nature Singapore Pte Ltd. 2020 J. L. Fitzgerald, Life in Pain, https://doi.org/10.1007/978-981-10-5640-6_3

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3.1 The Opioid Epidemic In a fascinating 2017 exposition about the opioid epidemic, then US Federal Secretary for Health, Tom Price, specifically named the transformation of pain from symptom to vital sign as a root cause of the opioid epidemic (Price 2017). Flowing from that transformation was a dissatisfaction with the elevation of the subjective experience of pain above the clinical assessment of pain. This was in his terms an overreach in the management of pain and a source of the epidemic. As with most things, how we define the problem necessarily directs us to the type of solution. In this chapter I will provide a different lens onto the US opioid epidemic that attempts to examine the root causes of the epidemic through the key terms in the cultural neuromatrix, affective economy and commodity shapeshifting. One would think that an epidemic is an observable and easily definable phenomenon. In some respects, the North American opioid epidemic is indexed quite easily in terms of the number of drug-related deaths, and the extent of morbidity caused by opioids. According to the Centre for Disease Control (CDC) the epidemic had some key characteristics (https://www.cdc.gov/drugoverdose/epidemic/index.html). From 1999 to 2017, more than 700,000 people have died from a drug overdose. Around 68% of the more than 70,200 drug overdose deaths in 2017 involved an opioid. In 2017, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 6 times higher than in 1999. Over this period, on average, 130 Americans die every day from an opioid overdose. Of the 20.5 million US residents 12 years or older with substance use disorders in 2015, 2 million were addicted to prescription pain relievers (Gostin et al. 2017). It is estimated that the opioid epidemic has had a combined economic impact of $92 billion (Gostin et al. 2017). In the most recent analyses, there were thought to be three waves to the epidemic (Unick et al 2013; National Center for Health Statistics 2017; Jalal et al. 2018). The first wave began in the 1990s with increased prescribing of opioids (mostly oxycodone and methadone) till around 2010 (Kolodny et al. 2015). The second wave began in 2010, with rapid increases in overdose deaths involving heroin. The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids—particularly those involving illicitly-manufactured fentanyl (Scholl et al. 2018; Rudd et al. 2016). Some of the statistics are extraordinary. General practitioners (GPs) prescribed opioids in more than 50% of 1.14 million nonsurgical hospital admissions from 2009 to 2010, often in high doses. Between 1993–2012 middle-aged women and the elderly were more likely than other groups to visit doctors with pain. In these groups, the largest increase in hospital stays came from those experiencing iatrogenic opioid addiction. However, the North American opioid epidemic is also understood through a wider codification of suffering. It is this codification of suffering that is captured by the US

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Federal Secretary of Health and Human Services Tom Price, in his 2017 address to the National Rx Drug Abuse and Heroin Summit April 19, 2017, in Atlanta, Georgia. I have reproduced a large section of the transcript of his address as it captures the key message of this chapter and perhaps characterises most completely an attempt at the wider codification of suffering in the opioid epidemic: As we think about pain, we must not forget the types of pain that can hurt the most but are often the hardest to treat — the pain of loneliness and despair, of feeling unloved or unvalued. The pain of living with a broken heart. Today’s epidemic is worse than drug crises we’ve seen before. But, at its core, it’s just the latest chapter in the story of the human condition — of man’s fallen nature and our search for meaning and purpose in a broken world. The problem today isn’t simply that it’s too easy for people to access highly addictive drugs, though this is certainly true. The deeper problem is that, for many of our fellow citizens, it’s too difficult to access the relationships and institutions — like family, faith, community and work — that make life worth living and the pursuit of happiness possible. This is a problem that can be difficult to describe, and even harder to solve, but it is impossible to deny. Across America, the bonds of family, faith, work and community are fraying and fracturing. Detached from these crucial sources of happiness, many are driven to drugs and then caught in cycles of hopelessness and addiction. Repairing these broken bonds is the key to recovery. That begins by meeting Americans with addiction where they are, while always reminding them of where they’re capable of going. Addiction isn’t a moral failing, but the addicted person is a moral agent. He may be enslaved to drugs, but he is not a slave. He may have lost control of his life, but he has not been robbed of his free will or his Godgiven ability to bear the greatest burdens in life and come out on the other end stronger for it. The Apostle Paul writes in his first letter to the Corinthians: “No temptation has overtaken you except what is common to mankind. And God is faithful; he will not let you be tempted beyond what you can bear. But when you are tempted, he will also provide a way out so that you can endure. As a nation, we can endure this temptation. But none of us — no person, no family, no community — can do it alone. (Price 2017)

In the above characterisation, Price does more than identify the problem as due to easy access to opioids. He goes further to discuss the different types of pain: pain associated with life, the pain of a broken society, and the pain of the “human condition”. I will return back to this codification later in the chapter. For the time being I will follow down a path to examine the epidemic. What should be clear from the start is that this epidemic is all about pain.

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3.2 The Early Stages Wailoo (2014) suggests that the current epidemic had its roots decades earlier in key policy moments in the construction of the relationship between opioids and pain. Wailoo suggests that in the 1970s and 1980s, successive US Federal Governments were reluctant to support people on disability benefits related to pain. This was crucial in setting the stage for how the US Government managed people in pain in subsequent years. He also noted the interests of the pharmaceutical industry and key figures leading the debates. Weissman and Haddox (1989) espoused a theory of pseudoaddiction as an “iatrogenic syndrome that mimics the behavioral symptoms of addiction” in patients receiving inadequate doses of opioids for pain. This became a foil through which to promote the use of opioids for pain relief. This idea rested on a hydraulic metaphor: the euphoria of opioids was balanced out by the pain being experienced (Green and Chambers 2015). The argument was that chronic pain (cancer) patients weren’t really addicted because the pain negated any euphoria from the drug. Without euphoria, there was no pleasure, and as such, there could be no real addiction. As late as 2008, pseudoaddiction was being referenced in Purdue Pharma educational materials to doctors (Commonwealth of Massachusetts 2018): A term which has been used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may ‘clock watch,’ and may otherwise seem inappropriately ‘drug-seeking.’ Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when the pain is effectively treated. (Clinical Issues in Opioid Prescribing 2008)

Early in the epidemic, Dr. Russell Portenoy from the Memorial Sloan Kettering Cancer Center in New York, promoted access to narcotics (Portenoy and Kim 1986). Portenoy said that a 1982 survey of 10,000 burn patients who received narcotics as part of their hospital care, reported no addiction. In another survey, among 2000 headache patients who had regular access to narcotics, only 4 people became addicted (Rosenthal 1993). Portenoy, who had financial relationships with opioid manufacturers, went on to lead many of the medical, administrative and policy changes that enabled the wide prescription of opioids across the United States in subsequent years. In 2012, Portenoy reneged on his earlier assertions, and went on the record in a Wall Street Journal article that he had underestimated the risks of opioid prescribing (http://www.wsj.com/articles/ SB10001424127887324478304578173342657044604). It is alleged that around 2008 Purdue Pharma was circulating false and misleading information about oxycodone through its information pamphlets. In one recent complaint filed in North Carolina, it was alleged that a Purdue leaflet suggested that there was no maximum dose for oxycodone and that as dose levels were increased, side effects could decrease: “Even if opioid doses need to be gradually increased in a patient common adverse effects may often decrease” (cited in State of North Carolina 2018: p. 28).

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Originally the opioid epidemic was characterised as segmented to low income, Appalachian, south eastern rural and midwestern states such as Kentucky, Maine and Ohio (National Drug Intelligence Centre 2001). Kiang et al. (2019) recently demonstrated that the epidemic has spread and diversified both in terms of the types of drugs and the geographic setting in which the epidemic is located (Kiang et al. 2019). The highest density of harm located was in the eastern US states. Originally South Carolina and Kentucky were “epicentres” of the oxycodone epidemic. They are however now experiencing high rates of overdose from synthetic opioids such as fentanyl (Kiang et al. 2019). There is not a consistent trend, as some states such as Utah and New Mexico, that were heavily affected by prescribed opioids (such as oxycodone), did not experience further subsequent high mortality from fentanyl and other synthetic opioids (Kiang et al. 2019). There was quite a bit of variation. Krueger reports that prescription rates vary by a factor of 31–1 (Krueger 2017). Southern states had the most prescriptions per person for painkillers, especially Alabama, Tennessee, and West Virginia. The northeast states, especially Maine and New Hampshire, had the most prescriptions per person for long-acting and high-dose painkillers. Nearly 22 times as many prescriptions were written for oxymorphone in Tennessee as were written in Minnesota. Kiang et al. (2019) conclude that there is a wide heterogeneity across the US States in terms of the number of the deaths from opioids. This suggests that there is no single cause of the epidemic and that the different stages of the epidemic have been expressed at different times in different places. Friedman et al. (2019) report that in California, lower income and predominantly white communities experienced both higher opioid prescription rates and opioid overdose rates compared to other areas. There was approximately a 300% difference in the race/ethnicity income gradient. The authors suggest this reflects the accessibility of the health care system to predominantly white populations.

3.3 Political Change and Liberal Pain Theory Melzack’s 1968 theory signalled a significant challenge to medical linear causal models of pain. This led to a proliferation of what Wailooo called “liberal pain theories” in the 1970s. These liberal pain theories had fiscal and political impacts. An economic downturn in the late 1970s and early 1980s created political and economic impetus to restrict the number of people on disability welfare benefits. A combination of a change in Federal Government in 1981 and a tighter focus on budget restraint in the welfare and health systems saw a winding back of disability payments related to pain (Wailoo 2014: p. 130). The US Department of Health and Human Services reviewed and subsequently removed hundreds of thousands of people from disability support schemes on account of unsubstantiated pain conditions. This clampdown in 1983 under the Reagan administration facilitated court contests over the capacity of government to determine how pain was codified.

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Whereas pain could be attested through subjective patient reports, 1984 legislation required claims based on pain symptoms to be accompanied by “medical signs and findings… which show the existence of medical impairment that results from anatomical physiological or psychological abnormalities which could reasonably be expected to produce the pain” (Wailoo 2014: p. 132). Patients previously receiving benefits now required there to be a proof of pain that extended beyond the symptom. Brena wrote in his 1978 book that “society had gone too far in passing laws granting monetary compensation to escape from work via pain complaints” (Wailoo 2014: p. 118). Developed from earlier suggestions that government had facilitated “learned pain” through liberal disability laws, from 1984, government would only support those who suffered pain, if pain was to be objectively assessed and related back to a pathological source. Brena et al. (1981) attested that chronic pain is often a conditioned socioeconomic disease, and that “biomedical data and pain behavior are independent variables, as the latter is heavily controlled by socioeconomic factors” (Brena et al. 1981). According to Wailoo (2014), in his comprehensive political analysis of pain management in North America, the relatively unfettered marketing behaviour of the pharmaceutical industry in the 1990s, resulted from significant discursive, political and administrative changes in the 1980s. Porter and Jick (1980) published a short but highly influential communication in the New England Journal of Medicine. Their case review of 11,882 patients found that “despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction”. The letter to the editor contained no evidence and was five sentences long. This highly cited communication has been said to be a key source of evidence for the early widespread prescription of opioids when Oxycontin was launched by Purdue Pharma in 1996 (Coleman 2019; Evans et al. 2019). In 2017, the editors of the New England Journal of Medicine unusually added an editor’s note to the publication: “For reasons of public health, readers should be aware that this letter has been “heavily and uncritically cited” as evidence that addiction is rare with opioid therapy” (Leung et al. 2017). A bibliometric analysis of the citation of the Porter and Jick communication reveals a substantive trend in citation (Leung et al. 2017). There were 608 citations of the Porter and Jick letter. In comparison, other short letters published in the New England Journal around that time had a median of 11 citations. The sequence of events throughout the opioid epidemic are complex. Hill (2019) has composed a run-sheet of significant moments in the epidemic (Table 3.1).

3.4 Marketing Having been subject to numerous law suits, there is an extensive literature on the marketing strategies of Purdue Pharma (van Zee 2009). I will not attempt to render the whole picture, but rather to select out key features of the strategy.

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Table 3.1 Purdue Pharma timeline Year

Item

1952

Sackler family buys Purdue Frederick

1980

Porter & Jick, 1 paragraph letter to the editor New England J Medicine

1980

WHO declares Morphine as “essential drug” NEJM. 1980Jan 10;302(2):123.;25(2):171–86

1984

Purdue Pharma releases MS Contin—Marketed for Cancer Patients

1986

Russell Portenoy “opioid maintenance can be used safely and effectively without fear of addiction in patients with non-malignant pain”

1989

Article in Pain by Dr. David Haddox coining the term “Pseudoaddiction”

1995

Purdue reformulates oxycodone into a long acting form and OxyContin is patented

1996

President of the American Pain Society urges Drs to treat Pain as a 5th Vital Sign

1998

Veterans Administration adopts “Pain as the 5th Vital Sign”

2000

US Congress passes The decade of pain control and research Bill

2004

OxyContin becomes most prevalent abused prescription opioid

2012

The American Pain Foundation disbands after a US Senate Finance Committee announced its investigation in OxyContin promotions

2015

>42,000 deaths in US from opioids

2016

CDC declares opioids as epidemic and publishes opioid prescription guidelines Both AMA and AAFP pass resolutions to drop “pain as the 5th Vital Sign”

2017

41 state attorneys general investigate opioid manufacturers

2017

President Trump declares the Opioid Epidemic a “Public Health Emergency”

Adapted from Hill (2019)

In 2007, the Purdue Frederick Company was fined over $600 million dollars and three executives were charged with criminal offences for fraudulently marketing their painkiller oxycontin (US Department of Justice 2007). The court action which commenced in 2003 found Purdue to have concealed clinical information, circulated misleading clinical information and withheld information about the misuse of slow release oxycontin from the public. Ultimately Purdue attempted to market slow release oxycontin as a medicine that was less addictive and had a lower abuse-liability because of its slow release properties. In a 2019 lawsuit lodged by the State of Georgia against the pharmaceutical industry, it was asserted that that in 2014 opioid pharmaceutical companies Purdue, Teva, Endo, and Allergan, spent more than $133 million on “detailing” branded opioids to doctors, more than twice what they spent on detailing in 2000 (State of Georgia 2019). The marketing was sophisticated and involved direct “education” of doctors and the funding and formation of “front groups” to advocate for pain management and the elevation of pain as a condition requiring treatment. Most prominent of these front groups was the American Pain Foundation (APF). The APF received more than $10 million in funding from opioid manufacturers from 2007 until it closed in May

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3 The North American Opioid Epidemic

2012. The APF issued education guides for patients, reporters, and policy makers. According to the State of Georgia (2019) the APF: … trivialized their risks, particularly the risk of addiction. APF also launched a campaign to promote opioids for returning veterans, which has contributed to high rates of addiction and other adverse outcomes, including death, among returning soldiers. APF also engaged in a significant multimedia campaign, through radio, television and the internet, to educate patients about their “right” to pain treatment. (State of Georgia 2019: p. 34)

A United States Senate Finance Committee began looking into APF in May 2012. Within days of the investigation, the APF industry-funded board was dissolved. As noted in a 2018 US Senate Homeland Security and Governmental Affairs Committee minority report, front groups such as APF aligned medical culture with industry goals to contribute to the opioid epidemic. These organisations amplified and reinforced messages favouring increased opioid use (United States Senate Homeland Security and Governmental Affairs Committee, HSGAC 2018). A network diagram of the various interest groups and key influencers from the 2017 State of Illinois and Cook County lawsuit is reproduced in Fig. 3.1. This network diagram convincingly describes the alleged complex web of relations between different participants in the opioid epidemic, clinicians, advocacy groups and pharmaceutical companies and key publications arising through the epidemic (State of Illinois and Cook County 2017). In 2008 and 2012, the US Drug Enforcement Agency issued show cause notices and fines to a number of wholesale opioid distributors (State of Georgia 2019: p. 65). The matters ranged from failure to notify suspicious activity, to poor record keeping and failure to maintain effective controls of supply. Among others, fines were incurred by McKesson Corporation ($150 million) and Cardinal Health ($44 million) for failures to report suspicious orders of controlled substances (State of Georgia 2019: p. 65). Although prosecutions have been launched at all levels of the supply chain, the main prosecutorial interest has been focussed on Purdue Pharma. Much has been written about the Sackler family and their “pain empire” (White 2004; van Zee 2009; Keefe 2017). They are thought to be one of America’s richest families. The Sackler family purchased Purdue Pharma in 1952. Sackler’s 1960 Valium marketing campaign made it Pharma’s first $1 million drug. Purdue Pharma currently has a value of $14 billion, with oxycodone being its highest value product. Between 1996–2002 Purdue conducted an extended educational campaign, conducted 20,000 pain-related educational programs, issued direct sponsorship/grants and provided financial and other support to a number of non-profit advocacy organisations American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards, the Joint Commission, pain patient groups, and other organizations. With support from Purdue Pharma, in 1995 the American Pain Society and the Department of Veteran’s Affairs launched a campaign called “Pain is the 5th vital sign” and a campaign against “opiophobia” (Department of Veterans Affairs 2000). Since 1995 Oxycontin has enjoyed estimated sales of more than $35 billion. In 2014 OxyContin had global sales of $2.5 billion, more than any other prescription pain reliever.

3.4 Marketing

53

Fig. 3.1 Network of relationships between key influencers, advocacy groups, pharmaceutical companies and key publications in the opioid epidemic. Source State of Illinois and Cook County (2017)

The General Accounting Office (GAO) reported that by 2003, nearly half of all OxyContin prescribers were primary care physicians. The Drug Enforcement Administration (DEA) expressed concern that Purdue’s aggressive marketing of OxyContin focused on promoting the drug to treat a wide range of conditions to physicians who may not have been adequately trained in pain management. Further, Purdue did not submit an OxyContin promotional video for FDA review upon its initial use in 1998, as required by FDA regulations (http://www.forbes.com/sites/alexmorrell/2015/07/01/the-oxycontin-clan-the14-billion-newcomer-to-forbes-2015-list-of-richest-u-s-families/#66b393b6c0e2).

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In December 2003 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) allowed Purdue Pharma to fund the “pain management educational courses” that taught the new standard of care for treating pain to JCAHO hospitals and facilities. Purdue has been subject to numerous law suits and class actions. It has defeated more than 10 class-actions. In 2007, The State of Kentucky alleged false marketing in a court case. Eastern Kentucky where many injured coal miners were prescribed the drug received a $24 million settlement (http://www.bloomberg.com/news/articles/ 2014-10-20/purdue-says-kentucky-suit-over-oxycontin-could-be-painful). According to a 2019 Commonwealth of Massachusetts lawsuit (Commonwealth of Massachusetts 2018) by 2006, OxyContin’s “profit contribution” to Purdue was $4.7 billion. From 2007 to 2018, the Sackler family received more than $4 billion in payouts from Purdue (https://psmag.com/social-justice/purdue-pharma-misledpeople-about-the-strength-of-oxycontin). By mid 2019, in the face of extensive ongoing litigation, Purdue filed for bankruptcy.

3.5 Unleashing the Pain Tiger—Pain as the Fifth Vital Sign Coleman (2019) suggests that there were three important policy initiatives that embedded pain in the culture of medicine. The 2000 Decade of Pain and Research law enacted by Bill Clinton; the adoption of pain as a vital sign, and thirdly, the inclusion of pain outcomes in healthcare financing through the Joint Commission on Accreditation of Healthcare Organisations (Coleman 2019). Some of these were clearly initiated by the pharmaceutical industry. Some were less visible and undertaken by advocacy and interest groups. The most important initiative was in 1996, when the American Pain Association adopted a policy to promote pain as a 5th vital sign, alongside temperature, respiration rate, blood pressure and heart rate. The guidelines were also adopted in the United Kingdom (Levy et al. 2018). Tompkins et al. (2017) suggest that the opioid epidemic had its origins in a series of seemingly unrelated changes in pain treatment during the 1980s and early 1990s. The progressive underfunding of multidisciplinary pain treatment clinics and the preferential training of pain fellowship clinicians in lucrative procedure-based care (ablations, nerve blocks and spinal cord simulators) left the majority of chronic pain patients in the hands of solo primary care providers and procedure-based chronic pain treatment clinics. Pain became a problem to be medically managed rather than a multidisciplinary challenge. Accordingly, the institutions to support multidisciplinary approaches were incrementally defunded, re-directing those who were in pain to either primary care physicians, who were more inclined to prescribe opioids, or to procedure-based centres who again were more inclined to prescribe opioids. In 1996 Purdue Pharma introduced the slow release formulation of Oxycodone. Between 1996 and 2000, sales revenue rose from $48 million to $1.1 billion. Richard Sackler made sure that Purdue bought the internet address 5thvitalsign.com so it could promote pain as the “fifth vital sign” (Commonwealth of Massechusetts 2018).

3.5 Unleashing the Pain Tiger—Pain as the Fifth Vital Sign

55

Once pain monitoring was institutionalised as a vital sign, to be monitored in a routine consultation, it was placed on the agenda for every North American doctor. This is a refrain operating out of the pain cultural neuromatrix. This refrain organised materials, machines and institutions to produce bodies that were in pain. This is one of the master strokes that ensured that pain would rise above other conditions. In 2007, the Centers for Medicare and Medicaid Services (CMS) required healthcare organizations to report more detail about patient satisfaction with pain management through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (Thompson 2017; Jung et al. 2018). Institutionalising the measurement of service performance when managing pain, enshrines pain management as a service priority. This is perhaps what Massumi would call a deployment of ontopower, where capital creates the conditions for the expansion of markets. Ontopower creates the conditions for the successful deployment of biopower onto segments of the population. Biopower will find ways to give life to productive parts of the population and ways to identify those unproductive segments. Here is the essential point where the cultural pain neuromatrix begins operating at the level of the population. In the case of the 5th vital sign, this refrain creates the conditions for the emergence and expansion of a new category of patients—those who are chronic non-addicted consumers of opioid pain relievers. This category is extremely important because (1) it is a productive segment of the population—they can work and are not in pain and; (2) they are a chronic segment, i.e. they can continue to consume for the rest of their lives. This enables the deployment of biopower, to ensure that the most productive segments of the population are able to be supported and fostered, whilst leaving the least productive segments of the population to wither and die. “Pain is a the 5th vital sign” is a resonant and resilient slogan. Even in Australia during 2016, the term was being used in chronic pain educational settings by reputable health services such as the Peter MacCallum Cancer centre (https://www.petermac.org/events/5th-vital-sign-prevention-andmanagement-acute-and-chronic-pain-workshop).

3.6 A Drug Epidemic or Pain Epidemic There are several lines of evidence that suggest that underpinning the opioid epidemic was a pain epidemic. Bradford et al. (2018) reports that between 2010 and 2015 there were 23.08 million daily doses of any opioid dispensed each year in the United States under Medicare Part D. States with medicinal cannabis laws consumed 3.742 million fewer daily doses. States with home cultivation medical cannabis laws consumed 1.792 million fewer opioid doses. The findings were most substantive with regard to hydrocodone and morphine. Those states with medicinal cannabis laws witnessed a 14.4% reduction in the use of any opioid. These results are also supported by 24.8% lower levels of opioid mortality in states with medicinal cannabis laws (Bachhuber et al. 2014).

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3 The North American Opioid Epidemic

Wen and Hockenberry (2018) similarly reported that States with medicinal cannabis laws had a 5.88% lower rate of opioid prescribing in the period 2011–2016 among medicaid enrollees. Where there was an existing legal alternative to opioids, this seemed to have a demonstrable impact on opioid mortality. This is even more surprising given the lack of strong evidence for cannabis as a pain reliever. This will be explored further in Chap. 4. In what was an orthodox and valuable piece of epidemiology, Friedman et al. (2019) examined the distribution of opioid prescribing across race and income gradients in California: The vast majority of individuals receiving opioid prescriptions in California are not dependent opioid users. As shown in previously published work, the bulk of these individuals are receiving sporadic prescriptions for small quantities of opioids, representing short term treatment courses for acute conditions. (Friedman et al. 2019: p. 472)

At least in California, contrary to popular press and mainstream commentary, the epidemic is not principally an epidemic of addiction, it is an epidemic of pain. Friedman et al. (2019) allege that the health care system has participated in the development of opioid-using populations who may not previously have engaged in this type or level of opioid use. However, the overarching problem that has been revealed in this epidemic is the problem of treating pain across the population. Indeed Friedman et al. (2019) ironically observe that the concentration of opioid-related prescribing in poorer, predominantly white communities, has inadvertently protected traditionally marginalised hispanic and black populations from the drug-related harm that is usually experienced by these communities.

3.7 The Pharmaceutical Machine in the Body-Economy Milieu The picture that now emerges, is that the pain epidemic is not the sole accomplishment of Purdue Pharma, but is an outcome from a networked assemblage of manufacturers and distributors, wholesalers, prescribers, and pharmacies (see Fig. 3.1). It involves a shift in medical prescribing culture, government interest to reduce the costs of pain and the discursive effects of redefining pain from a subjective symptom into a measurable sign. Add into this mix a proliferation of third-party non-profit advocacy groups and interest groups agencies and the list of possible suspects implicated in the epidemic has grown substantially. As seen in the law suit brought by Massachusetts, opioid manufacturers and distributors have been bundled together to share liability for the epidemic. The networked pharmaceutical-machine brings together different elements within a milieu to extract value from an economy based on pain. As noted by Coleman (2019), the actions brought against the different elements of the machine are diverse (Table 3.2).

3.7 The Pharmaceutical Machine in the Body-Economy Milieu

57

Table 3.2 Multiple participants in the opioid epidemic Entity

Year

Drug

Volume (millions of doses)

Fine/settlement value

Southwood Pharm

2006

Hydrocodone

8.7

MOA

Cardinal Health

2007

Hydrocodone

>8

$34 million

Amerisource bergen

2007

Hydrocodone

3.8

MOA

McKesson

2008

Hydrocodone

~3

$13.25 million

Masters Pharm

2009

Hydrocodone

>4

$0.5 million

Sunrise wholesale

2010

Oxycodone

n/a

n/a

Harvard medical group

2010

Oxycodone

>13

$8 million

Key source medical

2010

Oxycodone

~48

$0.32 million

Omnicare

2012

Various

Unknown

$50 million

CVS

2012

Various

Unknown

$11 million

Cardinal health

2012

Oxycodone

Walgreens

2013

Various

Unknown

$80 million

UPS

2013

Various

Unknown

$40 million

$44 million

FedEx

2014

Various

Unknown

dismissed

CVS Health

2015

Various

Unknown

$22 million

McKesson

2015

Various

Unknown

$150 million

Masters Pharm

2015

Oxycodone

>6.5

MOA

Mallinckrodt

2017

Oxycodone

500

$35 million

MOA memorandum of agreement Adapted from Coleman (2019)

In fact, due to the ubiquity of litigants (across counties, cities and states), a large number of litigants (n = 700) have been bundled together in Federal Multidistrict Litigation (Gluck et al. 2018). Ohio Judge Polster when hearing this suit commented: In my humble opinion, everyone shares some of the responsibility, and no one has done enough to abate it. That includes the manufacturers, the distributors, the pharmacies, the doctors, the federal government and state government, local governments, hospitals, thirdparty payers, and individuals.

The recognition of the complexity and multiple complicity of actors in the epidemic poses significant challenges to litigation, but also suggests that this is not the same as other public health litigation: The plaintiffs, as we have shown, have cast a much broader net of responsibility beyond manufacturers. There is a far more complex chain involved in delivering opioid prescriptions to consumers than in the sale of tobacco products. For opioids, that chain includes doctors, distributors, pharmacies, and patients as well as the drug companies. This complexity may complicate efforts at litigation because of the difficulty of pinning blame on any single actor and thereby lessen plaintiffs’ leverage, as compared with the tobacco context. (Gluck et al. 2018)

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What this legal jurisprudential approach also signals is that it is not just a theoretical perspective that the opioid epidemic involves a complex network of actors. The cultural neuromatrix approach may well be what is needed to better understand the dynamic field of relations within which pain is situated. Certainly, when a US circuit court judge structures litigation in this way, it suggests that a diffuse model is one that will be most useful in articulating the flows of capital that will approximate the flow of liability in the epidemic. The networked pharmaceutical machine mobilises affect across pain when it moves through different commodity forms between different milieu. At the level of the body, in the self-body milieu, pain is a subjective experience. It is then transformed into a measurable sign as pain medicine transforms the symptom into an objective sign through visual analog scales institutionalised through the doctrine of the “fifth vital sign”. As a sign it is then transformed into an outcome indicator. Patient satisfaction surveys and aggregated pain outcome measures then enable pain to shape shift into a new object. In this aggregated form, the measures of pain then become indices. The crucial measure is not the absolute value of pain, but the relative differences between pain measurements under different conditions (e.g. at different times or under different clinical settings, such as pre or post-treatment). The aggregated measures are then bundled together into cohorts (e.g. “patients this quarter on average rated ….”) or tranches. High-risk and low-risk patients in different segments of the health service may be examined differently; for example cancer patients will be assessed differently to orthopaedic patients and differently again to diabetes patients. In this way, the pain measure again shape-shifts when the relative pain measure becomes dislocated from the absolute measure of pain into a relative change from pain measures at other times or under different conditions. It is at this point that the pain measure shifts into being amenable to being treated as a derivative. At the level of the retailer the dose level is crucial is generating another dimension to the pharmaceutical machine. As was noted in litigation materials (Commonwealth of Massachusetts 2018: p. 25), opioid sales staff were encouraged to transform low dose prescriptions into higher dose prescriptions as manufacturer and distributor profits were indexed to higher dose regimes. Indicators of consumption such as the number of prescriptions or the dose level, should refer in some way to the level of pain, however, in this situation, it is a relative term dislocated from the pain being experienced by the consumer. As Table 3.2 reveals, there are multiple agents in the pharmaceutical machine who were found to be culpable for parts of the epidemic. The multiple players in this diffuse network, the manufacturers, the distributors, the American Medical Association, the American College of Surgeons, The Joint Commission, The American Academy of Family Physicians, and the Centers for Medicare and Medicaid services have all withdrawn their advocacy of “pain as the 5th vital sign” campaign (Levy et al. 2018). Their complicity in the epidemic is however all too clear. Consider the linkages between the pharmaceutical industry and the network of affiliated agencies (Fig. 3.1).

3.8 Pain as a Shapeshifter

59

3.8 Pain as a Shapeshifter As noted in Chap. 2, pain is a shapeshifter. Literature has for some time provided deep illustrations of the capacity of pain to shapeshift: “The peculiarly changeable nature of pain – its power to take on new meaning, or abruptly to lose or regain, or to transform the meaning it temporarily possesses – requires that we understand this most ancient and personal human experiences as indelibly stamped by a specific place and time”. (Morris 1991: p. 37)

This contingent and dynamic model of pain stands at odds with the medical model of pain, and even with Melzack’s neutromatrix model. Morris asserts that pain is a perception, not a sensation. It is a perceptual experience in which “consciousness, emotion, meaning and social context all play a part” (Morris 1991: p. 268). Pain absorbs the scent and feel of its social life (Morris 1991: p. 38). Pain is an experience that continues to change as it passes through “zones of interpretation” such as culture, history and individual consciousness. Pain exists in an open-ended social field and sediments only in people as it wraps itself up in meaning. Although Morris later in his work purports to assert a postmodern model of pain, Morris is not abstract enough. For Morris, pain gathers weight as it gathers meaning. There are however deeper shape transformations that go beyond the attribution of meaning. A key insight from the history of Purdue marketing was the capacity, through the mobilisation of capital, to shift the identity of pain. Purdue moved pain from being a symptom into an objective sign. As an objective sign, it could be measured, monitored and incorporated into accountability mechanisms across the health care system. Here pain through its shapeshifting quality was transposed from being an experience into an objective metric. As a sign, it has the status of indicator of the health of the organism, and must be monitored routinely, in the same way that temperature, blood pressure, respiration rate and heart rate should be monitored routinely in every doctor’s visit. The development of various analog (verbal and visual) scales assisted this process. As pain become an objective metric rather than a subjective symptom, it shape shifted. The distinction between symptom and sign is crucial. Traditionally a symptom is any subjective evidence of disease, an experience. A sign is the objective evidence of disease, a phenomenon that can be detected by someone other than the diseased individual. For Foucault, the work of the medical clinical gaze transforms symptoms into signs: Between sign and symptom there is a decisive difference that assumes value only against the background of an essential identity; the sign is the symptom itself, but in its original truth. At last, there emerges on the horizon of clinical experience the possibility of an exhaustive, clear, and complete reading: for a doctor whose skills would be carried to the highest degree of perfection, all symptoms would become signs. (Foucault 1973: p. 94)

The work to create the objective measure of life through the sign, is a product of the modern positivist discourses that constructed the idea of clinical medicine, in the

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absence of God (Foucault 1973: p. 199). Here at the formation of clinical medicine in the latter part of the eighteenth century was when “the subjective and the objective changed faces” (p. 198). Within this historical and discursive context, it is not unusual therefore to consider the re-transformation of symptom into sign and visa versa. It is the work of discourse that enables the discrimination of symptom from sign, and the practice of medicine that then transforms a subjective symptom into an objective sign. What is perhaps the more important point to be derived from Foucault, is the challenge that such a re-transformation would have to the configuration of all disease during the recent opioid epidemic. Reconfiguring pain in this way enabled a repositioning of the phenomenological/subjective into an objective and clinical truth that transcended specific disease states. Under the direction of pain specialists, the subjective rating became an objective measure. Many clinicians recognised the limitations of the scales. However, at the heart of this rendering of pain was a process: the self-assessing patient marks a position on a relative scale, and that position inscribes and transforms the internal experience into an external truth to be witnessed by others. The number of pain scales proliferated. Verbal rating scales, the Numerical Rating Scale (1-10), the Wong-Baker scale (Whaley and Wong 1995: p. 1085) and the 11-face McGrath pain scale to name a few, were all tested for their psychometric properties—their stability and construct validity—to ensure that the scales were measuring what they were meant to be measuring (Kim and Buschmann 2006; Haefeli and Elfering 2006; De Knegt et al. 2016). There were scales for different ethnicities, for the young, the old, the able-bodied and disabled. Subjectivity was segmented into units and subunits in an attempt to capture pain and transform it. These “affective” scales were a primary tool in this affective economy. One consequence from the opioid epidemic is the weakening of the relation between symptom and sign that made it possible for the re-transformation of pain to occur. No longer were opioids to be prescribed for a shortlist of musculoskeletal problems, or even for neuropathic conditions. When pain became ubiquitous and common to all conditions, opioids could be the remedy. No wonder the markets for these drugs went through the roof. Now, through the transformation of symptom into sign, pain became a common destination for all unease, disease, and ill-at-ease. If it could be felt it could be dealt. This transformation of sign from subjective to objective is not an aberration, or even an historical fiction imputed by Foucault. Even now in contemporary emergency departments, discursive work is undertaken by nurses to transform the verbal analog pain scale into a workable and meaningful objective sign (Vuille et al. 2018). The true horror is how easily this transformation was undertaken, how easy it was for pain to be reinscribed into an object. The final set of transformations can be witnessed in the text of the ex-DHHS secretary Tom Price. In his text, pain shapeshifts between addiction, to a moral deficit, to part of the human condition to be tempted, and ultimately to a lack of faith in God. When Price cites St Paul (in his recourse to a lack of faith in God that underpins the epidemic), he connects the current dilemma to the early moralistic work from

3.8 Pain as a Shapeshifter

61

Brena who asserted the need to understand pain in terms of the commitment to be productive and to work. Pain has moved in the space of a few paragraphs from an individual symptom to a spiritual deficit. Of particular note is the shapeshifting of pain in popular discourse. Deyo (2014) recounts the story of Steve Rummler, popularised in death by his family in their advocacy for tighter restrictions on the prescribed pain-reliever hydrocodone. Rummler died of a combined drug toxicity overdose (benzodiazepine and hydrocodone). Famously, a post-it note from his belongings was quoted by his mother in news media items (Deyo 2014: p. 53) and subsequently in a Centre for Disease Control (CDC) public advocacy campaign (https://www.youtube.com/watch? v=Hqn9BIOJGIg), “At first, it was a lifeline. Now, it is a noose around my neck”. How rapidly it was possible for the pain reliever to become a source of death. The CDC used this hook-line in an attempt to enhance patient awareness about opioid use. This ambivalence between remedy and poison has been recognised as a characteristic of the “pharmaka” discourse for some years (Derrida 1981; Fitzgerald 2015). This ambivalence has now been mobilised by the state in a campaign to focus on patient awareness. Interestingly, the target for this education is the individual pain sufferer and their family. Given what we know already about the multiplicity of culpability that has gone into the epidemic, targeting the pain sufferer seems unusual within the broader context of the affective economy underpinning the epidemic.

3.9 Affective Economy and Pain Affect is central to pain (Lumley and Schubiger 2019). Whether as a mediator of pain information, a neural modulatory path, or as a source of interpretation, affect is central. As noted in Chaps. 1 and 2, affect has different meanings in different discourses. In the discourse of affective economy, it can mean both the flux of emotions and the more abstract meaning of the flux of potential across fields of energetic life flows. We will start with thinking about affect as emotion and move through to the more abstract rendering of affect. The Wong Baker Pain Scale (Whaley and Wong 1995) is a classic example of an affective pain scale. In this scale the image of the transformation of a face from a smiley face to that of a crying face, is a visible rendering of the appearance of emotions. More literal visual pictorial scales show the photographic images of children in various states of distress. At the heart of an affective pain scale is the linking of thoughts about pain to feelings about pain. Emotion is at the heart not just of an experience, but as part of the cognitive work that transforms pain from a symptom into a sign. For Lumley and Schubiner (2019) emotions are also central to understanding and managing the phenomenon of central sensitization. Central sensitization has gone by a number of names, and the neural mechanism is not well understood in cartesian medical terms. Also referred to in slightly different ways as somatoform disorders,

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3 The North American Opioid Epidemic

allodynia (pain due to a stimulus that does not usually provoke pain) or hyperalgesia (increased pain from a stimulus that usually provokes pain), central sensitization is the basis for understanding how pain originates from the brain rather than from a peripheral site or peripheral lesion (Jensen and Finnerup 2014). As noted in Chap. 2, there are well-developed frameworks now for understanding central sensitization through pain neuromatrix models (Moseley 2007). As Moseley (2007) has noted, a common misconception is that when pain is “just in your head”, it discounts the importance of the fact that for many with central sensitization, pain is “just in your head”. In the Lumley and Schubiner (2019) framework for managing central sensitization, a crucial step in controlling how the brain creates pain (in a less-than-conscious manner), is to link thoughts and feelings of pain, to the experience of pain. Creating a mindful awareness of emotions and pain, emotional disclosure and writing, and experiential enactments and rescripting: these are all steps in managing central sensitization, a less than conscious brain process. The tensions and potential contradictions should be immediately apparent. How can you consciously intervene in a less-than-conscious brain process? We will leave this to one side for the moment. The important point here is to recognise how central emotions are to pain. For Morris (1991) who tends to equate affect with emotion, it is the changing meaning of pain as it moves though social fields that gives pain its salience. It sediments only in people as it wraps itself up in meaning. This is the entry point for thinking about affective economy. Affective economy as a discourse has its origins the influential 1983 work of medical anthropologist Arlie Hoschchild who observed the value of “emotional labour” done by people working in the services sector. Emerging from the 1983 work was the notion of “feeling rules”, or ways in which cultural (and ultimately individual) rules are established for the appropriate management for emotions. Feeling rules are one of the most obvious ways in which culture mediates and inserts itself into the feeling of emotions. Children are taught at an early age about acting out their feelings. Adolescents are taught mechanisms for filtering their emotions and as workers, we are trained to deploy our emotions into the work (Hoschchild 1983). The original insights from Hoschschild about flight attendants has been extended across a range of service sectors, to sex workers and nannies (Ehrenreich and Hochschild 2003). Importantly, analytical devices such as “feeling rules” provide a link between culture, emotion and economy. We will now bring those different discourses together, starting with economics and pain. Kreuger in 2017 observed the material economic impacts of the opioid epidemic (Kreuger 2017). In 2016, over 40% of out-of-work male workers were estimated to be using opioid painkillers in 2016. He also asserted that lower county-level labour force participation rates were intimately linked to opioid prescription patterns. Those areas experiencing rates of economic deprivation suffer to a far greater extent than more privileged areas. Kreuger estimates that up to 20% of the drop in labour force participation was due to opioid prescribing (Kreuger 2017). Participating in work and opioid use were closely linked. As noted in Chap. 1, there are strong links between the material economy and opioid use. However, less is known about how the opioid epidemic intersected with

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63

the “affective economy”. This is most readily done when we extend the discussion of affect beyond emotion and into more abstract terrain. Taking affect beyond emotion, as discussed in Chap. 2, pain is an energetic debt. It is a debt caused by the movement of force through an affective field of intermodulation. Pain is what is named. It is the object, a perceptible sign of what is stirring in the relational field. Pain is an indexical marker, it points to movement, to an energetic debt. At the end of this section I will move through a theoretical logic that connects this debt to the deployment of a particular form of power. Pain, it will be seen, is a product of ontopower (Massumi 2015). Ahmed (2004a, b, 2013) locates the germinal force of affect and emotion in her framework for affective economy. Emotions create the boundaries and surface of bodies and worlds. Emotions do things. Emotions align individuals with collectivities, and connect bodily spaces to social spaces. Emotions mediate relations between taken-for-granted structures, that adhere and cohere. Affects attach and move through bodies. This is where Ahmed connects affect to Marxian economy. Affect does not reside positively in the sign or commodity, but is produced only as an effect of its circulation. In the money-commodity-money relation, money accrues value through the exchange: The value originally advanced, therefore, not only remains intact while in circulation, but increases its magnitude, adds to itself a surplus-value or is valorised. And this movement converts it into capital. (Marx 1976: p. 252)

Ahmed shifts the focus away from the traditional commodity and onto the commodity as a sign. It is the shifting value of signs that, as they circulate, accrue a surplus value of exchange: Affect does not reside in an object or sign, but is an effect of the circulation between objects and signs (= the accumulation of affective value over time). Some signs, that is, increase in affective value as an effect of the movement between signs: the more they circulate, the more affective they become, and the more they appear to “contain” affect. (Ahmed 2004b: p. 121)

Tom Price relocates pain from one place to another, then to another and then onto the “human condition”. The pain of not being connected, the pain of a broken social order, the pain of a broken heart. According to Price, people are agents, they choose opioid medication when they cannot manage the pain of the human condition. When the brokenness of the world around you cannot be assailed by any other means we choose to medicate. The non-specific existential pain of living is the Other to life. It takes life away from us. Pain is an energetic life debt. Life debts exist in the form of maladies and the social and structural deficits in our life. These debts are amplified through somatoform amplifiers (Kirmayer and Sortorius 2007). We bundle these different debts into a package (“hope that tomorrow’s pain will be a better than today’s”), and we invest in this package in the hope that the pain we feel might be different. But the package does not carry with it the inherent value of the original debt. The package contains a series of indices that point to originary pain. The package is a bundle of relativities. The sign as index, carries

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with it affects that inhere and adhere to the signs that are bundled together. It is in this sense that the pain can be thought of as a derivative. Affects are mobilised through and between bodies to create surfaces and bodies. The affective economy is the engine that drives value through pain as a commodity form. The affective economy creates collectivities based on affect and emotion through refrains and repetitions that mark or score bodies and surfaces. Different refrains operate in different milieux. Pain is a derivative. The intensity of pain is related and mediated through somatoform amplifiers. These somatoform amplifiers are like little machines. In reference to the neuromatrix framework in Chap. 2 (Fig. 2.3), these amplifiers are refrains/cultural neurosignatures. The pain is not directly related to one cause or lesion, be it psychic, social or physical. Our investment in this package can be compared in some way to a contract for difference (CFD). What we are buying is a futures option where pain is a collateralised debt obligation.

3.10 Emotional Labour and Drugs It was her smile that surprised me. This diminutive wheelchair-bound woman in her public housing apartment who was selling her pain medicine to other drug users, smiled at us as we knocked and came in through the half open steel security door. We were there for a transaction. She needed clean syringes. We delivered free syringes to her because she found it hard to get out of her apartment. The transaction I am interested in is not the drug deal that brought drug users to her flat. Those drug users also picked up syringes as part of the package she sold them. She sold morphine, other opioid tablets and equipment to dissolve and filter them for injection. We visited her because we were distributing free syringes to her, so she could distribute them to other drug users we could not reach. Part of this transaction was that we would spend time with her. She was housebound as well as wheel-chair bound. Our visit was a highlight of her day. She would keep us there, tell us tit-bits of stories that could help us do our job. When we dropped in, she got a visit from people she trusted, service providers who did not judge her, or what she did to get by in life. She was a disabled drug dealer who was redirecting her medication for profit. The absence of moral judgement was essential. We created and shared a “normal” relationship with her when we arrived and asked her how her day had been, checked over her injection sites to make sure there were no infections in her pallid immobile legs which might, in the future, cause her significant medical troubles. This was emotional labour. We did not have to go inside her apartment to say “hi” and assist her in this way. In fact, in future years the service would stop doing house visits on account of safety concerns. But at this time, the affective economy produced a “normal” interaction for 20 min. On the face of it, the morphine was the traffickable commodity at the heart of her business. However, the real affective economy was in the relationship built out of the respectful encounter between two outreach staff and this drug dealer for 20 min every Thursday.

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3.11 Contracting for Difference As noted in Chap. 1, there are few commodities that can be revalued in such a variety of ways as pain. Pain as a commodity can assume different values by virtue of its value never being reliably fixed at any point in time. From this perspective, pain is infinitely amenable to being derivatised. The logic of the derivative is at the heart of understanding the value and ultimately, the political economy of pain. Before launching into pain derivatives, and opioids, I will explain the logic of derivatives by starting with an explanation of how weather derivatives work. In a given agricultural location and time of year (e.g. harvest), the weather can determine the quality of the produce. The producer will want some insurance, so that when the weather is unfavourable, the farmer can receive an income stream to protect from loss of income. The farmer will enter into a contract with a derivative offerer (i.e. an insurer), such that when the temperature is too low to harvest, the weather insurer will pay an agreed upon amount. If the weather does not fall to a predetermined level, then the insurer makes money from the premium paid by the farmer for that month. This is also called an event derivative, a payment is made when a specific event occurs. There is no essential value to a traded derivative, other than the risk of the unwanted event. Risk structures the value of the derivative, rather than the value of the produce. In the financial markets, the financial product that encompasses these kinds of “bets” is a Contract For Difference (CFD). The CFD generally has more risk attached to it than a stock investment. Because it is what is known as a leveraged product, the value of the profit or loss can vastly exceed the initial investment. The strength of the metaphor becomes apparent when we examine the CFD in more detail. So, we will now venture into the financial detail of a CFD to see how it relates to pain and the affective economy. A CFD is in simple terms a bet on the future value of an object. I will start with an example that will be developed in a later chapter on cannabis markets. The financial system uses industry indices to package together the performance of a sector. In the arena of cannabis finance there are a couple main indices. The Prime Alternative Harvest Index is one. Performance of this index reflects how the component stocks are valued on the market. Attached to the index are exchange traded funds (ETFs) such as the Horizons Medical Marijuana Life Sciences ETF. These funds are managed funds that invest into the index through a variety of investment strategies including investment into the component stocks. The index is composed of approximately 20 stocks, that are differentially weighted depending on the size and value of the stock. Interestingly, this stock also has two tobacco manufacturers in the index (Philip Morris and British American Tobacco). A cannabis CFD could track the performance of the index and, based on the performance of the fund, speculate on changes in the Horizon Medical Marijuana Life Sciences ETF. I will model a CFD investment to demonstrate how the value of a derivative is generated. A buy CFD that predicts an increase in value, and a sell CFD

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that predicts a decrease in value. Both investments are designed to make money. The calculation would go something like this. According to actual market information, the value of Horizon Medical Marijuana Life Sciences EFT has ranged from 8.2 to 27 per unit over the period April 2017 to April 2019. In December 2018 the value of Horizon Medical Marijuana Life Sciences ETF dropped dramatically to a value of 15. An investor could have purchased 1000 CFDs at this price and established a long CFD position contracting that they would sell Horizon ETF stock at 21.7000. The cost of the 1000 CFDs would have been approximately $1500. In April 2019 when the stock reached 21.7 (which it did) the return to the investor would have been approximately $6680 (based on a variety of transaction commission rates). The investor would make significant money from the increase in value of the index. Importantly, the capital that was sloughed off was not linearly related to the underlying value of the asset. Alternatively, I could sell these CDs to another buyer before they mature. Here the buyer is investing in the likelihood of the future event, and weighing up the risk of this CFD being exchanged by me before maturity. This is now another risk built into the value of the CFD, but also another value. Firstly, it is important to start the comparison by recognising that the logic of the derivative is not necessarily the logic of the cannabis consumer (i.e. the pain sufferer). The logic of the derivative is at the heart of global capital, it is an abstraction (Massumi 2018). It is also the product of a financial discourse, built from a history of financial practices and an economic paradigm about how assets should be valued and transacted. The logic of the derivative does not belong to anyone in particular. There are institutions that regulate its properties, assign value and maintain standards. The logic of the derivative is not transcendent, it is a product from a particular moment in time. Just as some economic historians anchor the development of the global financial crisis to the deregulation of derivative trading in the late 1990s (https://www.huffpost. com/entry/how-congress-rushed-a-bil_b_181926), the centrality of the logic of the derivative has emerged at a particular point in time for global capitalism (Massumi 2018). This applies equally to viewing pain as a commodity. The framework that I am suggesting here is simply an alternative way to think about the opioid epidemic and the cultural, economic and political systems underpinning the epidemic. This epidemic is unprecedented in the history of drug policy. It is unwise to think that the current ways of thinking about pain relief and drug policy will be adequate to understanding and preventing such events from occurring again.

3.12 The Pharmaceutical Machine as Derivative Trader Pain relief, in whatever form, is an event derivative. The derivative is a contract between the affect labourer assemblage and the pharmaceutical machine, that in the circumstance of pain reaching a certain relative point, the derivative will be drawn down. If pain does not reach that point, the contract is not activated. The problem is

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that we are not dealing with an objective experience or measure of discomfort. The subjective experience of pain is continually being transformed. Weather derivatives rely on an objective measure of temperature change, or rainfall, to trigger the execution of the contract. In the case of pain, the measure is contingent on deployments of power and the commodity changes shape to adapt to the conditions for capitalisation. The derivative is also a future-swap. The future swap is where derivatives bring the future into the present. Betting on the future changes the present. Pain relief has the potential to change the present not just through feeling better, but by bringing hope for a pain free future into the present. This is how a derivative logic can relieve pain by “presenting” hope. As noted in Chap. 1, the affective economy is the source for connection with the world around us. Emotions instantiate sovereign subjects, whereas it is through affects that change occurs, “not just the change of passing from one emotion to another, but becoming, the transformations that disrupt and undo the existing emotional order” (Read 2016). Ahmed (2013) asserts that pain is productive in the sense that it is an intensification of the affects that signal bodily limits. Wounds are what is left when there is a violence of negation, when we have abutted a limit and we form a surface with the world: The wound functions as a trace of where the surface of another entity (however imaginary) has impressed up on the body an impression that is felt and is seen as the violence of negation…. It is these moments of intensification that define the contours of the bodily dwelling, surfaces that are marked by differences in the very experience of intensities. … I become aware of bodily limits as my body dwelling or dwelling place when I am in pain. (Ahmed 2013: pp. 33–34).

Tom Price was correct when he talked about pain in its broadest codification. The incapacity to connect with people around you, managing the brokenness of the social structures that bind communities, and the pain of a broken heart. There is more than one type of pain that pain relief is contracted to fix. This is why emotions are important, and why affect is central to understanding the opioid epidemic. When affect labourers are not able to traffic in the affects to enable them to go beyond themselves, to become-other, life itself is at stake. This is why medical science only gets it half-right when the response focusses on reducing access to opioids. The response, to penalise those offering the contracts, is to miss the demand for pain relief. The demand is situated in the risk mitigation that the contract for difference attempts to achieve. The conditions for capitalisation have however transformed the affective economy to go beyond using pain relief as a derivative for managing singular problems. Modern medicine languishes far behind the derivative logic of modern capital. Being situated in the linear causal medical pain model, public health and social medicine tried to find explanations in high levels of workplace injuries in Appalachian states, in the exploitation of the welfare system by pain cheats, and evil doctors working in pill mills to develop a large population of drug addicts (https://www.cnbc.com/2018/ 11/19/florida-sues-walgreens-cvs-over-opioid-sales.html). Tom Price did not have a language, other than the theological, to attempt to find a cultural explanation for the widespread consumption of opioids across North America.

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The logic of the derivative is that the derivative doesn’t care what the original commodity [i.e. pain] is, the derivative is focussed on mitigating the perceived risk for the buyer and bringing the future into the present. If the person/community/affect labourer assemblage perceives a risk of pain, they will enter into a contract with a remedy to reduce that risk. The risk will never be singular. The risk of pain accumulates from multiple sources. Going back to an individual medical explanation might help here. A person with an original neck injury accumulates a range of pain sources. The C5–C7 vertebroplasty (a fusion of vertebrae) places more pressure on the adjacent discs (C3–C4) and degeneration can start two years after the procedure. This puts pressure on the third occipital nerve and chronic headaches become the pain focus. After experiencing chronic pain for so long, the patient has developed a central centralisation. What might have been rated a 2 on the pain scale now rates a 7 or 8 because of the central sensitization. The pain neuromatrix appropriates and recruits more and more neuronal circuitry, to the point that the brain itself is producing the pain, rather than the neck degeneration. Similarly, as the neck becomes more locked and immobile because of the pain spasm produced by the centralised response, the lower back is called upon to do more extreme rotations. The head cannot turn to see what’s coming when bike riding, and the patient cannot rotate sufficiently to look over the shoulder when crossing the road whilst jogging, so the lower back over-compensates and hyperrotates in the lumbar region. The central sensitization detects pain messages and fires off more muscle spasm, this time in both the neck, scalp and lower back. Now there are multiple pain sources. The patient has to go back to the musculoskeletal specialist each time for each injury. All this is occurring without conscious control. There is now the pain of being seen to be sick in multiple ways. The emotional pain of now seeing a life ahead dominated by pain extending right across the body. The pain of depression looms as more days have to be taken off work. There is more pain now, as the vultures at work who crave the patient’s job, circle around the carcass that once was the productive labourer, and now is the one with the neck problem who needs to be managed out because they are not performing. There is also the pain of isolation, of not being able to tell anyone else at work about this pain and how it has come to dominate life. The pain of keeping secret, something that everyone knows is best managed when the village can be mobilised to nurture and support the afflicted. Toye et al. (2013) tell this story of the chronic pain narrative in excruciating detail and astonishing abstraction. Much easier now for the patient, to treat all this pain, to reduce the risk of another back twinge, to stop the central sensitised response, is to take a 10 mg oxycodone tablet in the morning and a 10 mg oxycodone tablet at night. Much easier to deal with all these with one risk mitigating contract. It is here that the logic of the derivative gets extended, and where the heart of the opioid epidemic is misunderstood. As the risk of pain increases with centrally sensitised responses and the bundling together of different sources of pain, here is where opioid consumption increases. It is at this point that the addiction narrative emerges to explain overuse/overconsumption, drug addiction, drug misuse or any of the other explanatory terms used to describe levels of consumption that medicine cannot attribute to a singular lesion. As Friedman

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et al. (2019) observe however, the epidemic is not explained by the development of a population of drug addicts. The vast majority of consumption is explained by episodic short-term use of opioids in the management of pain. The addiction narrative, as paraphrased by Tom Price says, is that the “life line becomes a noose”. That which once relieved a singular medical problem becomes out of control because the moral agent has become addicted and chooses not to act morally. For Price, it is faith in God that will provide the strength for those in this situation to resist the temptation to keep using opioids. Although Price acknowledges the problem of bundled-up pain, he has no cultural solution for this sensitization. In terms of the affective economy, the repetitive drug-seeking needs to be seen as a “score”, a refrain. A “scoring over a world’s repetitions” (Stewart 2010: p. 339). This is not just “in the head” or psychical. It is material. The score incorporates and appropriates daily practices: going to the doctor, telling the pain story, then to the pharmacy to fill the prescription, then going to work to sleep on the floor while the pain subsides. There are material consequences as the structure of the day changes from going-to-work-and-then-coming-home, to a series of intervals and durations. Life is rutted through, it is materially marked by the pain refrain. The tragedy of the opioid epidemic is that pain derivatives get bundled together into a collateralised debt obligation and we haven’t noticed. The pain of the many maladies that afflicted small communities became bundled together into a contract that was then itself trafficked. Pain as a commodity, shapeshifts. The pain of unemployment in Kentucky, the pain of gun violence in Oklahoma, the pain of urban disinvestment in Chicago and the pain of gang violence in Los Angeles became bundled together. As the multiple sources of pain became bundled together, and opioid consumption soared to heights never before seen, the derivatives became more abstracted and the value of the derivative changed in a nonlinear relationship to the original pain. As pain derivatives became bundled together, the value of the pain relief rose as the pain that was being treated was not just the original injury. So too, the pharmaceutical industry began to take risks. In 2008 McKesson Corporation, a wholesale distributor of opioids who supplies various U.S. pharmacies was fined by the DEA for failing to report suspicious orders of opioids. From 2008 until 2013, McKesson Corporation continued to supply increasing amounts of oxycodone and hydrocodone. Even after being forced to introduce a compliance monitoring program in 2008, McKesson did not adhere to its own program. In Colorado, McKesson processed more than 1.6 million orders for controlled substances from June 2008 through May 2013, but reported just 16 orders as suspicious (United States Department of Justice 2017a, b; State of Colorado 2018). The collateralised debt obligation was drawn down in 2017 when the McKesson Corporation agreed to pay a $150 million civil penalty for failures to identify and report suspicious opioid orders at its facilities in Aurora, Delran, LaCrosse, Lakeland, Landover, La Vista, Livonia, Methuen, Sante Fe Springs, Washington Courthouse and West Sacramento (United States Department of Justice 2017a, b; State of Georgia 2019).

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Retail pharmacies were also prosecuted. In 2015, retail pharmacy giant CVS agreed to pay $22 million to resolve allegations that two of its retail stores in the City of Sanford, Florida distributed opioids based on prescriptions that had not been issued for legitimate medical purposes. CVS is an integrated service providing walkin medical clinics and over 9700 retail pharmacies. lt operates as a pharmacy benefits manager with nearly 90 million plan members, and has a stand-alone Medicare Part D prescription drug plan. These CVS locations, is it alleged, were some the infamous Florida Pill Mills (United States Department of Justice 2015). America’s largest retail pharmacy chain Walgreens were also prosecuted. Billions of opioid doses were distributed from its Florida pharmacies since 2006. It is alleged that the company distributed 2.2 million opioid tablets from its store in Hudson, a small town of 12,000 residents. In another small town of 3000, 285,000 pills were sold in a month. The company paid $80 million to resolve allegations of inadequate record keeping in Florida (State of Florida 2018). A derivative trades not in the commodity, but in risk. The higher the risk, the higher the value that is sloughed off from the derivative when it reaches its settlement price. For non-profit companies, who received grant and gift income from pharmaceutical manufacturers, the risk they were taking seemed to be delimited to reputational risk. There seemed to be little risk in the American Pain Association promoting the agenda of Purdue Pharma by instituting Pain as the 5th Vital Sign. Likewise, there seemed to be little risk to the American Academy of Pain Medicine to support the interests of key opinion makers such as Webster, Porteney and Fine (influencers who were directly connected to the opioid pharmaceutical manufacturers Endo, Purdue and Cephalon). As noted in a Commonwealth of Massachusetts lawsuit (Commonwealth of Massachusetts 2018), the marketing team at Purdue took enormous risks when marketing oxycontin. John Stewart (former Chief Executive Officer), Russell Gasdia (former VP marketing), Mark Tymney, and Craig Landau all took risks to ensure the sales growth of high dose (40–80 mg) oxycontin during the period 2010–2013. It is alleged that these individuals, whilst knowing that long-term use of high dose oxycontin increased the risk of overdose, actively put in place strategies and practices to increase the number of people being prescribed high dose oxycontin (Commonwealth of Massachusetts 2018). In February 2011 Purdue staff provided John Stewart and the Purdue Board with documents illustrating the relationship between high-level oxycontin prescribers in Massachusetts and reports of oxycodone poisoning, burglaries, and robberies. Staff also presented John Stewart with an analysis of penalties imposed on pharmaceutical companies for illegal marketing, concluding that penalties for breaking the law are “relatively small… compared to the perpetrating companies’ profits” (Commonwealth of Massachusetts 2018: p. 208). In May 2011, sales staff were asked to improve their performance, where sales performance was indexed through the number of targeted calls, number of sales, visits to doctors and rates of high dose prescriptions (Commonwealth of Massachusetts 2018: p. 209). Purdue staff were no longer trading in pain relief. They were trading the risk of prosecution against the promise of large company profits and employee bonuses. The

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value of risk is not related to the originary pain. The pain underpinning the demand for oxycontin was displaced by the difference between profit and regulatory imposte. Several elements of the pharmaceutical industry entered into derivative contracts to supply pain relief. They engaged in practices that, if they were to get caught, they would suffer an administrative fine. If they didn’t get caught, pain would have produced a massive financial windfall for the manufacturers and distributors. The original pain was amplified as consumption increased beyond that which could be “legitimately” required for medical purposes. Different members of the pain cultural neuromatrix then amplified the value of the pain. The drugs work, they provide a relief from the pain, but not in the medical sense. Opioid medications were the investments made to manage the risk of pain, writ large. The opioids were however much more than that. Pain became the keystone commodity in a system of risk exchange that amplified the costs and material outcomes from pain. As pain shapeshifted into a different kind of debt, and those debts were bundled together into more complex derivatives, the risk of the system started to spiral. Pain had become the hidden commodity at the heart of an epidemic that was killing thousands of Americans. Pain however was also the commodity that was providing financial support to thousands of American families. The cultural pain neuromatrix recruited multiple elements into the pain response. New types of pain relief distributors emerged. Broad-based pharmacies became vertically aligned to the pain relief industry. The Florida “Pill Mills” were both a cause and an outcome from a public that had become culturally sensitised to pain. Even employment was now connected to pain relief. In 1998, during the final months of the Clinton administration when the Commodity Futures Modernization Act was being rushed through Congress, regulatory mechanisms that could have limited the derivatives market were removed. Since the global financial crisis in 2008, constraints have been placed on derivatives markets. There are however no regulatory controls on pain and its derivatives. Pain will continue, and the affective economy will drive the movement of affect through networked assemblages. Because the focus of government is primarily on restricting access to pain relief, both through tighter scheduling of opioids and the prosecution of the pharmaceutical industry, the pain relief market will continue to burst through regulatory shields. As Chen et al. (2019) have noted, the current suite of interventions may have a modest impact on prescription opioid deaths rates in the US. Additional policy interventions are needed. As was observed in the third phase of the epidemic when heroin and illicit fentanyls replaced semi synthetic opioids (such as oxycodone) as the drugs most likely to cause high levels of drug overdose, the demand for pain relief remains unsatisfied. This is not only at the level of the individual affect labourer. The demand is not just for relief from pain at the level of the individual. As Tom Price tried to recognise, there is a cultural explanation for the piling up of social and structural malady into pain tranches. The cultural neuromatrix has become sensitised to the presence of the shapeshifting commodity pain. As soon as the markets get a sniff of new pain relievers, the value of pain derivatives will surge and the engines of capital will look for the next best thing to relieve pain.

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As we will see in the next chapter, prescription opioids are soon to become displaced by another pain-relieving drug, cannabis, and not necessarily because of its strength as a pain reliever. The pain epidemic will continue.

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Chapter 4

Pain and Cannabis Markets

Cannabis is being transformed from an illegal drug that is a blight on the community, to a life-saving pain reliever. According to the American Bankers Association, thirtythree US states covering 68% of America’s population now have access to legalized cannabis for medical or adult-use (American Bankers Association 2019). However, because US Federal legislation prohibits cannabis use for any purpose, banks that engage with the cannabis industry can be considered money launderers. Federal Government legislation and drug policy in the United States have struggled to keep pace with cannabis markets. Similarly, in Australia, since 2015 two very different images of cannabis have emerged. First there is the image of the “stoner sloth”, a character from a Government anti-drug television advertisement. The second image is the face of Olivia Newton-John, international celebrity, cancer sufferer and medicinal cannabis consumer/producer. One image describes the illicit recreational cannabis user and the other is associated with pain relief. We start the chapter with some dysjunctions between two very different images of cannabis use. In 2015 an Australian State Government—New South Wales—commissioned a TV advertising campaign to discourage young people from smoking cannabis. It was called the “Stoner Sloth” campaign and its tag line was “You’re worse on weed”. Saatchi & Saatchi produced the campaign reportedly at a cost of around $500,000 (https://www.theguardian.com/society/2015/dec/28/500000-stoner-slothadverts-defended-by-creators-saatchi-saatchi). The advertisements featured young people as teenage-sized sloths in school and family situations, being the target of ridicule and contempt from those around them for being cognitively-impaired “stoner sloths”. The campaign, whilst designed to send a cautionary message to young people to not consume cannabis, became an internet hit. The message was so poorly targeted that the ads became entertainment for young people. Additionally, the search engine query “Stoner Sloth” inadvertently redirected people to a Colorado cannabis retailer (https://www.theguardian.com/society/2015/dec/21/stoner-slothanti-drug-campaign-drives-traffic-to-site-promoting-cannabis-use). The stoner sloth

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campaign spawned T-shirts, merchandise and a number of You Tube parodies, including one parody featuring the then Australian Prime Minister Tony Abbott (https:// www.youtube.com/watch?v=RKRQD04dviU). After one week the online advertisement had generated over 4 million views on Facebook and the You Tube clip and had over 30,000 likes (https:// www.smh.com.au/national/nsw/saachi–saachi-defends-500000-stoner-sloth-antimarijuana-campaign-20151225-gluwrv.html). Critics labelled the messaging as old fashioned and out of date. The Australian National Cannabis Prevention and Information Centre distanced itself from the campaign (https://www.smh.com. au/national/nsw/stoner-sloth-antimarijuana-campaign-from-nsw-governmentrelentlessly-ridiculed-20151219-glrjzh.html). In 2017, not long after the Stoner Sloth had disappeared from the public arena, Olivia Newton-John visited Australia on a promotional tour for her cancer charity and to publicise her interest and support for medicinal cannabis. News of her cannabis use was covered internationally (https://www.thesun.co.uk/tvandshowbiz/ 5143866/olivia-newton-john-is-using-cannabis-to-stop-agonising-pain-duringcancer-battle/). The message from the Olivia Newton-John campaign was ostensibly, when you are surviving cancer and in pain, you are better on weed. The message wasn’t just coming from an average citizen, it was coming from one of the world’s most respected entertainers. This is the dysjunction that the Australian public (and the markets) were facing in 2017. On the one hand, cannabis was life-giving, whilst on the other hand, cannabis was ruining our children. The source of the message was also important. One source was highly respected and looking to the future. The other was a government that has a history of fear-mongering through drug information campaigns. The dysjunctions are not limited to the public representation of cannabis consumers. The changing policy context across different jurisdictions in North America, also provides a confused picture for policy makers (Caulkins et al. 2015; Kilmer 2017). This is as unstable a drug policy arena as can be imagined. Not only do adjacent sovereign nations differ in their approach to cannabis (as is the case with Canada and the United States), even within federated countries there are profound differences. Colorado, Oregon and California have different taxation regimes for legal recreational and medicinal cannabis consumption (Oregon Liquor Control Commission 2019). Washington has a different regulatory approach to cannabis, as does Nevada. A broader context provides an even more perverse view. At a time when US doctors are being prosecuted by federal authorities for the inappropriate provision of opioid analgesics to pain sufferers, and opioid manufacturers are being prosecuted for not disclosing the full evidence base for their drugs, medicinal cannabis is now accessible to a large slice of the American population when there is little clinical evidence that it is effective for pain relief. Looking across the globe, cannabis drug policy is in a policy freefall. Speculative global cannabis markets are driving investment in cannabis industries, even in countries that have restrictive regulatory regimes. In Australia for example, although the Federal Government has established a regulatory regime for people to get access to

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medicinal cannabis the actual number of people able to navigate the system is negligible. This hasn’t stopped global cannabis industries from generating investment interest about future Australian cannabis market activities. There are numerous threads in the complex pattern of relations. Economic, cultural and political forces are all at work. The pain cultural neuromatrix, operating across different milieu will structure the subsequent analysis. Following the flows of capital linked to the cannabis economy, and recognising shapeshifting commodity pain as driving the flows of capital, we can obtain a better understanding of the cultural and political-economic context for the cannabis policy arena. Importantly, it is essential get a better handle on how pain is located in the operations of the market and structuring the desire for cannabis. We will start with examining the basis of market interest in cannabis, pain relief.

4.1 Cannabis as a Pain Reliever The evidence for cannabis as a pain reliever is on the one hand very simple: people report that it is effective as a pain reliever and it makes them feel good. On the other hand, the clinical evidence for cannabis as a pain reliever is not clear. Pre-clinical data in animal models and in vitro systems has shown that cannabinoid receptor agonists block pain in various models of acute and chronic pain (Fitzcharles and Eisenberg 2018). Human clinical data is not as straight-forward. Lutge et al. (2013) systematically reviewed the impact of cannabis treatment on morbidity and mortality in patients with HIV/AIDS. Although THC was found to have effects on mood, peripheral neuropathy and the subjective effects of the drug, the review found there to be little evidence of efficacy in this patient group. Deshpande et al. (2015) reported in their review of cannabis efficacy in noncancer patients that marijuana, when smoked, is of questionable efficacy for managing chronic non-cancer pain. In a commentary on the review, Ladouceur (2015) asserts that this finding “confirmed what most of us thought: that marijuana is not effective for the treatment of pain and that the beliefs of proponents are based more on myth than reality”. Ladouceur (2015) noted also the dysjunction between the clinical findings and the widespread use of cannabis for pain relief. Canadian population survey data suggests that in 2011, approximately 420,000 Canadians had used cannabis for medical reasons, prompting the question “How can a substance purported to have so little efficacy also be so widely used?”. A systematic review of twenty-four randomised controlled trials suggests that cannabis and cannabis-related medicines have a small but significant impact on chronic pain (Aviram and Samuelly-Leightag 2017). Specifically, inhalation was found to be the most efficacious route of administration for pain relief; cannabisrelated medicines were not effective for postoperative pain but were effective for neuropathic pain and non-cancer pain. The clinical significance of these findings is however not clear.

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Häuser et al. (2018) in a qualitative review of ten systematic reviews of cannabis and pain, report that there were inconsistent findings on the effect of cannabisbased medicines on neuropathic pain and muscle spasm in multiple sclerosis. There was insufficient evidence of any cannabis-based medicine for pain management in patients with rheumatic diseases or in cancer pain. Abrams (2018) when summarising the findings of the National Academies of Sciences, Engineering and Medicine (2018) report on medicinal cannabis suggests that there was conclusive and substantial evidence that chronic pain patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms. In a review of 41 studies, Amato et al. (2017) reported that there was evidence of a small effect for people suffering chronic and neuropathic pain (compared with placebo). However, confidence in the estimate is low and these results could not be considered conclusive. Lötsch et al. (2018) suggest that controlled studies showed: Cannabinoid-based drugs heterogeneously influenced the perception of experimentally induced pain including a reduction in only the affective but not the sensory perception of pain, only moderate analgesic effects, or occasional hyperalgesic effects.

It was also noted that in uncontrolled or “open-label” studies, cannabis was nearly always associated with analgesia. Lötsch et al. (2018) propose reluctant support for a broad clinical use and that the main effect of cannabis was on well-being or mood rather than on sensory pain. According to Lötsch et al. (2018) THC has its most profound impact on the affective system, rather than on direct pain processing. A controlled human experimental study (Walter et al. 2016) demonstrated that THC acts by disrupting pain processing in the neuromatrix. THC interferes with sensory processing, which in turn reduces sensory-limbic connectivity and reduces the activation of affective regions. In a mixed methods online survey of 1365 medicinal cannabis clients, Piper, et al. (2017) reported that approximately 75% of the sample in answer to the question “How effective is medical cannabis in treating your symptoms or conditions?” rated the use of medical cannabis as effective. This reflects other open-ended and qualitative studies in the US (Reiman 2009; Zaller et al. 2015; Boehnke et al. 2016); United Kingdom (Ware et al. 2005), Canada (Walsh et al. 2013), and Australia (Swift et al. 2005). In a systematic review of 16 studies with 1750 participants Mücke et al. (2018) report that cannabis-based medicines may increase the number of people achieving 50% or greater pain relief compared with placebo. Mücke et al. (2018) also report that cannabis products were better than placebo for substantial and moderate pain relief and global improvement. They reduced pain intensity, sleep problems and psychological distress. There was no difference however between all cannabis-based medicines pooled together and placebo in improving health-related quality of life. The “subjective” effects of cannabis are that it reduces trauma pain, menstrual pain, cancer and abdominal pain. It is reportedly, not-so effective on neck and back

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pain, neuropathic and post-surgical pain (Piper et al. 2017). Observational studies report a much higher level of patient pain relief outcomes. Although this picture may seem to be confused and contradictory, there is a framework emerging for understanding the effects of cannabis on pain. How you appraise the evidence of cannabis pain efficacy depends on how you understand pain. Traditional evidence-based clinical medicine has difficulty with evidence for cannabis efficacy. As noted in this review commentary by Fitzcharles and Eisenberg (2018): … there is currently limited information available from reliable randomized controlled trials examining the therapeutic effects of cannabis for chronic pain, although there is increasing report of considerable subjective effect. (p. 488)

The key to cannabis pain relief is on understanding how pain is perceived. If pain is a measurable objective experience, then the evidence is minimal. If pain is accepted as subjective and relative, the evidence is much clearer. We know from Chap. 3 that the methods for measuring “objective” pain are themselves relative and subjective. Pain rating scales transform the experience of pain as a symptom, into a measurable and reproducible sign. This is a discursive process rather than a blind empirical process. So, the distinctions between “reliable” randomised trials that use subjective measures and non-randomised trials that report on “subjective” effects are not empirical, they are discursive. Does this mean that objective measures are measuring real pain and subjective measures are measuring inauthentic pain, pain that originates from emotion? Similarly, if measuring pain is inherently discursive, regardless of whether you use a visual analogue scale or a self-reported survey response, does this discount the reliability of pain measurement? For pain specialists such as Lorimer Moseley, it is all pain: “Pain is always real, no matter what is causing it” (https://www.theguardian.com/australia-news/2019/apr/04/coalition-toannounce-68m-in-funding-for-pain-treatment-and-education). It is the sense we make of pain that counts, because depending on how pain is framed, will determine how open we are to finding remedies, and how successful those remedies will be. The North American cultural pain neuromatix is now sensitised to pain. The cultural pain neuromatrix has experienced over 15 years of pain marketing campaigns; clinical practices that elevated that status of pain; industry-self reporting regulatory mechanisms that enabled the rampant distribution of pain relievers; commercial payment systems that rewarded doctors who prescribed pain relievers; political processes that supported pain-reporting interest groups and financial markets that are geared to finding an economic benefit from pain-relieving drugs. At this stage, it doesn’t matter whether the pain measurement is objective or subjective, discursive or empirical, the sensitized cultural pain neuromatrix now produces central protective responses. Even in the absence of “tissue damage”, central sensitization generates protective pain messages. The cultural pain neuromatrix is the source of pain.

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When people look for the source of pain that has been driving the desire for pain relief, the answer is to be found in higher levels of industrial injuries, economic despair, addiction or clinical greed. But these are not the drivers of pain. The cultural pain neuromatrix produces the refrains that organise the institutional practices of various elements within different milieu. These are the equivalents of muscle spasm, referred pain and phantom limb effects.

4.2 Replacing Other Drugs In one of the few studies to examine the replacement of opioids with medicinal cannabis, Haroutounian et al. (2016) found that chronic pain patients (mostly musculoskeletal pain), experienced a significant reduction in chronic pain measures following an open-label trial. Measures of disability and emotional functioning also all improved from baseline. The improvements were modest: the main pain measure only improved by 10% from baseline. Most importantly, 44% of those who had been using opioids, discontinued opioid treatments after 7 months of cannabis treatment. For those patients who continued to use opioids after the trial, their use declined from 60 mg to 45 mg oral morphine per day. However, this was not a statistically significant reduction. The clinical significance of these findings are not clear. Dose was not held constant, as patients modified their dose level to manage their pain. A small 10% reduction in pain score may seem insignificant for some patient groups. However, for “treatmentresistant” patient groups such as this one, the changes may be quite substantial. There were strict entry criteria into the trial. Patients were only eligible if they had a history that included no pain relief from at least 2 pain relievers from 2 different drug classes at full dose. Many pain patients use cannabis as a partial or complete substitute for opioids (Boehnke et al. 2016, 2019; Davis et al. 2016; Lucas and Walsh 2017; Lucas et al. 2016; Nunberg et al. 2011; Piper et al. 2017; Reinarman et al. 2011). Eighty percent of an online sample of concomitant cannabis and analgesic patients reported substituting analgesics with cannabis. Respondents reported substituting on average two other medications with cannabis (Boehnke et al. 2019). High proportions of respondents also reported that cannabis substitution resulted in complete cessation of: opioids (72%), benzodiazepines (68%), NSAIDs (44%), and gabapentanoids (74%) (Boehnke et al. 2019). Bradford et al. (2018) report that between 2010 and 2015 there were 23.08 million daily doses of any opioid dispensed each year under US Medicare Part D. States with medicinal cannabis laws consumed 3.742 million fewer daily doses. States with home cultivation medical cannabis laws consumed 1.792 million fewer opioid doses. The findings were most substantive with regard to hydrocodone and morphine. Those states with medicinal cannabis laws witnessed a 14.4% reduction in the use of any opioid. These results are also supported by 24.8% lower levels of opioid mortality in states with medicinal cannabis laws (Bachhuber et al. 2014). States

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having medical marijuana laws were also likely to have reduced hospitalizations for opioid use disorder (Powell et al. 2018; Shi 2017) and reduced levels of traffic-related harm (Kim et al. 2016). The substitution seems also to extend beyond opioids. Bradford and Bradford (2017) report that from 2007 to 2014, antidepressant and anti-anxiety prescriptions were lower in states with medical cannabis laws than in other states. The consumption and replacement data suggest, that whether or not cannabis is “actually” reducing pain, in those places where cannabis is available as a pain reliever it is being consumed as a pain reliever often to replace opioids. The question of whether pain is being reduced or not, is in one sense a moot point. People are choosing for cannabis to be used as a pain reliever.

4.3 Temptation Goods From a public policy perspective, Caulkins (2017) asserts that marijuana is a “temptation good”, more similar to video games and doughnuts than to cocaine or heroin. These goods are consumed with an immediate benefit, with a delayed cost. For Caulkins, cannabis is an indulgence that is not dangerous in moderation, but can easily get out of control. From an economic point of view, a temptation good can be contrasted with an investment good. An investment good is one that has current costs and future benefits. Banerjee and Mullainathan (2010) suggest that “temptation goods” are the set of goods that generate positive utility for the self in the present. For Banerjee and Mullainathan (2010) temptation good theory helps to explain the consumption patterns of poor people who are thought by some, to differentially discount future costs in preference for present benefits. In an analysis of cash availability and alcohol and tobacco purchases, Evans and Popova (2016) suggest that cash availability has no impact of the consumption of temptation goods. In an experimental study of food consumption in Thailand, peer observation has an effect on the consumption of temptation goods; peer observation can counteract the effect of a lack of knowledge of a product; and importantly, group temptation food choices when they are observed, have less variation within a group (Grohmann and Sakha 2015). In other words, consumption of temptation goods is inherently structured by social forces. Being aware of being observed neither increases nor reduces consumption, rather, it reduces the variation of consumption, it is driven to a mean. In Foucauldian terms, this would indicate the presence of a disciplinary force in consumption. Consumption of temptation goods are not just regulated through individual choice but are subject to normative social forces. Taking into account this economic perspective is critical in understanding the force of the social in shaping the consumption of cannabis in North America. Now that the social acceptability of cannabis has reached a normative level, it is likely that consumption of this temptation good will follow social forces. As a temptation good, it has an acceptability for a number of population segments. The wisdom of the

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crowd (and the market) has asserted that cannabis is an effective pain reliever. Almost regardless of the clinical perspective (as rooted as it is in the artifice of objective rendering of pain measurement), people are voting with their wallets. There is a population of pain sufferers who will continue to consume cannabis, as the immediate benefits will outweigh any possible future costs. The population of recreational consumers will also continue to consume cannabis for similar reasons but not for the purpose of pain relief. It is a temptation good that produces a valued altered sense of self. Cannabis can assume a commodity status that few other objects can enjoy. It shapeshifts between therapeutic good and temptation good. It almost doesn’t qualify as a therapeutic good because of its low clinical efficacy. When drug policy leaders such as Caulkins (2017) advise that cannabis should be considered a temptation good, this is a major departure from the framing of cannabis as a dangerous illicit substance, a framing that has dominated illicit drug policy for the past 100 years. This shapeshifting is one of the reasons for the policy freefall.

4.4 Public Opinion of Cannabis Considering the widespread consumption of cannabis both as a pain reliever and as a recreational drug, it is worthwhile to examine the public opinion literature to try and gauge changing beliefs about cannabis. The US “Monitoring The Future” student survey collects data about the perceived harmfulness of cannabis use. The percentage who believed cannabis use is risky has declined 50% since 1991 (Miech et al. 2018). There were two period of decline, from 1991 to 1997 and from 2007 to 2018, with a 10-year plateau between 1997 and 2007. Over the same time period, there were also declines in the perceived riskiness of use of other drugs. The perceived riskiness of cocaine, whether in powder or crack form declined from around 60% to around 50% between 1991 and 1997, however the perceived riskiness has remained quite stable from 2007 to 2018. The perceived riskiness of trying heroin once or twice has also remained stable between 1995 and 2018. Grade 8 opinion is an interesting indicator as this cohort is the least likely to have used these substances compared to older cohorts, so this indicator not only measures grade 8 student opinion, it is also a proxy for normative opinion reflecting children before they start using a range of illicit substances. Interestingly the perceived riskiness of oxycodone, perceived as the least risky of all these substances, has remained stable from 2012 to 2018 in this third phase of the US opioid epidemic, suggesting the late stage of the epidemic has had little impact on risk perception for this age group. There is no generic dilution or elevation in the perceived riskiness of illicit drugs over this time. Cannabis is however the exception. Using data from the National Survey on Drug Use and Health (NSDUH), that reports on adult perceptions of risk, Compton et al. (2016) report on the relationships between perceptions of cannabis risk and its use prevalence. Adults’ perception of a great risk of harm from smoking marijuana decreased from 50·4% in 2002 to 33·3%

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in 2014. Over the same period the prevalence of daily or near daily use of marijuana increased from 1·9% in 2002 to 3·5% in 2014, translating to an increase in the number of daily or near daily users from 3·9 million in 2002 to 8·4 million in 2014. The awareness of state legalisation of medical marijuana increased from 17·9% in 2002 to 32·6% in 2014, with a significant upward trend starting in 2004. Interestingly, the prevalence of marijuana use disorders in adults remained stable at about 1·5% between 2002 and 2014 (https://www.primeindexes.com/resources-file.php? key=MTQ). Hasin (2018) notes that four of the eight states that decriminalised recreational cannabis use, did so after 2014. Although by 2007, twelve US states had legalised medical marijuana use and use had increased. Compton et al. (2016) found neither an increase in marijuana use disorders nor an association between changes in the perceived risk of harm and the prevalence of marijuana use disorders. Together these findings suggest that the medicalisation of cannabis that occurred through the introduction of medical cannabis laws has accompanied a change in public perception of the risk of cannabis. This has resulted in an increased level of use, however has not produced any substantive increased level of cannabis use disorders. Public opinion is an iterative feedback process, where public opinion feeds policy which then feeds evidence of public opinion (Sznitman and Breteville-Jensen 2015). The increase in public discourse supporting the medical benefits of cannabis will increase the belief about medical benefits of cannabis in the general population which may in turn increase public support for cannabis legalization more generally. Results also suggest that once medical cannabis is legalized, factors beyond cannabis-specific beliefs will increasingly influence medical cannabis legalization support. In an analysis of cannabis policy maker perspectives in Michigan, New Mexico, Illinois, Kentucky and Louisiana, Grbic et al. (2017) suggest that research evidence plays only a small part in decisions about the legal status of medicinal cannabis. McGinty et al. (2016) reported on news media coverage of cannabis policy news items over the period 2010–2014. An analysis of 610 news stories published/aired across a range of media channels showed coverage of recreational marijuana policy to be dominated in five jurisdictions that legalized cannabis for recreational use during this time. Arguments for (53%) and against (47%) legalization were relatively balanced. In an attempt to assess what sense the public makes of media and political discourses, McGinty et al. (2017) conducted an online survey (N = 910) of public attitudes about the policy arguments for and against legalised access to cannabis. The results were compelling: On both sides of the recreational marijuana legalization debate, there are arguments that resonate with the American public. However, public health risk messages were viewed as less compelling than pro-legalization economic and criminal justice-oriented arguments.

It was found that although there was a strong level of agreement with arguments that cannabis may increase road deaths and influence youth, these argument did not appear as drivers of public attitudes in their statistical analysis. Instead, arguments that

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focussed on reduced crime, reduced policing and economic benefits of legalisation were found to both have high agreement in the sample and were drivers of public opinion. McGinty et al. (2017) also noted that reduced crime, reduced policing and economic benefits of legalisation were the most prevalent media stories in their media analysis. They interpreted this finding by saying: Recreational marijuana legalization advocates have either (a) identified and deployed a set of arguments that already resonated with the public, or (b) convinced the public that these are strong arguments in support of pro-legalization efforts. In contrast, the three anti-legalization arguments significantly associated with decreased support for legalization in the ordered logit model (expand marijuana industry, increase crime, and threaten moral values) rarely appeared in news media coverage. (McGinty et al. 2017)

What is interesting is the threat of an expanded marijuana industry is not one which significantly undermines pro-legalisation arguments. In fact, economic arguments are one of the strongest arguments for liberal policy reform. Dilley et al. (2017) reports that statewide recreational cannabis legislation does not necessarily result in increased access to recreational marijuana markets. Following the introduction of statewide cannabis laws in Washington, approximately 30% of local communities introduced laws that restricted access to cannabis. Washington is an illustration of a different approach to regulation compared to other states, such as Oregon, Colorado and California, which have large retail markets. Rather than support a commercial retail market, Washington residents are allowed to produce and use small amounts of marijuana (McGinty et al. 2017). Recreational marijuana laws create regulated retail markets for marijuana similar to those for alcohol and tobacco (Caulkins et al. 2015). Even within this broader legalisation, California legislation (California State Legislature 2016) allows counties to impose local restrictions on cannabis markets (Medicinal and Adult-Use Cannabis Regulation and Safety Act (MAUCRSA), Chap. 20). Considering the heterogeneity of policy responses, it is worthwhile examining public opinion towards cannabis in wider population-level polling.

4.5 Broad-Based Opinion Polls According to a 2018 Pew Research Center survey (https://www.pewresearch.org/ fact-tank/2018/10/08/americans-support-marijuana-legalization/), 62% of Americans support the legal recreational use of cannabis, double what it was in 2000 (31%). Gallup polls estimate public support to be marginally higher. Their time series on public opinion dates back to 1975 when support for legal cannabis was as low as 12% (Jones and Saad 2018). Support for medical cannabis is very strong in Australia increasing from 69% in 2013 to 85% in 2016 (AIHW 2017). Although public support for legalisation is increasing in Australia, the levels of public support for legalisation of recreational cannabis is lower in Australia than in public opinion polls in the United States. The

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percentage of the Australian public who believe that possession of cannabis should be a criminal offence has dropped from 34% in 2010 to 26% in 2016. There is diminishing support for increasing penalties for the sale or supply of cannabis (from 58% in 2013 to 50%) in 2016. The longer trend (1969–2000) in American public opinion, is that of consistent low support for legal recreational cannabis consumption. The rapid change in sentiment emerged around 2000. Positive sentiment towards legalisation in the US doubled between 2000 and 2010 and then grew another 16 points up to 2018. Australian sentiment has only been measured routinely since 2010, where support for legalization has grown 14 points over 9 years from 21% to 35% in 2016. It could be argued that the rate of change in public opinion over the past 8 years has been similar in the US and in Australia. Where the two jurisdictions differ is in the baseline levels of support for law reform. The differences between US and Australian public opinion towards cannabis reflects profound historical differences in cannabis law enforcement, different population segments’ experiences with illicit drugs and different population demographics. There is a significant principle emerging regarding the perception of cannabis. Cannabis can be many things to many people. The substantive heterogeneity both within and across jurisdictions is borne out of the different histories of engagement with cannabis. In the United States, even within states with legal recreational cannabis laws (such as Washington and California), counties have the capacity to prohibit legal cannabis consumption. Interpreting population-level opinion polling is difficult when there is such heterogeneity.

4.6 A Shapeshifting Commodity Shapeshifting is a quality of the commodity and a product of the instability of the categories we use to classify the commodity. As noted in Chap. 3, underneath the opioid epidemic was commodity pain. An additional complexity to the shapeshifting is the possibility that the frameworks being used to classify the substance are themselves producing instability in the identity of the substance. The very framework we use to classify and contain the drug, itself contributes to the shapeshifting quality. As noted, cannabis is used as both a pain reliever and recreationally for its mood-altering properties. This is however not just a property of cannabis. Prescribed pain relievers are not just used to relieve pain. Interestingly, according to the US National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration 2017), only 62% of people who report misuse of a pain reliever use it to relieve “physical” pain. Table 4.1 shows the other uses to which pain relievers are used. This table reveals two foundational framings in understanding the use of pain relievers. The framing revolves around the category of “physical pain”. As we know from previous chapters, pain is not just physical. The first framing is the distinction

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Table 4.1 Main reason for the most recent prescription pain reliever use among people aged 12 or older “who misused prescription pain relievers in the past year” % response Relieve physical pain

62.3

Feel good or get high

12.9

Relax or relieve tension

10.8

Help with feelings or emotions

3.9

Help with sleep

3.3

Experiment to see what it’s like

3.0

Hooked or have to have drug

2.1

Increase or decrease the effects of other drugs

0.9

Some other reason

0.9

Data from Substance Abuse and Mental Health Services Administration (2017: p. 23)

between physical pain and everything else (not called pain). This is an artefact of an antiquated model of pain. The problem of older pain models is that they continue to structure understandings of pain relief. Conversely, they also structure what can be considered drug misuse. The stability of the category “physical pain” enables the stability of the category of “drug misuse”. There is no other type of pain provided in the table of reasons. Pain relievers are used for pain other than physical pain, it is just the survey doesn’t recognise other types of pain. This distinction erases the intimate connections between different types of pain and the centrality of pain as a complex experience. The second foundational framing is the conflation of “feeling good” and “getting high”. These categories may well be two distinct experiences. Feeling good may well be a remedial state that provides respite from feeling bad or being “in pain”. Getting high is an altogether different experience, related more to consuming a mind-altering substance. This compound category compresses two experiences and erases those senses of being-in-the-world that do not fit between being in physical pain and feeling good. There is no single construct being measured here (i.e. a cognitive reason). There are multiple overlapping constructs (good-not good; pain-no pain; high-not high; addicted-not addicted). If a category “relieve mental pain” was included, a very different picture of substance use would emerge. I placed parentheses around the heading in Table 4.1. to emphasise the artefact produced by framings used to understand the use of substances. The primary measure of substance misuse in the United States is “without a prescription of one’s own or use at a higher dosage or more often than prescribed” (Substance Abuse and Mental Health Services Administration 2017: p. 23). Again, this primary demarcation between use and misuse creates categoric distinctions that add to the “shapeshifting”

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quality of the substance. Perhaps it is the incoherence of these foundational framings that contributes to a failure to capture the fluidity through which pain is felt, understood and managed in the body. The incoherence may not be due to the complexity of the drug, but to category confusion across multiple overlapping body states. No wonder, where there is confusion as to the effects of these drugs, that there are problems with framing the effects of cannabis.

4.7 Cannabis as a Pain Reliever in Australia The literature on cannabis as a pain reliever in Australia is patchy. The Australian Pain Management Association (APMA), a health promotion charity providing advocacy, information and practical support for people living with chronic (persistent) pain and their families, reports on a convenience sample from an on-line survey of 600 cannabis consumers recruited through Facebook and other APMA-related social media sites (https://www.painmanagement.org.au/using-joomla/extensions/ components/content-component/article-category-list/322-living-with-pain-viewsof-medicinal-cannabis.html). Survey respondents had a strong appreciation (87%) of State Government activities to legalise medical cannabis. The likely top five conditions thought to benefit from prescribed medicinal cannabis included, back pain (>80%), nerve pain (75%), arthritis, neck pain and fibromyalgia. In addition to the 11 medical conditions listed in the survey question, respondents nominated 258 other conditions that they thought could be treated with cannabis. The survey report noted that 85% of respondents believed that there was scientific evidence to support cannabis use for chronic pain conditions. When asked the source of their information, respondents referred to social media (48%) and online news or current affairs (44%). It was estimated that 72% of respondents had used cannabis for analgesic purposes: back pain (48%); nerve pain (41%); neck pain (32%) and arthritis (30%). Lintzeris et al. (2018) reporting from a convenience sample drawn from an online survey of 1588 medical cannabis users (recruited from online media and consumer group webpages, including Facebook groups, and at professional and medical cannabis consumer forums), found somewhat different results. The survey found that anxiety (51%), back pain (50%), depression (49%), and sleep problems (43%) were the main reasons for the use of cannabis. The symptoms most frequently managed with cannabis by respondents were pain (69%), sleep abnormalities (69%), and anxiety (57%). Again, it seems that cannabis means different things to different people. In this first section of the chapter I painted a particular picture of cannabis consumption and pain relief. My focus was on the heterogeneity of cannabis for the public. This is important because the cannabis policy arena is in freefall internationally, particularly because of the way North American jurisdictions are attempting to extract value from this substance, under the broader rationale of managing pain.

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These changes in North American sentiment have caused ripple effects internationally. These are what would be called modulations in the social arena. These modulations are what Deleuze and other social theorists suggest is at the heart of the “modulation society”. A second key feature of this picture that I have created is that of the centrality of affect and emotion in the pain-relieving action of cannabis. Up to this point of the chapter, I have referred to the orthodox medical rendering of emotion in the affective domain. Throughout the discussion of the efficacy of cannabis as a pain reliever, cannabis seemed to be working more with “affective systems” rather than “pain systems”. The split in the medical literature between those that measured efficacy using “objective” measures of pain, and those who rely on more “subjective” pain measures, also contributes to a suspicion that underlying the cannabis site of action is a category/discursive problem with framing pain relief. The affective domain is not just a site of action, but the affective may well be the medium of the clinical message. This then opens the way for the third feature of my rendering. Cannabis itself is a shapeshifting commodity. By virtue of (1) cannabis’ multiple sites of action; (2) the instability of framing devices for understanding its efficacy (pain as both objective and subjective); (3) its political movement from an illicit substance to a life-saving remedy; (4) economic identity as both a therapeutic good and a temptation good; and (5) its economic identity as both a state cost and a taxation opportunity, cannabis has become almost impossible to contain in one category. These multiple modulations across structuring categories produce a field of potential that is ripe for capital to extract value. The second section of this chapter will reiterate some of the key terms that enable a discussion of the intersection between culture, power, economy and pain. I will also introduce some new terms that facilitate the links between affect and economy. These key terms are one’s through which I will examine how money is made from pain through cannabis. These technical terms connect power to capital and the extraction of value from modulations in the policy field.

4.8 Modulation Deleuze was famously quoted as saying that society is moving away from a society where particular “docile” bodies are created by specific disciplinary settings (such as the school, the prison and the clinic), to a society of control where subjects are in continuous modulation as they move through different social fields (Deleuze 1992). As bodies move through different fields of relations they modulate. Both their form and substance is modified to fit their relations to the world. Based on the philosophy of technology by Simondon (2005), this form of modulation has been posited as a particular feature of modern society dominated by advanced surveillance technologies.

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Hui (2015) suggests that there are two dominant forms of modulation discussed by Delueze and Simondon and their secondary writers. The first refers to a technical change to the shape of an object. The second refers, in an ontogenetic sense, to the shifting nature of both form and matter in relation to the amplification and modulation of information (Simondon 2005; Hui 2015). Simondon posited that modulation, which can be imagined in informational, ontogenetic and in social terms, should be understood through “amplification”. Three levels of amplification are at the heart of modulation for Simondon. Transductive modulation, where the energy from a small nuclei of information then fuels the creation of new, larger, metastable structures. Modulatory amplification where a small amount of energy is applied to modulate an existing flow to create an amplified outcome. And the third, organisational amplification which contrasts two sources of information and adjusts the information output to reconcile or balance the flows of information (Hui 2015). Although Simondon explicitly rejects that these abstract principles should be dealt with through social analogies (as for Simondon they are not analogies, the principles operate at all levels), I will however use illustrations to ground the principles. An illustration for transductive amplification is the rumour that is spread through social networks through non-linear relations based of the affective power of the rumour. An example of modulatory amplification is the application of a marketing algorithm/filter to detect a data behaviour in web traffic to amplify a specific semantic/affective content and feed it into a social media newsfeed to mobilise political outrage. An example of the third amplification is where a commercial company will contrast two insurance rates to amplify consumption of one product against another. The consequences of different types of modulation are important for how we conceptualise how the governance of drugs relates to how value is extracted from cannabis policy. Post-Foucauldian theorists refer to different forms of governmentality arising from different forms of sociality. Rouvroy (2012) asserts that governmentality is not embedded in social and political formations (as is the case in neo-liberal governmentality), but in the material apparatus used to live. This is the rise of “algorithmic governmentality”. This form of governmentality is embedded in the devices of everyday life. All patterns of behaviour are monitored and, when registered as information, those patterns can be used to trigger social interactions on a larger scale or “data behaviourism” (Zuboff 2019). This is a form of modulatory amplification. Modulatory amplification through algorithmic governmentality produces a different configuration of the subject. For Rouvroy (2012), the subject, instead of being conceived as a self-regulating subject, is now de-subjectivised: it is a fragmentary collection of behaviours rather than a sovereign self. The subject is not produced within a certain disciplinary setting (as was the disciplinary or neo-liberal subject), the de-subjectified entity is contingent, produced by algorithmic governmentality in response to the detection of a pattern across a collection of behaviours in specific contexts (Rouvroy 2012).

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The modulation that occurs is not just in the appearance of the subject, but in the constitution of the subject in the field of relations within which it is situated. At stake is the capacity of traditional forms of governance to operate in this highly automated field of relations.

4.9 Neurochemical Selves Although Nikolas Rose (2005) was very much located within the discussion of the neo-liberal subject, the neurochemical self as posited by Rose, is nonetheless an important concept within the discussion of cannabis markets and modulation. The neurochemical self is an outcome from modulation. For Rose, the neurochemical self is flexible and can be reconfigured to obscure the “boundaries between cure, normalization, and the enhancement of capacities” (Rose 2005). A feature of the neurochemical self is that the psychoactive drugs that sit at the boundaries of therapy and enhancement, reshape how health, sickness and wellness are conceptualised and are central to the continuous work of the modulation of our capacities. The consequences for the neurochemical self are profound, as it is not just that the substances are used to modulate, but are used to identify and define subjects at the molecular level. In the terms of the cultural pain neuromatrix framework, the neurochemical self is a refrain. The cannabis user is now defined in terms of the type of cannabis-related component: it is the relative proportions of THC (tetrahydrocannabinol) or CBD (cannabidiol) in cannabis formulations that will define the patient as either a recreational or a medical consumer. The refrain of the neurochemical self has produced the licence that is granted to medical cannabis users. However, there is no licence given to recreational cannabis users, and the criminalisation refrain that has been at the heart of the cannabis discourse for nearly 100 years is losing its efficacy, at least in North America. The neurochemical self, operating at the edges of therapy, well-being and temptation is modulating. The modulation between different neurochemical selves is one of the key contributors to the policy freefall. In order to see how capital extracts value from these modulations, we need now to examine how affect operates in fields of potential.

4.10 Affect in the Field of Potential Defining affect is crucial to understanding the affective economy and the broader economy. As noted in Chap. 2, affect is defined differently by a range of authors. In earlier chapters I wrote about affect in such a way, so as to limit the discussion of affect to emotion. In this section of the chapter I will extend affect into its more abstract definition. Affect will refer to what Brian Massumi refers to as “virtual

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potentials”. Massumi is famously difficult to read for those not embedded in continental philosophy. However, it is in his interviews that he translates his complex conceptual work into concrete illustrations (Massumi and Kim 2005; Massumi and Zournazi 2006). Massumi describes the relationship between emotion and affect: No one emotional state can encompass all the depth and breadth of our experiencing of experiencing — all the ways our experience redoubles itself. The same thing could be said for conscious thought. So, when we feel a particular emotion or think a particular thought, where have all the other memories, habits, tendencies gone that might have come at the point? And where have the bodily capacities for affecting and being affected that they’re inseparable from gone? There’s no way they can all be actually expressed at any given point. But they’re not totally absent either, because a different selection of them is sure to come up at the next step. They’re still there, but virtually - in potential. Affect as a whole, then, is the virtual co-presence of potentials.

Massumi’s affect is “the virtual co-presence of potentials” (Massumi and Zournazi 2006 http://www.assembly-international.net/Interviews/html/brian% 20massumi.html). When we walk down the street we are surrounded by a swarm of virtual potentials. Our sense of these potentials around us, is what we would call freedom. Our degree of freedom centres on our capacity for openness, to be open to the changing potential in the world around us, our openness to the roll of the dice. Our affects are however never just ours: “In affect, we are never alone”. Affects are a way of connecting to others in the field of relations within which we are situated. A heightened sense of affect intensifies our sense of embeddedness in the world around us. It is an intensified sense of belonging. Most importantly an affect is not tied to a feeling or an emotion: There’s an affect associated with every functioning of the body, from moving your foot to take a step to moving your lips to make words. Affect is simply a body movement looked at from the point of view of its potential - its capacity to come to be, or better, to come to do. (Massumi and Zournazi 2006)

Cannabis users do not choose subjectivity based on the THC:CBD ratio in their medicinal cannabis formulation. It is chosen for them. The modulation of the dividual across social domains and subjectivities is determined for them by the form of the neurochemical self defined by their drug formulation. Pain relief is the refrain through which the modulations occur. Affect is central to pain. It connects to pain as it emerges from the field of relations. When the cannabis user examines the various offerings at a medical cannabis store, the consumer is bringing the vision of a pain-free future, the affect-laden object, into their life. The THC:CBD ratio brings the neurochemical self-to-be into the life of the consumer. Affects circulate through cannabis. Medicinal cannabis has been spiked with affect that enables a pain-free body. The will to be-in-the-world, to do-in-the-world is bound to medicinal cannabis through these virtual potentials. Call it a placebo if you want. The placebo is just a refrain anyway for the location of pain-free future affects in the present. This is how affect moves through bodies. This is not to deny that cannabis has neurochemical effects. It does. But it also does so much more. This is the surplus value of life, where affect, when working through cannabis mobilises value through affect.

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Consider the above scene of the cannabis consumer being played out across North America. Then consider it across the world, as cannabis policy changes facilitate the circulation of affect through cannabis worldwide. Underneath it all is pain. It is commodity pain that is making this all possible. With pain shapeshifting at a cultural and material level and cannabis itself defying categorisation, it is hard to see an end to the amplificatory modulation and the limit for the cannabis pain relief market. To study an affective economy is therefore to examine the way in which the trafficking in affects is organised. An affective economy organises the ways these virtual potentials connect, enable a sense of being in the world, and affect the capacity to be-in-the-world. It is the organisation and actualisation of virtual potentials, that lies at the heart of affective economy. For most, this affective economy is evident in the movement of emotion. Connecting the affective economy to the operations of capital, is most obvious through the movement of emotion in financial and other markets. Emotion only captures part of the story. When affect is however connected to potential, then we can start to see how capital thrives in economies based on future prediction and the movement of risk. The affective economy operates in any field of potential, however it is particularly stark when affect is examined in the field of potential that underpins the financial management of the risk of pain (Massumi 2015). For the purposes of understanding cannabis and the cultural pain neuromatrix, I will focus on emotion as a marker of the movement of affect through fields of potential and cultural milleux.

4.11 Derivative Logic or How Much Is Cramer’s Affect Worth On June 19, 2014 Jim Cramer, in his “Stop Trading” spot on CNBC announced that GW Pharma was not a marijuana stock, it was a “pain killing company”. The segment was titled “CNBC’s Jim Cramer says GW Pharmaceuticals represents the future of managing pain”. [https://www.cnbc.com/video/2014/ 06/19/cramers-stop-trading-this-will-replace-oxycodone.html?__source=yahoo% 7Cheadline%7Cquote%7Cvideo%7C&par=yahoo]. The text of the segment went something like this: Host: I was trying to remember when you started pounding the table on this [stock] name, it must have been half of what it is now. JC: yeah, and that’s because my doctor is also, happens to be the CBS doctor, doctor john le poop, saying “look out – we need this”. We need this for compassionate use. Children with epilepsy, people who have extensive pain. This is going to replace oxycodone. OK. Oxycodone bad. That’s my prediction. Host: Interesting JC: Oxycodone,- too many people. This will replace oxycodone, oxycodone will be… It will be a remarkable product, and they’re the only guys, based in

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Britain, so they can. The only repository of pure marijuana in our country is at the University of Mississippi, odd. Host: It’s a little strange JC: Right and this company I think, represents the future of how to be able to handle pain, because cannabinoid has many different uses. I don’t trust any of the penny stocks in marijuana, this is not a penny stock, this is not a marijuana stock. This is a company which is a pain killing company. Host: It’s not a penny stock anymore that’s for sure In 2014, Jim Cramer named the elephant in the traders room. GW Pharma stocks were reporting on epidiolex, a drug approved for treating childhood epilepsy, but Jim was talking about GW as a “pain killing” company. Cramer focussed on the strength of confidence in the stock. Noting that it had come from a low base of $8.90 on first offering. He also mentioned that Morgan Stanley were anticipating high price targets—again bolstering confidence in the stock as an investment (https://www.cnbc.com/2014/05/02/seeking-new-high-cramer-turnsto-cannabis.html). Nearly two years later on CNBC (Mar 14, 2016), on the release of positive epilepsy clinical trials data for GW Pharma’s epidiolex, Cramer again was asserting the pain killing properties of GW Pharma (https://www.cnbc.com/2016/03/14/cramer-gwpharma-finds-an-oxycodone-replacement.html). In his CNBC financial news segment “Mad Dash” he asserted that GW Pharma stock movements were actually not about preventing childhood epilepsy, but on the hope for cannabis as a pain reliever. The segment went as follows: Host: This is a name Jim that you have been championing for a long time. JC: If there is a way to replace oxycodone, which has been a rampant, illness, that has killed, it is an addictive drug, overprescribed, that has been an epidemic. This is pure cannabinoid, made in Europe. Host: Made in the UK right JC: You’re not allowed to make it in this country, it’s a felony to make. They got some incredible results on a phase 3 for children’s epilepsy, which is just absolutely terrible, this is a way to be able to prevent dravets seizures, now that’s a small populace. What is really going on, if you want to prescribe actual medical marijuana, a real doctor is reluctant to do it, because you don’t know, there is no uniform standards, and all you really want is the pure cannabinoid, There will be off-label use of this galore, now the insurance companies won’t pay, but this is a way to be able to get rid of a terrible, terrible drug, oxycodone, and Host: That’s what it is used right now for JC: for pain Host: oh for pain, but you’re saying the off-label use is for pain JC: That’s right, but that’s Host: But the childhood epilepsy, that’s not JC: Its just a very small market. Host: But that’s what the stock is up on now?

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JC:

Well yes, because if they get this, believe me, doctors will say, listen here’s a cannabinoid prescription. Look in Oregon, in Washington, in Colorado, you can go to a pot store, there’s a pot store next to my daughter, it’s a you know, a green cross, I said what’s the green cross sign, ok, it’s a pot store, you’re kidding me. No, but it’s not regulated in terms of what’s in the dose. So, doctors can’t say here take this is. Noo, this is regulated. Right now the only storage of pure cannabinoid now, is at the University of Mississippi. This would be the pure cannabis that a lot of people, who have been waiting for an actual pain killer that is not addictive, this would replace I believe the terrible, terrible wave of death, that oxycodone has caused. Host: Right well the stock had obviously been drifting downward, and now is having, so now they will have an historic day. JC: Well because, right here [pointing to the downward price trend], people felt that maybe, the phase 3 wasn’t going to work. Now of course, for childhood epilepsy this is a huge, huge thing. But the off-label use is what’s driving this. You know I have been following this forever, because I’ve seen, I know people who have been addicted. Host: I know you have, you think this is a stock-trading stalwart JC: Oxycodone, I know people who have been addicted and died from it, and it’s got to end, it’s a youth epidemic that must end. This is a hope for it. Syndication of the segment resulted in the text of the segment being repeated on other online news feeds such as at the Champlain Valley Dispensary as part of the Southern Vermont wellness service: After GW Pharmaceuticals announced positive results of late-stage trials of a cannabisbased drug meant to treat children’s epilepsy, CNBC’s Jim Cramer said the medication could someday replace the opioid oxycodone as a leading prescription painkiller. https://www.cvdvt.org/cramer-this-could-someday-replace-oxycodone/

When Jim confirmed that it was the future off-label use that was driving the meteoric 47 point rise in the stockprice to $85.90, he really nailed the story. However as far as affect goes, the gold was yet to come. The explanation for why Jim Cramer had maintained such a strong interest in GW Pharma was his personal interest. He had seen people addicted and die from oxycodone. It was his hope in GW Pharma and medical cannabis that was driving his investment. The hope in GW Pharma was in some way dealing with Jim’s, and the nation’s pain from oxycodone. The stock had risen from a low of $38 to a high of $85.90 in response to the clinical trial announcement. Historical reporting data suggest that this represents a change in GW Pharma’s market capitalisation, growing from $809.66 million on 9 March 2016 to $1.569 billion on 16 March, 2016 (https://ycharts.com/companies/GWPH/ market_cap). If Jim Cramer was correct that the rise in stock price was related to the hope of future off-label use for pain relief, then that would mean hope drove $759.34 million dollars of value. The value of GW pharma is indexed to the hope for relief from the pain from oxycodone. Media coverage of the massive rise in GW Pharma stock price included reference to Cramer’s comments (Anson 2016; Imbert 2016). News media also reported that

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GW Pharma in a letter to CNBC that day (16 March, 2016) rebuked the Cramer assertion that future off-label use was driving the stock price rise (Anson 2016). Forbes did not report on the link to oxycodone or to Jim Cramer, reporting only on epidiolex as a solution to childhood epilepsy (Vardi 2016). Cramer has a history of engaging with stocks that deal with opioid dependence. On July 17, 2012 he recommended investors buy into Alkermes, manufacturer of Vivitrol (Natrexone) a long acting opioid antagonist (a blocker of opioid drugs such as morphine, heroin and oxycodone) (Chang 2012). He wasn’t at this stage framing opioid use in relation to pain. Opioid use was framed as a drug of dependence, and although he referenced a wide range of substances in the production pipeline for Alkermes, cannabis was not mentioned at all in his monologue. This is a form of modulation of commodity pain. Cannabis derivatives are indexical to pain. Not because they are actually linked to the prevalence of pain, or even that the cannabis-derived substances will be used for pain management, but because the value of cannabis is indexically linked to pain through the affect of market narratives such as Jim Cramers’.

4.12 Capitalism and the Field of Potential Capitalism trafficks in the affects to become other (Deleuze 1987). Capitalism has its main focus on the movement of product and its derivatives, not on production. Market control over the socius is through continuous modulation of rapid rates of turnover. The unit of analysis is not the original commodity form or the consumer, but the value gained from the movement of debt, in this case the life debt in the form of pain. Back in Chap. 2, I posited that in the post-humanist paradigm (Braidotti 2008), pain is of the world, rather than just of the individual. In this paradigm, the focus is on potentials in fields of relations. Bodies-in-the-world emerge from these fields of relations. All objects in the world emerge from an “infra-corporeal level”, a field of potential from which forms of life emerge. Pain is one such object. This tradition also accounts for how objects enter into systems of capital. In fact, according to Massumi (2017: p. 58) the field of relations from which life is extracted overlaps entirely with the capitalist field—they have a mutual belonging. According to Massumi this has consequences for how we consider the category of pain: … it is necessary to call radically into question the “hedonic” categories of pleasure and pain, in favor of notions of intensity of activation and the fullness of that activation with potentials. (Masumi 2017: p. 58)

Drawing on Massumi (2017), pain is an intense object that is named and enacted, and thus formed from a virtual energetic debt at an “infra-corporeal level”. This infracorporeal level is immanent to existence, it is “the well-spring from which streams of life emerge” (Massumi 2017: p. 12).

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I asserted earlier that pain is an energetic debt caused by the movement of force through an affective field of intermodulation. Pain is what is named. It is the object, a perceptible sign of what is stirring in the relational field. Pain is an indexical marker, it points to movement (Massumi 2015). As Bergson (2002/1986: p. 133) asserts, “Thence arises pain, which, in our view, is nothing but the effort of the damaged element to set things right—a kind of motor tendency in a sensory nerve”. The energetic debt is not empirical, it is a virtual potential. It is the potential diminution of the body’s capacity to act in the world. It is related to Spinoza’s tristitia—“man’s transition from a state of greater perfection to a state of less perfection” (Spinoza 1994). The three affects ‘pity’, ‘regret’ and ‘shame’ are a form of tristitia (Ethics, III, definitions, 18, 27, 31). The crucial point here is that pain is a tendency, a potential that is formed into an object that functions as an index. Capital, through biotechnology creates the conditions for life and pain to emerge from this field of potential. Capital produces the conditions through which pain, as an object, emerges into life. The body with chronic pain is a “capital life form” produced by ontopower. Pain etched into the assemblage of bits and pieces that constitute a body is a commodity. As the assemblages modulate, so too does the shape of commodity-pain. Neuropathic pain is different from phantom limb pain for neuroscientists. Existential pain is different from physical pain for social scientists. Cancer-pain is treated as different to non-cancer pain in a reporting document from a medicinal cannabis company when it does its annual report to the Australian stock exchange. Pain is a shapeshifter, primarily because the varied conditions of its emergence define its quality. Different refrains enact the modulations, that produce the opportunities for capital to extract value. Modern capitalism thrives on virtual potentials and therefore also thrives on pain. Capitalism captures and multiplies potentials for doing and being, from the “social factory” (Palazzo 2014; Clare 2019; Massumi and Zournazi 2006). Modulatory governmentality and disciplinary governmentality coexist in modern economies such that there are both de-subjectivised entities and disciplined bodies that are produced in urban economies (Iversen and Maalsen 2019). Capitalism thrives on both, but in different ways, depending on the field of potential. For example, recreational cannabis consumption under prohibitive laws produces criminals, medicinal cannabis laws alternatively, produce licensed cannabis patients. This is a classic Foucauldian analytical framework that focuses on the production of docile bodies. Also, modulatory governmentality is evident in the changing form and substance of the cannabis user. This is most readily seen in the multiple transitions of the cannabis user in North America, from the illicit recreational user (1990s) to the medical user (2000s) to the licit recreational user in the 2010s. These modulations produce new actualisations of affect. They produce real outcomes from the refrains of legislation, industries, markets and social identities. The seemingly nonsensical dysjunction between Olivia Newton-John and the Stoner Sloth noted that the beginning of the chapter seems to make more sense now.

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Changing cannabis identities are modulations from which the market captures affect and extracts value when those affects are actualised. The actualisation of affect produces a felt experience. What is felt, leaves a trace and constitutes a memory which will return (Massumi and Kim 2009). Each repetition can form a series of repetitions or a refrain. The success of the repetition to achieve an institutionalised refrain depends on the context. Whether it be click-throughs on a website, the repeat purchases of a cannabis pain reliever, or registrations at a cannabis pain clinic, the refrain is the sedimentation of affect into a pattern, a scoring or marking of the world through repetition. Importantly, pain, as framed through affective economy is contagious. This is perhaps one of the most important dimensions of pain as understood through the cultural pain neuromatrix framework. Massumi (2015: p. 78), drawing on French Philosopher Gilbert Simondon, outlines the “germinal forms” that orient affectations in familiar paths (political groups, ethnic groups, etc.…) in the field of potential. Perhaps the most compelling part of the Massumi account of affect is the contagious, less-than-conscious manner in which affect is transmitted. The source for Massumi’s theory on affect is Hume. Here Massumi connects the event of another’s pain with our own level of experience: A perception of another’s affection gives rise to an idea of the other’s pain or pleasure. The idea strikes me, and the force of the strike converts the idea into an impression. This yields a vivacity of feeling, which generates a passion—which I directly experience as an affection in me, of myself. All these modes must be seen as occurring instantaneously, fused into a single event occurring at a nonconscious level of immediate experience”. (p. 57)

Citing Deleuze’s (1991) reading of Hume, Massumi notes that in this formulation, the actualisation of the event of perception creates the mind. The mind “becomes” through the encounter with the event. This is all happening at a nonconscious level. In this philosophical tradition, pain is communicated through affect non-consciously. The degree to which an affect can “become”, is related to its intensity (Massumi 2018: p. 142). Massumi uses pain to articulate the attributes of the intensity of affect. It also helpfully reveals to us more about the philosophical framing of pain in this tradition. Following from Bergson (2002/1896: p. 90), pain is a “pure quality”, requiring no mediation (Massumi 2018: p. 144). It has a “self-sufficing” quality. It is nothing other than itself. It does however also have a quantitative dimension. In terms of pain, Massumi notes that: The affect of pain is greater when its conditioning factors include a greater number of physical disturbances, meaning that the tissue damage is more extensive (Bergson 2002/1896: p. 34). The number of disturbances does not express itself directly in the felt intensity of pain. The disturbances express themselves not quantitatively, but at a greater degree of the same quality. By degree of quality is meant its insistency: a greater degree of pain insists more on its own quality. It claims more emphasis for that quality, and backgrounds other concurrent qualities of experience behind the cry of its own expression. Insistency is a question of qualitative emphasis. A lesser pain is not less qualitative, it is more insistently purely qualitative.

Pain becomes more insistent as its contagious intensity grows. Thrift contends that affects spread contagiously in a less-than-conscious state. Through semiconscious

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imitation, we mimic and reproduce affect from the world around us. The strength of contagion is related more to the capacity to force other disturbances into the background. Thrift also contends that we are, more-than-ever, prone to exploitation through affective economy aimed at structuring our “premediation”, the investments into the mechanisms that predispose us to particular semiconscious imitations (Thrift 2009). The media and material culture itself inserts into our day-to-day experience, ways of being and ways of doing that predispose us to particular imitative practices. We are now in an era of permanent survey which is active, able to initiate, modulate, and premediate feelings and behaviours (Thrift 2009). A consequence of this constant monitoring is the provision of what Thrift calls “worlds”, “doors” and “stages”, through which our worlds are modified through the virtual organisation of affect to exert influence over our predispositions. The introduction of iconography and indexical experiences into spaces are all part of the toolkit of influencing that is now working through our automatisms (Thrift 2004a: p. 68). For Thrift, the deployment of power through affect has become increasingly important to the ways in which urban capitalism reproduces and reinvents itself (Thrift 2004b). Through being sensitised to pain, the cultural pain neuromatrix enables pain’s contagion to grow through the movement of affect. Pain appears in the objects of everyday life through spaces that combine the intimate with the public. These everyday spaces, such as internet social media threads bring affective intimacy into communication. Not just media, it is through imitative practices that the shape and language of everyday practices incorporate pain. The pain of life becomes through the objects we have at hand.

4.13 How Cannabis Is Working Culturally What is evident is that cannabis produces effects. People report that it makes them feel better and it reduces their pain. As discussed earlier in the chapter, whilst medical pain specialists are sceptical about the analgesic effects of cannabis, there is pain relief. Rather than try and develop an explanation based on affective neural pathways, we should be looking towards an explanation of how cannabis might be exerting its effects through the affective economy. What is valued in the experience of cannabis pain relief may not be the blockade of pain pathway signalling, or the remediation of central sensitization for chronic pain patients. Cannabis may well be acting at a cultural level to block negative affects from being sedimented into refrains. It may not be a neurochemical pain reliever in the medical sense, however, because of its activity in the affective economy, it is organising the mobilisation of positive affects. This is happening at a number of levels, it can be happening at the level of the pain neuromatrix, by engaging with the “affective system” in the brain, by simply making people feel good. It can be working at the level of the cultural pain neuromatrix by providing a vehicle for

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modulation in the production of neurochemical selves. It is also working at the level of the politico-economic milieu by being the vehicle for the flow of capital though financial markets. Cannabis has an extraordinary set of flexible attributes that have enabled this to occur.

4.14 Cultural Pain Sensitization, and Cannabis As pain specialist Lorimer Moseley said in relation to individual pain, “Pain is always real, no matter what is causing it” (https://www.theguardian.com/australianews/2019/apr/04/coalition-to-announce-68m-in-funding-for-pain-treatment-andeducation). Cultural pain is felt and is real. The pain of the oxycodone epidemic is being felt across North America at the level of families, communities and health care systems. Pain is felt through grieving parents and siblings, through the economic hardship of children, and pain is felt in the shame of the families of medical practitioners prosecuted for failing to restrict the flow of opioids. Jim Cramer’s narrative was a condensation of this pain. When the value of GW Pharma stocks more than doubled in one day, this also was evidence of the cultural pain caused by the oxycodone epidemic. The value of cannabis pain relief is indexed to this cultural pain. What is extraordinary about the GW Pharma share price story is that none of the elements were directly connected to pain relief. Almost all the elements of the story were derivative. Epidiolex (cannabidiol) was not approved for the treatment of pain, the clinical trial was not for pain relief, and the rapid increase in share price was not related to the drug that was being trialled. As revealed at the end of Jim Cramer’s on-camera rant in 2016, his emotional investment was related to the replacement of oxycodone, rather than in epidiolex itself. As Massumi (2015: p. 69) noted, capitalism is focussed on capturing future value: Capitalism is the capture of the future for the production of quantifiable surplus value. Capitalism is the process of converting qualitative surplus value of life into quantifiable surplus value.

For Massumi the key process is converting qualitative surplus value of life into quantifiable surplus value. The qualitative surplus value of life is the excess affective intensity, the vitality of an event, the potential to effect transitions in the world. Objects emerging from the field of potential that have a greater variety of possibilities, gather a greater intensity, and therefore a greater potential for surplus value of life (Massumi 2015: p. 63). Those objects that are rich in their potential have the greatest value. Pain is one such object, and pain is full of potential life. Cannabis is indexed to hope. It is hope that people invested in when GW Pharma stock prices soared in 2016. In a society where the pain cultural neuromatrix has been sensitised to pain, the value of pain is amplified through refrain-driven modulations. This goes some way to explain why cannabis has grown in status as a pain reliever,

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independent of the “clinical evidence”. The real commodity however in this affective economy is pain.

4.15 Conclusions With all the discussion of the consumption and the economics of cannabis there is often a question raised as to why this all matters. Beyond the politics, economics and the cultural consequences of increasing consumption trends, what often matters is whether there are negative health consequences to cannabis consumption. Gage (2019) has a most sensible account of the relationship between cannabis and harm. The key is to understand how much cannabis is consumed. In her analysis of di Forti et al. (2019) she comes to the conclusion that it was at daily use of high THC concentration cannabis that the risk for psychosis increased. In short, it all comes down to dose. Reiterating Caulkins’ primary position of cannabis noted early in this chapter, that it is an indulgence that is not dangerous in moderation, but can easily get out of control. The deeper question for regulators and policy makers, is to what extent have regulatory controls enabled a market free fall or have adequate controls been put in place to maintain controls on this temptation good. Managing pain was the mechanism that brought the public along from being fearful of cannabis to being at home with the risks it poses, and choosing to consume it. It worked for Cramer and GW Pharma. Pain opened the way for normative practices that established a social appetite for a new temptation good. But it wasn’t physical pain that cannabis was solving. The real pain behind the transformation of cannabis was the pain borne from a drug war that the community has suffered for over 50 years. The argument that landed on fertile ground for legalisation advocates was in the economic benefits from the removal of a criminalised setting for cannabis: the pain of incarceration, of three-strikes policy and the hopelessness produced from criminalising a large segment of the community. This was the pain that was being resolved through a changing cannabis policy. There is not a large population of people in physical pain that will drive consumption of cannabis. The consumers of cannabis are consuming welcome relief from the pain of suffering derived from a prohibitive drug policy.

References Abrams, D. I. (2018). The therapeutic effects of cannabis and cannabinoids: An update from the National Academies of Sciences, Engineering and Medicine report. European Journal of Internal medicine, 49, 7–11.

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Powell, D., Pacula, R. L., & Jacobson, M. J. (2018). Do medical marijuana laws reduce addictions and deaths related to pain killers? Health Economics, 58, 29–42. Reiman, A. (2009). Cannabis as a substitute for alcohol and other drugs. Harm Reduction Journal, 6, 35. Reinarman, C., Nunberg, H., Lanthier, F., & Heddleston, T. (2011). Who are medical marijuana patients? Population characteristics from nine California assessment clinics. Journal of Psychoactive Drugs, 43, 128–135. Rose, N. (2005). Neurochemical selves. Society, 41(1), 46–59. Rouvroy, A. (2012). The end(s) of critique: Data behaviourism vs. due process. In M. Hildebrandt & E. De Vries (Eds.), Privacy, due process and the computational turn. Philosophers of Law Meet Philosophers of Technology. New York: Routledge. Shi, Y. (2017). Medical marijuana policies and hospitalizations related to marijuana and opioid pain reliever. Drug and Alcohol Dependence, 173, 144–150. Simondon, G. (2005). L’individuation à la lumière des notions de forme et d’information. Grenoble: Jerome Million. Spinoza, B. (1994). A spinoza reader: The ethics and other works. (Edwin M. Curley, Trans.). Princeton and Chichester: Princeton University Press. Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/. Swift, W., Gates, P., & Dillon, P. (2005). Survey of Australians using cannabis for medical purposes. Harm Reduction Journal, 2, 18–27. Sznitman, S. R., & Bretteville-Jensen, A. L. (2015). Public opinion and medical cannabis policies: Examining the role of underlying beliefs and national medical cannabis policies. Harm Reduction Journal, 12, 46. Thrift, N. (2004a). Intensities of feeling. Geografiska Annaler, 86B, 57–72. Thrift, N. (2004b). Movement-space. Economy and Society, 33, 582–604. Thrift, N. (2009) Pass it on: Towards a political economy of propensity. In M. Candea (Ed.), The social after gabriel tarde: Debates and assessments (pp. 248–270). London: Routledge. Vardi, N. (2016). Marijuana stock soars 130% after study shows its drug reduced seizures. Forbes, March 14, 2016. https://www.forbes.com/sites/nathanvardi/2016/03/14/marijuana-stocksoars-130-after-study-shows-its-drug-reduced-seizures/?utm_campaign=yahootix&partner= yahootix&ref=yfp#710818265315. Walsh, Z., Callaway, R., Belle-Isle, L., Capler, R., Kay, R., Luca, P., et al. (2013). Cannabis for therapeutic purposes: Patient characteristics, access, and reasons for use. International Journal of Drug Policy, 24, 511–516. Walter, C., Oertel, B. G., Felden, L., Kell, C. A., Noth, U., Vermehren, J., et al. (2016). Brain mapping-based model of delta(9)-tetrahydrocannabinol effects on connectivity in the pain matrix. Neuropsychopharmacology, 41, 1659–1669. Ware, M., Adams, H., & Guy, G. (2005). The medicinal use of cannabis in the UK: Results of a nationwide survey. International Journal of Clinical Practice, 59, 291–295. Zaller, N., Toplelz, A., Frater, S., Yates, G., & Lally, M. (2015). Profiles of medicinal cannabis patients attending compassion centers in Rhode Island. Journal of Psychoactive Drugs, 47, 18–23. Zuboff, S. (2019). The age of surveillance capitalism: The fight for a human future at the frontier of power. London: Public Affairs Hachette Book Company.

Chapter 5

Over the Counter (OTC) Pain Relief and the Self-treatment of Pain

The body with its ordinary pains is a forked branch that can point to a hidden underground stream of historical pain. That pain tunes us into the past. Jackson (2002: p. 172) Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage it should be accepted as pain. (International Association for the Study of Pain, IASP, https://www.iasp-pain.org/ terminology?navItemNumber=576) For the past 60 years, Australians have trusted Panadol to help relieve pain. But in today’s fast-paced world we have a new type of pain – it’s called a ‘life headache’. Being always-on and connected 24/7 via our phones and personal devices has become a life headache, with our research showing this can cause pain and tension, as well as interrupt our lives and the way we connect with those around us. (GlaxoSmithKline, https://www.panadolswitchoff.com.au/)

5.1 The Therapeutic Goods Administration (TGA) Decision to Up-Schedule Codeine Up until May 2018, low-dose codeine (up to 30 mg) in combination with ibuprofen or paracetamol, was available in Australia as an over the counter (OTC) drug from pharmacies. However, the Federal Health Minister, with support from the Therapeutic Goods Administration (TGA) up-scheduled codeine in order to reduce access to the drug.

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The Australian Government asserted that the core of the problem with codeine was that it was being abused by consumers who were self-administering the drug. Codeine is a commonly used medicine of abuse. Low-dose codeine (less than 30 mg) is currently available in a number of formulations in pharmacies over the counter (OTC) for consumers to self-administer. These include cough and cold preparations, and analgesic preparations combined with other pain relief medicines such as paracetamol or ibuprofen. There is substantial evidence of harm from the abuse and misuse of low-dose codeinecontaining medicines. TGA (2016: p. 13)

In addition to the direct risks of codeine the TGA document cited evidence that codeine was a stepping stone to broader opioid “addiction”. Importantly, through citation of personal testimony, this was placed directly in the context of the opioid epidemic in North America: Most cases of opioid addiction start with abuse of xxx [OTC codeine-containing medicine] It is incomprehensible that we still have an opioid available for self-selection (with the approval of the pharmacist) when we are battling an opioid crisis. Low-dose codeine has next to no place in treatment and the risk of harm is much higher than any potential benefit TGA (2016: p. 25)

What is of interest is that this evidence was not drawn from a rigorous quantitative scientific survey, or from material obtained under oath, rather it was drawn from personal narratives associated with an online survey reported in a Canadian pharmacy practice magazine (Canadian Healthcare Network 2016 cited in TGA (2016: p. 26)). The trend to use clinical evidence and testimony in building the evidence base for codeine up-scheduling should have aroused alarm bells for how the evidence was being assembled in this policy change. In fact, the evidence used by a key spokesperson for the TGA initiative to up-schedule codeine did not come from a rigorous meta-analysis. The quote used by the Chief Medical Officer for the Australian Commonwealth Department of Health, was a quote from a case report: The combination of lack of efficacy, risk of acute toxicity and dependence suggests that the use of OTC codeine is not warranted. (O’Reilly et al 2015. BMJ Case Reports, cited in Greenaway 2018)

With a risk of getting into too much detail too early in the chapter, it is worth noting just how precarious the evidence was in the case report from which the above “evidence” was drawn. O’Reilly et al. detail the risk of dependence in their case report: Although there was no suggestion of addiction in this case, a local newspaper recently reported problems of dependence among adolescents—a common theme in the Irish media in recent years. (O’Reilly et al. 2015)

The authors then proceed to cite a variety of sources from the USA to develop an argument about codeine and the risk of dependence. It is not unusual in case reports for a case to be contextualised within a variety of other cases, and different types of evidence, however this is not the kind of “evidence” that would usually be used by a

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regulatory authority to change the status of a scheduled drug. I make this point early as it is a feature of the narrative in this chapter about how evidence is deployed in this case. The Australian Federal Minister for Health, Greg Hunt asserted in press releases that codeine up-scheduling would prevent over 100 deaths per year (https:// www.2gb.com/podcast/greg-hunts-war-on-codeine/). This assertion was examined by an independent news media fact checking service and found to be lacking a factual basis (https://www.abc.net.au/news/2018-03-23/fact-check-over-thecounter-prescription-only-codeine/9522916). In fact, according to a report commissioned by the TGA only five codeine-related deaths per annum were predicted by economic modelling (KPMG 2016: p. 9). The numbers didn’t stack up, but behind the numbers was a threat. The threat of an epidemic based on the risk that codeine users would become dependent on opioids and then progress to become heroin users. This cascade of risk, based on the three phases of the prescribed opioid epidemic in the US, was barely whispered here in Australia, however it was a howling whirlwind in the USA that was spiralling out of control in the three waves of the opioid epidemic (https://www.newscientist.com/ article/2201155-sales-of-opioid-painkiller-codeine-have-halved-in-australia/). A time-series analysis of Australian prescription opioid consumption over a 25year period, suggests that although codeine was the most popular prescription opioid pain reliever (by a factor of 3 over oxycodone), prescription codeine consumption peaked in 2007 and had been slowly declining since that time (Karanges et al. 2016). The rates of codeine-related deaths in Australia increased substantially from 3.5 to 8.7/million between 2000 and 2009. It should be noted however that these deaths were not solely caused by codeine. In fact, codeine was found to the sole cause of toxicity in only 7.8% of all deaths involving codeine. Approximately 35% of all deaths were intentional and over half of the deaths were from codeine obtained by prescription. A significant proportion of people who died intentionally had a history of mental health issues (65%). A significantly lower proportion of intentional deaths had a history of chronic pain (34%) (Roxburgh et al. 2015). In a subsequent analysis of a case series of codeine-related deaths, Hopkins et al. (2018) analysed the patient characteristics of those who died. They reported that the profile of those who died from codeine was specifically poly drug users who were using codeine in a non-therapeutic manner. Overall these data suggest that deaths caused by codeine were not because of codeine’s addictiveness. It is more likely that codeine is one of a number of substances (including benzodiazepines) being used by several groups of users whose deaths were either planned or came about from polypharmacy in the context of mental health problems. Overall, regardless of the intentionality of death, 36% of deaths related to codeine had a history of chronic pain. The dominant picture from this analysis is that the response to codeine-related deaths should be focussed on the everyday-life circumstances and mental health services for vulnerable people rather than access to codeine. The TGA in its modelling of codeine consumption segmented the population of codeine consumers according to the volume of codeine being consumed. On the basis

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Table 5.1 TGA segmentation of the Australian codeine consuming population Number of consumers

Therapeutic use

Non therapeutic use

Acute

Chronic dependent

Chronic not dependent

Chronic

Acute

Total

Total baseline use by type of consumer

As % of all users

80%

3.8%

15.2%

0.1%

0.9%

100%

Number of packs

4,624,637

3,347,226

12,595,103 214,340

63,421

20,844,727

As % of all packs sold

22.2%

16.1%

60.4%

1.0%

0.3%

100%

Total baseline expenditure

Total expenditure ($M)

$23.1

$31.3

$105.3

$2.0

$0.3

151.7

Adapted from Source https://www.tga.gov.au/book-page/regulatory-and-health-economic-impactmodels#heim-five-consumers

of this method they then back calculated the relative impact of up-scheduling on different segments of the codeine consuming population. The chronic non-therapeutic segment was actually the smallest consuming and lowest spending segment of the codeine consuming population (Table 5.1). The TGA modelling approach virtually ignored this segment in its modelling because of its low significance. A refrain was created by the Australian Government about the harmfulness of codeine, with an astonishing paucity of data. The refrain has produced marked outcomes—Australians cannot get access to codeine now in Australia without a doctor’s prescription (https://www.tga.gov.au/media-release/significantdecrease-amount-codeine-supplied-australians). Approximately 17.1 million packs of codeine were purchased in 2018, compared to the average of 34.7 million per year from 2014–17 (https://www1.racgp.org.au/newsgp/clinical/codeine-supply-inaustralia-has-almost-halved). More people are going without codeine for pain relief. Pharmaceutical companies in Australia are selling down their poppy licences for alternative analgesics. This chapter is in no way a beneficent testimony to codeine. I have no interest in making codeine more available for pain relief. The point of this critical account is to reveal the affective components of regulatory machines, the tensions in understanding everyday pain and the dilemma of leaving pain management up to the whims of the marketplace. The story of OTC codeine up-scheduling reveals the biopolitical consequences of the way we codify pain. The pain of everyday life is a rich vein, tapped by big pharma through its continued quest to provide modulations in commodity pain. This chapter provides an account of one of those modulations.

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This is the refrain—a neurosignature. It is the pathway that has cleared the way for a different medicalisation of everyday pain relief. It is also however, a deeply revealing line that has made visible the arbitrariness of the risk cascade underpinning the policy change. The evidence for each of these steps is spurious, the calculations partial and yet the relation proceeded to a material endpoint. Later in the chapter I will develop the argument that this is a good example of “a-signifying semiotics”, where it is not the meaning of the evidence that proceeds, it is the a-signifying relations, the seemingly automated calculations between the scientific evidence that produces the refrain, and the pathway to action. A central learning from this case study is the centrality of a-signifying semiotics to the cultural pain neuromatrix.

5.2 Everyday Life Pain Relief As noted in Chap. 1, there are many different types of pain. In this chapter the focus is on pain that is “self-treated” with OTC analgesics. From a constructivist and narrative perspective, the stories of everyday pain are drawn from existing cultural and corporeal discourses about and of pain. The extent to which these fragments of experience are available depends of an individual’s socioeconomic and cultural position (Toye et al. 2013). Importantly, OTC analgesics are particularly targeted at “normal” or “everyday” types of pain. Of course, what constitutes normal is entirely relative and culture-bound (Aldrich and Eccleston 2000). Thematic analysis of texts of everyday pain in the UK report eight distinct accounts of everyday pain: pain as signal of malfunction, pain-as-self-growth, pain-as-spiritualgrowth, pain-as-alien-invasion, pain-as-coping-and-control, pain-as-abuse, pain-ashomeostatic-mechanism, and pain and power (Aldrich and Eccleston 2000). There is also a pain of everyday life that extends beyond the presence of injury and infection. The pain of everyday life is intimately related to our political and economic conditions as subjects who can only exist as subjects when they exercise extraordinary self-control. This hyper-volition needs to be deployed in the context of cultural and market forces that encourage the modern subject to seek pleasure. This is the pain of liberalism—the horror of truly being alone in resisting pleasure. The pain of everyday life is the constant threat of failing to be resilient (Evans and Reid 2014). As Acker (2010) and others have observed, the rise of neo-liberalism has produced a subject who must sustain high levels of self-control in the face of “ubiquitous inducements to seek pleasure”. Evans and Reid (2014) go further and assert that the modern subject is rendered ontologically vulnerable on account of the volition imposed upon it. A central feature of biopolitics for Evans and Reid, following from Thrift, is the deployment of affect as a tool to manipulate less-than-conscious desires. The subject, as well as being defined by their volition, are also manipulated through affect (understood as emotion for Evans and Reid). Evans and Reid are the most recent in a long list of theorists who map out the maladies associated with the postmodern self (Gottrschalk 1997).

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Crucially, there is a contest over who has the responsibility for treating these life pains. In a press release for the Royal Australian College of General practitioners (RACGP), the professional college for Australian General Practitioners (GPs), eminent Australian GP, Dr Evan Ackermann interpreted the 50% reduction in codeine supply in terms of the importance of the deployments of power in pain relief: The 50% reduction is a good sign. It demonstrates the effectiveness of up-scheduling, getting a drug away from the retail influence of a community pharmacy and under the professional oversight of a GP. (https://www1.racgp.org.au/newsgp/clinical/codeine-supply-in-australia-has-almosthalved)

For this GP, it is essential to get pain relief away from the retail influence of a community pharmacy and under the control of a GP. It is not the agentic selftreating individual who is responsible for this pain. This regulatory discourse deeply distrusts the retail imperatives that drive OTC analgesia. There is a strong sense in this discourse that the everyday pain sufferer is vulnerable to retail manipulation. The everyday pain sufferer needs the doctor to control the consumption of pain relief. Some of the accounts of everyday pain are more amenable to pharmacological intervention than others. For example, in the pain-as self-growth account of pain (Aldrich and Eccleston 2000), pain is seen as an inevitable part of life, and the ability to withstand and learn from pain is a measure of strength and self-control. Alternatively, where pain is thought of as alien-invasion, a malign external force threatens to overpower the individual. There is no virtue in resisting pain and it is not a valued part of life experience. In this account, pain is to be avoided at all costs. Common to a number of accounts in the above study and in the literature of chronic pain is the narrative of pain as a threat to selfhood (Fig. 2.2). Being able to relieve pain enhances the capacity to maintain a coherent self (Risdon et al. 2003). OTC pain relief is a mechanism through which the self, through self-managing pain, can take control of the self and avoid the deligitimisation of self that is experienced in chronic pain. It should come as no surprise therefore that OTC analgesic marketing campaigns often target the enhancement of self and sense of control as touchpoints in OTC analgesic advertising. In tension with the cultural force to be an agentic self who treats their own pain, is the threat of going too far and losing the self to the force of pleasure. This discursive tight rope is what the OTC pain relief consumer is meant to traverse. The problem is that there are very few meaningful measures through which to guide when pain relief flips into drug abuse. The only guide for the consumer is based to the number of tablets used, or more abstractedly, the number of days on which the OTC drug is being consumed. This is not just a labelling trope, the “number of tablets used” is a parameter deployed to segment the populations of codeine users in the TGA modelling report (Table 5.1). At the heart of the tension for those obliged to “selftreat”, is the risk of becoming dependent on the substance, and thus losing their capacity to be agentic. The self-treating subject needs to be able to delineate when pain is being managed appropriately and when pain management has become drug abuse.

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The problem is that the judgement of this threshold is fundamentally fraught. In terms of the deployment of power, it is the clinician’s eye that judges when the force of medicine is needed to control desire. Administratively, drug abuse is consumption that is over the recommended daily dose. This however has little to do with the experience of pain. The recommended daily dose is not related to pain relief but to safe limits of consumption. Also, as we know, the experience of pain is not normative, it is relative and subjective. The OTC analgesic consumer is left in an invidious position. They are neither authorised to judge the threshold between pain relief and drug abuse and nor are they in a position to challenge the very terms through which legitimate consumption is framed. Why is legitimate OTC consumption a trade-off between pain relief and drug abuse in the first place? As noted in Chap. 3, there is no doubt about the harm that can accrue when there is widespread and uncontrolled used of powerful opioids, as has been observed in North America. An important starting point in this account of Australian codeine upscheduling is the degree to which the USA problems with oxycodone and fentanyl were related to codeine and the self-treatment of pain with OTC analgesics. However even comprehensive time series consumption data cannot untangle this relationship (Karanges et al. 2016).

5.3 The Contagious Pain of Opioid Addiction As Ritter (2016) notes, Australian illicit drug policy is rarely driven by rational evidence. Routinely, Australian illicit drug policy is driven by responses to single tragic events. Policy analysts have sought to find models of policy making that can either explain or predict policy development. Even when these policy making models are more nuanced (Lancaster et al. 2014), they still are mostly based on rationalist principles or leave the explanations of strategic policy choices to “politics”, chaotic metaphors (“rising to the top of the primeval soup”) or more pragmatic reasons such as technical feasibility (Lancaster et al. 2014). Although the TGA re-scheduling was portrayed as an evidence-based process, it would seem that it was far from the case. The basis of the TGA rescheduling of codeine was a fear of the three waves of opioid epidemic crossing from the USA to Australia. The fear of addiction to opioids is global and contagious. Regardless of fundamental differences between USA and Australia in their illicit drug use patterns, regulatory mechanisms, geopolitical context of illicit drug markets, health, medical and social service systems and approaches to law enforcement, Australian regulators used the North American case to reduce access to codeine. According to the Centre for Disease Control (CDC) codeine sales were not substantive in the early stages of the US opioid epidemic. Data from the Drug Enforcement Agency (DEA) show that oxycodone and hydrocodone were the main controlled prescription substances being sold at a retail level between 2007 and 2016 (https:// www.dea.gov/docs/DIR-040-17_2017-NDTA.pdf).

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The TGA had trouble enumerating the actual extent of codeine use and misuse. In its modelling, the TGA (https://www.tga.gov.au/book/export/html/733435) noted the difficulty in modelling the impact of up-scheduling as it did not have data to inform the following estimates: • the number of people who are currently dependent on low-dose codeine; • the number of adverse events attributable to low-dose codeine; • the number of people who use low-dose codeine chronically and, while currently not dependent, are at risk of dependence. Additionally, the modelling did not account for benefits for the most at-risk group: While non-therapeutic use is often referred to in the media, it is likely to be only a very small share of consumers in this group. Nonetheless, a conservative approach was used and this group was included in the total volume of sales. However, the model did not account for any benefits that might result from the proposed up-scheduling for this group. It is likely that use of low-dose codeine medicines will be limited substantially if they are required to go to a GP to obtain a script. TGA (2016, p. 52)

Karanges et al. (2016) suggest that the changes in Australian opioid consumption were not seen in mild analgesics like codeine. The profound changes were in the consumption of long acting, slow release stronger opioids like tramadol and oxycodone. Increases in use were driven mostly by increased government price subsidies through the Australian Pharmaceutical Benefits Scheme (PBS). However, the North American opioid epidemic was being watched closely in Australia. Pain experienced in the USA became contagious. The international cultural pain neuromatrix had become centrally sensitised. In an analysis of the development of Canadian illicit drug policy, McCann (2008) suggests that policy knowledge and policy models can move from one location to another through “urban policy mobilities”. Drawing on Rose (1999), McCann suggests that a key component of these mobilities is the work of “experts of truth” who evoke their “concepts of normality and pathology, danger and risk, social order and social control” (Rose 1999: 30). These are no longer academics or government Ministers, these experts could be characterised as key influencers, such as public relations and marketing specialists. According to McCann this is a feature of policy mobility in liberal democracies. Drug policy transfer is not a technical process located in rational evidence-based policy making. Policy transfer should now be considered an affective process. Policy transfer networks are increasingly central to the movement of policy from one setting to another. These networks create spaces of emulation through the citation of spatial imaginaries developed from global case examples. What can happen in Australia is re-imagined in light of the rationalities from other jurisdictions. The imaginaries in McCann’s account of the Canadian drug policy, were formed from narratives emerging from a diverse range of media commentators (McCann 2008). For Vancouver it was a narrative about supervised injecting rooms in Frankfurt that specifically informed the development of the medically supervised injecting facility in Vancouver.

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Absent from the nuanced account of Canadian drug policy was reference to the emotion mobilised in urban policy mobilities. Although McCann acknowledged the centrality of influencers, public relations and marketers, the next part of the process of policy transfer was left blank. Marketers and public relations experts are effective as truth experts because they mobilise affective accounts that connect imaginaries from one location to another. Lancaster et al. (2014), also emphasise the importance of “policy entrepreneurs” in Australian illicit drug policy. They fall short however in describing how these policy entrepreneurs mobilised affective narratives to shape and facilitate drug policy transfer. As has been noted for some time, the compelling arguments are those that connect best with the imagination of the listeners. The argument that is most effective is the affective argument (Welch 1997). Considering affect in public policy is not just a luxury, it is considered a central tool in public policy making (Pykett et al. 2017). Emotional politics “renounce the notion of a highly rationalised state bureaucracy in favour of personalised forms of self government” (Pykett et al. 2017). Affective contagion, where emotions move beyond subjectivities, work in less than conscious registers to influence behaviours (Blackman 2008). In a context where the empirical basis for policy change is both contested and inadequate, the emotional basis for policy change is worth exploring. The origins for the predominance of emotion in the OTC policy change has its roots in a deeper cultural anxiety about the capacity of the individual pain sufferer to self-treat. According to the Australian Government website, the functional definition of an OTC medicine is one that “You can buy over-the-counter (OTC) medicines for self-treatment”. The difficulty with the self-treatment of pain is that the judgement of what constitutes pain is left to the individual. As discussed in Chap. 4, it is the clinician’s eye that transposes the symptom of pain into an objective sign. Until is it transformed, the self-reported pain symptom carries little weight. The risk with self-managed pain is that the pain bears little legitimacy. Pain needs to be authorised and authenticated. A key feature of legitimate pain is the distinction between pain that is experienced physically and pain that has emotional origins (such as the pain of heartbreak or disappointment). Even Melzack in his early writings believed there was a distinction to be made between physical pain and other types of suffering: “Anguish or anxiety without concomitant activity in the somatic-afferent system is not pain,” … the ‘pain’ of bereavement or the ‘heartache’ of the scorned lover do not legitimately fall within this definition. Melzack and Wall (1982: 71)

As noted at the beginning of this chapter, the international society of pain authorises a wider codification of pain: Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage it should be accepted as pain. (International Association for the Study of Pain, IASP, https://www.iasp-pain.org/ terminology?navItemNumber=576)

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The historical Cartesian perspective runs counter to a widespread appreciation of an integration of mind and body especially in diverse ethic contexts. For example, Indian culture expresses an integration of mind-body systems through a “continuity of metaphors across the somatic and the affective dimensions of pain” (Pugh 1991). Although considerable time could be spent on “cultural” models of pain, I will not review them here, other than to engage more broadly with the idea that culture inevitably becomes internalised in some manner, either through constructions of the body or through language. The neuromatrix model incorporates culture as not “out there”, but something integrated into all the patterns of thinking in our mind (Melzack cited in Jackson 2002). Hence, the inclusion at the opening of the chapter of Jackson’s rendering of historical pain: The body with its ordinary pains is a forked branch that can point to a hidden underground stream of historical pain. That pain tunes us into the past. Jackson (2002: p. 172)

It is not just historical pain that may be running through our bodies, but also the cultural residues of previous OTC medications. As Dr. Matthew Frei asserted in his workshops to practitioners about codeine up-scheduling he asserted that Australia has a love affair with OTC analgesics: We’ve got a very strong history in Australia in over-the-counter, a bit like the English and the New Zealanders, it’s a colonial thing I guess, that um, we’ve had some ground-breaking work done by Priscilla Kincaid-Smith in analgesic nephropathy from Becks powders back in the 60’s, from phenacetin. So, it’s a cultural tradition in Australia, is what I wanted to say… Australians are very keen on the medical use of opioids and over-the-counter. (Dr. Matthew Frei 2017: Time code 14:40), https://www.tga.gov.au/presentation-overcounter-down-hatch-otc-codeine-use)

The cultural residues of OTC consumption are always already present in pain narratives (Barker 2015, 2017a, b). It is here that the dilemma for the self-treating OTC consumer is at its most poignant. The pain sufferer has historical discourses of desire for pain relief; pain that is ill-defined and not authorised and perhaps illegitimate and few resources to determine what are appropriate levels of consumption (Toye et al. 2013). Lastly and most importantly the OTC pain sufferer is at the mercy of OTC retail advertising. A key rationale for the up-scheduling of codeine was that there is little evidence that OTC codeine is more effective than alternatives without codeine, and yet is somewhat more dangerous. To illustrate this point a key truth expert cited evidence to other medical practitioners (Greenaway 2018) that combined codeine 60 mg/paracetamol 1000 mg was found to be only marginally better than paracetamol alone in the treatment of postoperative pain (Toms et al. 2009). The issue then arises as to why codeine, if it is only slightly more efficacious as a pain reliever than paracetamol, should be thought to be more addictive. How is it’s “addiction-forming” activity different to its pain-relieving activity. There is always the possibility that a strong component of the effect for people who feel better with codeine, is not pain relief but a placebo effect and is simply the experience of feeling

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something. It is not surprising that endogenous processes that mediate pain perception can be initiated by the administration of inert substances (Gay and Bishop 2014). If this is the case, then the up-scheduling really is protecting people from attributing efficacy to a barely-efficacious substance. Given this, it offers a significant challenge to orthodox ways of understanding opioid addiction. Perhaps codeine is a modern “quack” medicine and through a combination of historical residues and retail marketing practices, codeine has assumed a magical quality beyond its pharmacological activity. Historically, patent medicine advertisements communicated power and magic and the consumer was in some senses, just a passive conduit (Albrecht 2018). Advertising for patent medicines has historically changed according to dominant cultural discourses. Albrecht (2018) suggests that from the 1800s to the 1900s advertisements changed from presenting disease as an external foe, to presenting disease as an internal obstacle. In some respects, the cultural transition to foreground the internality of pain, may provide a ground to begin to understand the power of a drug such as codeine. One way of approaching the cultural belief in the analgesic effect of codeine is to question whether the pain it was relieving had any organic origin. There are three dominant medical discourses when the source of pain is not organic (and therefore calculable): malingering, hypochondriasis and psychogenesis (Barker 2017a: p. 5). With the battleground shifting to an internal site, the remedy doesn’t need to battle an identifiable “external” narrative foe such as a bacterial infection, a wound or a torn muscle. In narrative terms, the remedy just needs to make the individual feel better. It is relieving pain because it is making the individual feel better. The internal fight is won, seemingly when the consumer says it is. The problem for the TGA was that codeine was available over the counter and there was little the TGA could do to limit its consumption or to assess whether it actually was relieving pain (considering that pain was thought to be objective and measurable). For those who believe that pain is objective and measurable, the magic of codeine as a pain reliever was under the control of the marketers, retail pharmacists and the organised OTC self-treatment industry. Television marketing of Nurofen plus, (a combined codeine/ibuprofen medicine) was focussed on its power, strength and speed of action. Television advertisements for Nurofen plus focussed on extreme pain (screams, https://www.youtube.com/ watch?v=5X8jUtIFOKM); imitation action heroes (“hit strong pain fast, before it takes hold”, https://www.youtube.com/watch?v=gwdNn7uoEYM) and its efficacy (“stronger for longer, nurofen plus”, https://www.youtube.com/watch?v= 8lvjVRzz5eQ). Codeine was marketed as more powerful than other analgesics, and there was little the TGA could do about its consumption, other than to upschedule it.

5.4 Semiotics and Pain Although semiotics is commonly thought of as a linguistic tool, it has had some important moments in medicine. As discussed in an earlier chapter, pain symptoms

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are routinely transformed into objective signs by clinicians. Priel et al. (1991) suggested however that pain signs are usually interpreted as indexes. An index points to a target meaning without itself having similarity to the target meaning. The relation between the index and its target meaning is concrete and causal. Symbols more generally on the other hand, have an arbitrary relationship between the signifier (form) and the signified (content). In medicine, signs as indices need to have a fixed causal relationship if they are to be interpreted properly as signs by the clinician (Kleinman 1988). Priel et al. (1991) suggest that a distinction for people living with chronic pain is that the signs that point to pain cease functioning as indices. Rather they become more like arbitrary signs where the target meaning (or source of pain) is not direct and causal, rather it is mobile and transferable. While some see the more labile character of pain indices as difficult to manage, Priel et al. (1991) see this labile character of chronic pain as an opportunity for clinical intervention. What if this mobile and transferable dimension to pain is not an aberration, but part of the ontology of pain to begin with. In the next section I will explore how mobile the meaning of analgesics can be, through examining how sophisticated semiotics are used and exploited in the marketing of an OTC pain reliever.

5.5 Neurosignature Analysis: “When Pain Is Gone, Life Takes Its Place” (LTIP) In 2015 GlaxoSmithKline embarked on a marketing strategy for its OTC pharmaceutical acetaminophen (paracetamol), known as Panadol. Paracetamol has become one of the most used antipyretic and analgesic drugs worldwide (Moore 2016). The global paracetamol market was valued at around USD 801.3 million in 2014 and is expected to reach USD 999.4 million in 2020, growing at around 3.8% between 2015 and 2020 (http://www.marketresearchstore.com/news/global-acetaminophenparacetamol-market-148). Over-the-counter painkillers pose a particular dilemma for regulators. On the one hand these substances have such low efficacy, it is unlikely that significant harm can arise from their consumption. However, loose regulatory controls make it possible for them to be commercially exploited to a greater extent than substances that are more highly regulated. They may on their own pose little harm to the population, however by virtue of low regulatory control they may be overconsumed, consumed in the wrong way or used in combination with other more harmful substances. Going beyond the substance itself, the marketing of OTC counter painkillers can reinforce discourses of pain management that promote dangerous drug consumption. Extensive marketing of cure-all pills has been identified as a problem for those who both promote the quality use of medicine and non-pharmacologic pain relief.

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In this chapter I examine the GlaxoSmithKline marketing campaign (“When pain is gone, life takes its place”) of one of the world’s most widely used OTC painkiller, paracetamol. I examine the marketing not in an attempt to identify fallacies or unreasonable claims, but to examine the techniques used to inscribe the refrain that is implicit in its message. I will then locate this messaging in a broader attempt to “world” bodies with a Panadol refrain. I will end the chapter with an argument that not only does the Panadol “When pain is gone, life takes its place” (LTIP) campaign try to territorialise pain, it attempts to territorialise life itself. The consequences of this analysis are discussed in light of the Toye et al. (2013) “moving forward with pain” refrain. GlaxoSmithKline is part of the cultural neuromatrix. It generates cultural pain neurosignatures—refrains that trace out pathways through which pain is materialised in bodies. These neurosignatures are diffuse, they spread as contagious viruses. They are not uniform, nor do they follow classical sociological rules. They abut epistemes, are ontologically mixed and troublesome. The create actions, effects and things in the world. The neurosignature is a territorialisation of the body. The LTIP marketing campaign attempts, through the repetition of its refrain, to create a vital resource that will score a new territory (McLeod 2017). Being able to move beyond languagebased touch points and to insert the iconography of the tablet into everyday objects is quite a specific and ambitious intervention. As an anti-inflammatory, the main therapeutic target is pain. Paracetamol is categorised by the WHO as having mild pain-relieving qualities (WHO 2018) and in most countries is an over the counter drug, and does not require a prescription. Early analyses suggested that codeine was only mildly more efficacious than paracetamol (Toms et al. 2009). There is considerable debate in the medical literature as to its actual analgesic efficacy. Systematic reviews of randomised controlled trials now tend to find that paracetamol is no better than placebo for a range of conditions such as back pain (Saragiotto et al. 2016). Moore goes further in a blog and states that in acute back pain, paracetamol: … doesn’t work. Not immediately, not later. At no stage between one and 12 weeks is 4,000 mg daily any better than a placebo. Nor does the review find any evidence that it works in chronic back pain either. (Moore 2016, https://uk.cochrane.org/news/paracetamolwidely-used-and-largely-ineffective)

Whilst the poor efficacy presents a challenge to the marketers, there are also other challenges. Consumption of paracetamol is not uniform internationally. There are wide differences in paracetamol consumption in different European cities (Hudec et al. 2012). The LTIP campaign visual designer Antonio Bonafacio ran a blog commentary about the design of the campaign: Background Panadol is different. Understanding that to the vast majority the real issue is that pain impacts their relationships. It hinders them to take part and share moments that matter. Panadol shares this social view as expressed in the tagline: “When pain is gone, life takes its place.”

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The Campaign Panadol’s perspective on life needed to be expressed in a unique, own-able style— with visuals that can work in any of the 120+ markets. Hence the iconic capsule-shape of most Panadol products became the central design element—with deep meaning: in each poster groups of people engage in, on or around a capsule-shaped space or object. Moments of togetherness, of people living life together—in many different expressions—from grand and exciting to personal and intimate. Executed in highgrade CGI, but made to look 100% real—after all: it is a brand talking about life (Fig. 5.1). Source: (http://cargocollective.com/antoniobonifacio/following/antoniobonifacio/PanadolLife-Taking-Place). The campaign designer expanded on the prominence of the capsule shape: (https://www.antoniobonifacio.live/#/panadol-life-replaces-pain-2/): Background Panadol puts a focus on people and their lives, understanding that pain is an unwanted, inhibitive interruption keeping people from their relationships. It’s not about harsh pain-killing, its about safely and effectively getting pain out of the way. A powerful positioning in a category that all too often is about scientific ingredients and aggressive performance. Campaign We developed the idea of a seamless, dynamic, real-life journey around an astonishing capsule shaped planet. Uplifting, positive, impactful and memorable. Allowing Panadol to own the capsule shape: turning it from a non-utilized category code into a powerful branded icon. Iconographic substitution is not a new idea in marketing. Indeed inserting a brand icon into everyday life is one of the holy grails of brand marketing (Rossolatos 2016). The connections between the iconic capsule shape are not difficult to make. The capsule shape is connected to moments of life, and to that which gives life, the planet itself. The iconic replacement is meant to operate in a number of life arenas: family life (dinner table, playground), work life (work bench), our cultural celebrations (sporting arena, skydiving) and social life (pool). The capsule is present in all aspects of life. This is a vastly different approach to the medicine as a pain killer. The semiotic work is attempting to connect the medicine to life rather than to negating pain. What is assumed is that there is a pre-existing cultural code that will enable the semantic connection to be made between the shapes in different contexts and the elevation of these shapes into an iconic reference. The attempt here is to transform or translate an arbitrary sign (capsule) into an “icon”. The repetition of the shape in different aspects of life is attempting a multimodal transformation. The double movement is to connect the shape to panadol and then to connect panadol to life. This is repeated in the campaign tag line “when pain is gone, life takes its place.

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Fig. 5.1 Campaign image gallery sourced from https://www.antoniobonifacio.live/#/panadol-lifereplaces-pain-2/

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Fig. 5.1 (continued)

The transformations and translations that occur through metaphor do more than create meaning. Metaphorical transformations create social realities and material outcomes (Roderick 2019). Early metaphor studies constructed metaphors as primarily concerned with thought (Lakoff and Johnson 1980). Subsequently, this has expanded to connect thought with embodied experience (Lakoff and Johnson 1999). Metaphor materialises the realities in which embodied actors act (Hayles 2001): … it allows us to discover regularities between what we perceive and what exists outside of ourselves; and it entwines cultural presuppositions with scientific frameworks. These complex functions can be summed up by saying that metaphor works to connect and contextualise, broadening the space of abstract thought by embedding it in physical, sensory, linguistic and cultural contexts.

Those metaphors that mediate the translation between the material and the metaphorical are in literary and digital studies sometimes called “material metaphors” (Hayles 2002). Material metaphors condense two references. Unlike conventional metaphors, a material metaphor condenses a conceptual reference with a material indexical reference. Hayles was writing about electronic textual forms, where text, such as hypertext code, would not just convey meaning but act, open a door, open a file, or turn the lights on. Material metaphors condense iconicity and indexicality (van den Boomen 2009: p. 263). The mechanism through which metaphors translate material outcomes is an extension of Austin’s performative function, whereby signs create that of which they speak. Drawing on complex systems theory, Hayles (2001) goes further to link the operations of metaphor to the generative function of life itself. In this framework, there are two opposing processes—constraint and metaphor—that enable the production of organised life from the undifferentiated flux of the world. Metaphor enables connections to be made across ontologically distinct arenas, and constraint works to

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delimit what connections are possible in these emergent processes (Hayles 2001). Both forces are productive and opposing. Constraint ensures that only the most viable systems emerge, whilst metaphor opens the space of possible connections. Hayles (2001) compares the metaphor/constraint framework (usually applied to language and sign systems) with philosophical frameworks used to understand biological and evolutionary processes in models of posthuman life. It is here that Hayles finds a useful comparison with Deleuze and Guattari’s contrasting forces of territorialisation and deterritorialisation. In Deleuze and Guattari’s framework, deterritorialisation is aligned with the openness of metaphor, whereas territorialisation is aligned to the forces of constraint. Hayles unfortunately did not engage with the constraining force of the “refrain” in Deleuze and Guattari’s A Thousand Plateaus (1984) and misunderstood the degree to which they agree with her homeostatic balancing act between forces that open out to the world and those that constrain. Regardless of the intricacies of Hayles’ (2001) account, the important point is to be found in the deployment of metaphor as a process, not just in the construction of meaning, but in the embodiment of actors in the world. It is here, in the gritty detail of the function of metaphor, and the translation inherent in material metaphors specifically, that sense can be made of the cultural function of OTC marketing campaigns such as LTIP. A key challenge in the LTIP campaign was to create a universal language, and a universal refrain for a condition that is known to vary according to language and culture. According to Bourke (2014) those speaking Finnish are unable to share the same language of pain as English. Japanese can have bear, musk deer and woodpecker headaches and headaches that present themselves with a chill can require an aquatic animal metaphor (octopus headache or crab headache) (p. 68). In India, the everyday language of pain does not distinguish between bodily discomfort and emotional suffering (p. 69). Different languages, different body parts and bodily experiences are selected to map into and structure similar abstract concepts of pain. The metaphors that structure the language of pain have also changed over time. According to Bourke (2014: p. 72), humoral theory dominated physiological explanations of pain in the 1700s. The passing of humoral physiology gave way to more individualised and mechanistic accounts that located pain in more specific locations. Bourke notes also that metaphors are drawn from everyday encounters with material objects and as war dominated in the mid nineteenth century so too did militaristic metaphors for pain relievers (2014: p. 75). Pain was an enemy to be conquered and pain relievers became “pain killers”. Similarly, industrial and mechanical metaphors for pain and pain relievers also grew more popular in advertising (Bourke 2014: p. 79). Given the metaphorical history of pain relievers as prosthetic, redemptive and complementary to the body, the LTIP campaign is even the more interesting. The semiotic work is to embed in the consumer the belief that panadol is a source of life. It is both simple and a highly sophisticated piece of marketing. The complexity however was enhanced even further when a second stage to the campaign was executed in Australia in 2017. This involved the propagation of a new narrative centred on the “life headache”.

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5.6 The Panadol Campaign—The Contemporary Life Headache In this campaign, (referred to as “Switchoff”) the advertisers created a reality TV style documentary of a celebrity family spending a weekend in an isolated house (the “Home of Reconnection”) where all internet and communication devices were locked away (http://panadolswitchoff.com.au/). There was no overt consumption of pain relievers, the focus was on the experience of life unplugged. The family had the experience of becoming more connected to each other as they became less connected to social media and the digital world. Ironically, the experience of the celebrity family (the Fitzgerald’s—no relation to the author) was captured on video and became the narrative vehicle on the campaign website, YouTube and social media. A competition was launched that enabled other families to have the same experience of reconnection by “switching off”. As the campaign website (http://panadolswitchoff.com.au/) asserts: To launch our campaign, we gave Australians the chance to win a stay at our ‘Home of Reconnection’ and Switch Off Life’s Headaches. The house was stripped of all interruptive technology to help Aussies reconsider how much time we spend with our devices, and the way it affects our sense of wellbeing and relationships.

The experience was personalised through the testimony of a well-known celebrity: When finding the perfect guest to launch the Home of Reconnection we started with a man whose career was built on the use of technology. You hear him on the radio, see him on TV and read about him on celebrity gossip sites - all the time. You may know him as Nova’s radio host ‘Fitzy’ - but to his family he’s Ryan and Dad. We sent ‘Fitzy’ and his family to the home where they enjoyed time off to reconnect with each other, tech free. Time away from our devices really opened up our eyes to how small changes, like no phones at the dinner table, can lead to less distractions, less stress, and more quality time. - Fitzy

The naturalistic visual register of the campaign website focussed on pleasant, reflective family moments in the house of reconnection. There were no capsules, no tablets, just a small branding watermark in the top left hand corner of the frame. An industry press release for the campaign referred to this as an “altruistic brandfocussed campaign” (https://campaignbrief.com/panadol-puts-its-brand-purpose/). Advertising company WhiteGrey national ECD Chad Mackenzie whose company worked on the campaign said his team were delighted Panadol had embraced its brand purpose: It’s a strong message and we are proud Panadol is at the forefront of encouraging Australians to switch off from technology and increasing their sense of wellbeing and health by spending more quality time with loved ones, he says. Panadol is a global product, however the focus of this analysis will be on Australia. The marketing strategy was deployed globally with slight variations in different cultural contexts.

Industry coverage of the campaign quotes the Panadol marketing manager Annalee Combis on the changing nature of headaches:

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The world is changing at an unprecedented pace and it’s more challenging than ever to stay ahead of the curve. For 60 years Panadol has been synonymous with managing pain caused by headaches – but headaches have changed so the way we deal with them, must change as well. Our independent research highlighted many Australians have suffered tension/stress headaches or migraines due to being constantly switched onto their devices. ‘The Home of Reconnection’ will help Australians disconnect from technology and restore and reconnect with family and friends. (https://campaignbrief.com/panadol-puts-its-brand-purpose/)

Importantly, the focus of the campaign is not on Panadol, but on the positive experience of life. There are no images of people in pain or under stress. The visual narrative is pain free and stress free, because they have switched off their devices. As noted in a critique of the Switchoff campaign, marketing copywriter and television commentator Karen Ferry suggested that Panadol was “expertly inserting itself into the issue of our lives causing headaches”: They’re inserting themselves into the problem. We know that life’s headaches are caused by blue screens. So next time you get a blue screen headache, instead of turning off you’ll be like, ‘Oh my god Panadol,’ go take a box and then you continue watching the full season of Twin Peaks. (https://www.weeklytimesnow.com.au/news/national/have-headaches-actually-changed/ news-story/a29b252fb1d85df5ba030008f4b4302c)

Panadol was now bigger than a capsule. Panadol was being connected to life itself. The semiotics were different. Rather than focussing on inserting the shape category (capsule) into life, the strategy was to connect the idea of panadol with this “new” phenomenon of a “life headache”. As noted in the commentaries, “The net Panadol can now cast over pain management is becoming increasingly wider—only helped by the amount of time we spend on technology these days” (https://www.weeklytimesnow.com.au/news/national/have-headachesactually-changed/news-story/a29b252fb1d85df5ba030008f4b4302c). The GlaxoSmithKline campaign focuses on its wider brand message, rather than the actual product (http://www.adnews.com.au/news/radio-star-fitzy-appearsin-panadol-s-first-ever-big-brand-campaign#lg37r4lxLOtizL7X.99). In further commentary about the campaign, the Panadol marketing manager asserted that: We really want to drive relevance with Australian consumers and tackling this ‘always on’ technology as a physical and emotional pain point is a highly relevant issue in society. We believe that when pain is gone, life takes its place. And that life is at its best when filled with rich, human relationships. For the past 60 years, Australians have trusted Panadol to help relieve pain. But in today’s fast-paced world we have a new type of pain – it’s called a ‘life headache’. Being always-on and connected 24/7 via our phones and personal devices has become a life headache, with our research showing this can cause us pain and tension, as well as interrupt our lives and the way we connect with those around us. Source: https://www.panadolswitchoff.com.au/

The campaign materials assert that “On average Australians spend 68 h a week on devices. That’s almost three days non-stop” and that “13 million of us say devices

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harm our physical or emotional wellbeing” and “12 million of us agree the devices designed to connect us do the exact opposite”. The Switchoff campaign is attempting to de-individualise pain. They are redefining the pain of everyday life as generic. This kind of pain affects millions of us. GlaxoSmithKline is selling us a new human condition, and at the same time offering us the remedy in the tagline. The strategy to de-individualise pain is a very contemporary approach to pain. It aligns with some of the most contemporary models of diffuse pain, wellbeing and self-health management. For Mcleod, everyday life assemblages are contingent combinations of material and non-material bodies. For Mcleod the work of living needs to be situated within a wellbeing bioeconomy where the “success” of affective labour (also called collaborative connective labour) distinguishes illbeing from wellbeing (McLeod 2017: p. 11). For Mcleod (2017: p. 169), the crux of overcoming the pain of depression from life is located in a balance between experimental modes of bodily disorganisation and the formation of sustainable bodily organisation. Most importantly, even though the terms of the debate may change with more complex theoretical framings, a homeostatic metaphor (Toch and Hastorf 1955) still exists at the heart of McLeod’s framework. Although the locus of agency has shifted from the rational individual to a disseminated assemblage, and social interactions are replaced with “affective labour”, the objective is to seek balance between those forces that organise and those that disorganise. Mcleod supports the use of “vital materials” and bodily practices that facilitate the above balancing act. Again, the terms change from environment to “vital materials” and from behaviours to bodily practices, however the deeper framework remains that to be well in life, requires the accessibility and utility of things-in-the-world and the capacity to act in the world. Mcleod also notes (2017: p. 171) that there has been a tendency of Deleuzian health scholarship to emphasise the deterritorialisation of individuals (e.g. Hayles 2001), scholars have had a tendency “to align health with deterritorialisation processes that expand relational capacities and move the body closer to the limits of its actions”. In a cautionary move, McLeod asserts that the question is: How best to resource and organise encounters to facilitate experimentation with disordered and ordered assemblages. This demands the proximity or resources for adequate doses of both subjectification and bodily disorganisation.

Now, the homeostatic metaphor is complemented by a pharmacological metaphor of “dose”, ironically applied to the deployment of subjectifying force in the formation of the sovereign subject. McLeod cleverly re-inserts a medical metaphor in her project of de-medicalising the pain of depression. At the heart of the project of everyday living is the operation of metaphor. In the case of Mcleod, homeostatic and pharmacological metaphors are applied to the deployment of abstract forces (deterritorialisation and subjectification). In the case of everyday narratives of pain the metaphors may be different but the semiotic principles are similar. The cultural pain neurosignature is a territorialisation of the body, it is a refrain. The LTIP campaign attempts, through the repetition of its refrain, to create

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a vital resource that will score or mark out a new territory (McLeod 2017: p. 169). Being able to move beyond language-based touch points and to insert the iconography of the tablet into everyday objects is one of those markings. The second refrain, was to redefine the nature of pain itself. Here the cultural pain neurosignature located pain in all the devices and screens around us. Life’s headache was diffuse and ubiquitous. This is perhaps the most stunning move of the campaign. The solution to ubiquitous pain is either time out or Panadol. Most importantly the marketers are using more complex and nuanced semiotics to achieve their goals. These semiotics are multimodel and involve a series of transformations and substitutions.

5.7 Signature, Self-hood and Territory The whole point of a refrain/neurosignature is to mark out a territory. This marking out constrains the production of subjectivity and creates bodies in the world. The refrain is a material metaphor. It brings together the conceptual and the indexical into a condensed assemblage. The Panadol consumer who is always on because they can cope with life’s headaches, is produced by the refrain. The marketing does not just suggest, it performs, it creates that of which it speaks. The campaign does more than simply create an icon for the brand, it brings life to the drug. Panadol brings life. The curious word play in the campaign tagline is the clue to how life is inscribed into panadol. Panadol is never openly declared as the source of life. There is no actor in the tagline “When pain is gone, life takes its place”. However it is Panadol that will be consumed in the event of a life headache, and it will give life. The outcome from taking the pain reliever (pain is gone) causes life. This is a classic metonymy, where there is a substitution of an effect with a cause. Deleuze and Guattari insist that a subject is not constituted by a signature, but rather the signature is the constituting mark of a domain. This “chancy formation” of a domain is a territory drawn from a refrain. these qualities … delineate a territory that will belong to the subject that carries or produces them. These qualities are signatures, but the signature, the proper name, is not the constituted mark of a subject, but the constituting mark of a domain, an abode. The signature is not the indication of a person; it is the chancy formation of a domain. (Deleuze and Guattari 1987/1980: pp. 348–9)

The traditional subject for Deleuze and Guattari is not a sovereign individual but a domain, an aggregate of elements. This is a dissolved subject that departs ontologically from the model of self-hood so common in western medicine. The qualities that delineate a territory, that a body has, are signatures. The signatures mark the terrain. The refrain draws the signature through its repetition. This is how a refrain comes to make bodies in the world. The metaphors, stories, and practices that are engaged when a body is in pain both make and mark the territory of the individual and its associated entities.

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Not all refrains are successful. Some territorialise and some gather forces to deterritorialise. The three refrains in the LTIP campaign operate differently. Inscribing the capsule into everyday life and connecting the shape category assumes a territorialisation within an existing assemblage. The metonymic substitution that connects life to Panadol is also in an existing assemblage. Finally, re-inscribing and redefining the pain of a life headache is a functional refrain that marks out a new territory. In the Philippines the LTIP campaign focussed on a different set of refrains. Here the LTIP refrains built on an established gendered neurosignature, masculinity. The tagline for the campaign could have been named “when pain is gone, love takes its place” as the affect mobilised in the narrative and visual materials of the campaign focussed on the love between a father and son: Headaches are no fun. The pain weighs you down especially on days you need to be at your best — may it be at work or spending time with family. Trusted healthcare company GlaxoSmithKline puts the power to take away the pain with fast-acting (paracetamol) Panadol for faster recovery and more super moments with your loved ones. GSK Philippines Consumer Healthcare general manager Jeoffrey Yulo says, “Seven out of 10 Filipinos suffer from regular headaches. The time wasted on dealing with this kind of pain should have been better spent on more important things like quality time with the family. This dilemma encourages GSK to continue providing a fast and effective solution like Panadol to pain sufferers. Bringing Panadol’s life-affirming message to the fore is father, athlete and host Ryan Agoncillo, together with his son Lucho, at a media event held at the New World Makati Hotel. Ryan is known to be a dedicated father to his children Yohan and Lucho and spends as much time as he can with his family. Ryan says, “My family is my top priority. Even if I get busy with work and my other pursuits, I make sure that I get to spend quality time with my wife and my kids. But, sometimes, because of my workload, I suffer from terrible headaches. Fortunately, there’s Panadol. It offers fast relief to make my super moments with my family pain-free! Indeed, when pain is gone, life takes its place. (source: http://lemongreenteaph.blogspot.com.au/2015/03/panadol-helps-ryans-supermoments-with.html).

The refrains in the Philippines LTIP campaign were perhaps more explicit in the connections with older more established assemblages than in the Australian campaign. Images of men, in superhero outfits and medicines with life-giving super powers were connected to Panadol and headaches caused by “workload”. The refrain does not need to create new assemblages, re-articulating old identities and old subjectivities is part of the work of the refrain, and part of mobilising affect.

5.8 Machines and Milieu Now it is time to return to the pain cultural neuromatrix theory articulated in Chap. 2. At an individual level, a refrain will primarily organise subjectivities, bodies and sensitisations. For the cultural pain neuromatrix, the refrains organise relations between

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institutions, machines and materials. For the politico-economic neuromatrix, the refrains organise flows of capital, machines and materials. Passing through all the milieux is the shapeshifting commodity pain. Working through all milieu also is affective capitalism. Most desirable for GlaxoSmithKline is the “worlding” of the Panadol refrain in its marketing. “Worlding” is where a particular world emerges through the engagement of human and non-human forces arising from the repetition of a refrain (Stewart 2010). As noted in Chap. 2, analysis of pain refrains and their efficacy focusses on their capacity to enable individuals to redefine normal, integrate my painful body, tell people about my pain, realise there is no cure, become the expert, and be part of a community. The success or not of the Panadol LTIP refrain is the degree to which it can connect to the experience of the pain sufferer and connect its product to those experiences. The Panadol LTIP refrain attempts to redefine normal. The life headache refrain asserts a new type of pain. The pain sufferer is not separate to the community, as the cause of pain—our digital 24/7 world—affects us all. The LTIP refrain also reinforces self-management—you are the expert. The celebrity family is shown in the visual materials from the campaign to choose to switch off from the source of pain. The campaign competition offered families to also get the experience of switching off by getting to stay in the house for a weekend. Just as individual neurosignatures produce pain, this refrain, (the cultural neurosignature) of the “life headache” is meant to be performative. It is a common experience that life produces headaches, however the neologism “life headache” is meant to become a household name. In the same way that “mansplaining”, “manflu” and “manboobs” are all terms that are meant to describe commonplace gendered behaviour, for advocates of the terms, it is intended that the terms gather a life of their own and occupy a permanent place in language. Once named, these objects can become actualised and enter into material worlds. This is “worlding” at its most concrete. Cultural pain neurosignatures do not just mediate or communicate, they cause pain. The other performative is through the material metaphor in the tagline for the campaign, which in this case is a metonym, where the effect (“when pain is gone”) of the referent has been substituted by the cause of the action (taking the capsule). This is a special type of metonym, where although the effect has no resemblance to the cause, they are logically related. It also has indexical qualities. One points to the other. As noted in Chap. 2, indexical markers provide a cultural scaffold for pain (Throop 2010: p. 255).

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When pain is gone

life takes its place

Metonymic subs tu on (Effect for cause)

Taking a capsule

gives life

Taking the Panadol capsule makes pain go away, which then allows life to come to prominence again. More importantly, the attempted performative is to imbue Panadol with life-giving qualities. This is a refrain that through repetition, the manufacturers hope will produce material outcomes. The problem for Panadol is that taking the capsule may not always make the pain go away. As a mild analgesic it is unlikely that the pain will go away in the majority of cases. In this regard, the likelihood that this refrain will achieve the intended performativity is low. Just as individual neurosignatures are diffuse, so too cultural neurosignatures are diffuse. Just as individual neurosignatures can exist as “Ghosts in the machine”, old resilient cultural neurosignatures cause painful signatures to dominate the understanding of pain in culture. A key machine structuring the discourse of OTC drugs is the world self-medication industry (http://www.wsmi.org/). In Australia, the self-medication industry has a public-facing industry group called Consumer Health Products Australia (https:// www.chpaustralia.com.au/Home). This peak body represents large pharmaceutical companies who aim to down-schedule prescription-only drugs to OTC, to enhance commercialisation of OTC substances and to enhance access to OTC medicines (https://www.chpaustralia.com.au/Self-Care/What-is-Self-Care). The board of CHP Australia is populated with senior executives from GlaxoSmithKline, Ego Pharmaceuticals, Pfizer, Aspen Pharmacare, and Bayer Healthcare. Self-management of health is a lucrative business because there are few mechanisms to regulate the consumption of OTC pharmaceuticals. This segment of the health marketplace is as close to a free market as can be imagined in the highly regulated Australian health sector. Advertising codes for OTC medicines are not regulated as strictly as more highly scheduled medicines. According to an industrycommissioned report, over 80% of Australian have used an OTC analgesic in the past month (Koslow 2015: p. 9). Of all OTC medicines, OTC analgesics were used with the highest frequency, with 31% of the sample reported using an analgesic four or more times in the past 12 months (Koslow 2015: p. 11). Not surprisingly, the precursor to Consumer Health Products (CHP) Australia, the Australian Self Medication Industry (ASMI) opposed codeine upscheduling (https://ajp.com.au/news/upscheduling-codeine-disregards-pharmacist-

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expertise-asmi/). The ghosts in the machine are “big pharma”, working to ensure that OTC medicines are able to be consumed with as few constraints as possible. The OTC industry lobby group works hard to ensure that the cultural neurosignatures that define the nature of pain (e.g. “life headaches”) and the appropriate pharmaceutical responses (capsules that give life) are subject to as few governmental restrictions as possible. It should also be no surprise that the self-medication industry engages senior figures in the politico-economic milieu to help craft its policy and political messaging. A key report commissioned by CHP Australia was co-authored by a former chief of staff to a senior government health minister (Duggan et al. 2017).

5.9 Leaving Everyday Pain Sufferers Behind: The Many Wolves of the Market In this third section of the chapter I will connect the two earlier seemingly disparate sections on codeine upscheduling and an OTC paracetamol advertising campaign. A tendency when examining this type of material is to (1) valorise Government up-scheduling of a potentially dangerous medicine and to (2) demonise the activities of Big Pharma. I intend to do neither. In fact I will pose a contrary view on both counts, but not for obvious reasons. The up-scheduling of codeine was a mistake. Not because I believe codeine is a necessary pain reliever, or that I hold to a liberal belief that people have a right to selfregulate their own pain relief. The up-scheduling of codeine was a mistake because the narrative that drove the up-scheduling was ill-founded and poorly executed. The up-scheduling was an exercise in vulgar partisan politics that held little regard for pain sufferers. It was a poorly executed narrative because ministerial claims that codeine up-scheduling would save 100 lives were publicly shown to be incorrect. These were vulgar politics because the up-scheduling was an attempt to demonstrate strong government through propagating a drug panic. A strength narrative was not needed by those suffering pain. What was needed was a greater investment in clinical pathways. What pain sufferers got was a confused message about codeine (and the risk of becoming dependent of opioids) based on an epidemic from another hemisphere. Secondly, I will not demonise Big Pharma or the advertising companies that supported the Panadol Life Takes Its Place (LTIP) campaign. It would seem logical to denounce an advertising campaign that cleverly gives life-giving qualities to a low-level analgesic. It would also seem reasonable to be appalled at the level of sophistication of a pharmaceutical—industrial machine that works hard to ensure a framing of pain and its management through OTC medicines, which guarantees high volume consumption of medicines with minimal state regulation. My outrage is not targeted at these two matters. It is instead reserved for a deeper concern over the tension inherent in the self-management of pain. When considered together, the botched up-scheduling of codeine and the sophisticated marketing of

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paracetamol remind me that the capacity to adequately regulate pain across the population is deeply flawed. I am concerned about the relegation of self-managed pain to the wasteland of free markets. There are numerous reasons why self-managed pain is not recognised/appreciated. Wailoo (2014, p. 118) noted that in the early 1980s the US government had facilitated “learned pain” through liberal disability laws. Suspicions grew that chronic pain was a conditioned socioeconomic disease. In his extensive political analysis of pain management in North America, Wailoo (2014), suggested that the relatively unfettered marketing behaviour of the pharmaceutical industry in the 1990s, resulted from that deep suspicion of subjective pain in the 1980s. As noted in Chap. 3, the “clinical eye” is crucial in determining what pain is credibly defined through the conversion of symptoms into signs. This clinical eye is however not trusted, and more importantly is not the property of a sovereign disciplined medical practitioner as would have been the case in a Foucauldian account. The experience from the North American opioid epidemic is that the “clinical eye” is not the expertise of an individual. The conversion of symptom into sign is diffuse. Pain diagnosis is an outcome from a networked assemblage of manufacturers and distributors, wholesalers, prescribers, and pharmacies (see Fig. 3.1). Add into this mix a proliferation of third-party non-profit advocacy groups and interest group agencies and it is clear that pain, when considered as a cultural experience is an outcome from multiple machines. The lesson from codeine up-scheduling is that the fear of addiction to opioids is contagious. The availability of OTC medicine is caught up in an affective economy whereby the lability of pain can be capitalised by a market ready to connect their product to the value that can be sloughed off from exchanging affect for indexes of pain relief. My outrage is that the OTC pain relief arena is so readily exploited, that the population is left to the ravages of the OTC pharmaceutical market so easily. The fact that so much of the OTC market is dominated by the consumption of pain relief attests to the centrality of pain to the population. This arena is inherently vulnerable to exploitation by the market.

5.10 Leaving Ordinary Pain Sufferers Behind Although there is substantial progress among pain management specialists, ordinary pain sufferers don’t benefit from this expertise. Judging from the sheer volume of OTC medication consumption, pain that is not physical, doesn’t pass the test. There is a large population of pain sufferers that suffers illegitimate pain that doesn’t see specialists and is left behind. This is pain that is not clinically defined, that has its origins in diffuse cultural sites. It has a number of clinical terms, and moral categories, but either way, it is there, because the consumption of OTC medication indicates it is.

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Morris (1991) suggests that in a trance of self-induced anaesthesia, society has helped create the wave of chronic pain that is upon us. Jackson suggests that: when the best we can do is throw pain-killers at it we have already set up the conditions for low-grade elusive deep seated forms of pain…. The thing is, pain will out. The more we run from pain, the more it will seek new paths. I think this goes for history that diminishes pain as well. If we try to mute or numb the legacy of pain in certain stories, such as the slow destruction of aboriginal people the eruption of phantom pains should come as no surprise. The level of suicide and self-destruction among natives is a form of phantom pain, the result of cultural amputation. The pain emerges when a community has been severed not only from its past but from an acknowledgement of the damage inflicted. Jackson (2012: p. 171)

The most comprehensive analysis of Australian prescription opioid consumption suggests that the prevalence of pain has increased in Australia (Karanges et al. 2016). Patient presentations to general practitioners for back pain and non-specific pain significantly increased between 2004 and 2014 (Britt et al. 2014). Also, between 1995 and 2008, the self-reported prevalence of pain in Australia increased from 57 to 68%, and the prevalence of severe to very severe pain increased from 7 to 10% (Australian Bureau of Statistics 2012). The fear I have is that those suffering pain will consume vast quantities of OTC medication in the vain belief that they are life giving. For those privileged enough to be able to access pain management specialists, there is a depth of experience and scepticism of pharmaceutical solutions. For all those who do not have access to the educative and critical resources that go with pain literacy (Butler and Moseley 2003; Moseley 2012) there is a wasteland of marketing and false promises. My fear would be mitigated if the marketing techniques were vulgar. However as noted earlier in this chapter, the marketing is elegant, subtle and comprehensive. It defines the condition and then connects the solutions to everyday life. On the one hand I am happy that codeine has been removed from the available OTC pharmacopeia. On the other hand, codeine was removed without adequate pain-management resources being made available to those patients who were selfmedicating their pain. Those who were taking codeine will now be consuming other OTC medications and being subject to the rapacious force of OTC analgesic advertising. Another possibility is that another OTC medication may emerge which takes the place of the “self-medication” being done with codeine formulations. My suspicion is that we will see the market promote another pain reliever, as there is now a modulation in the pain relief market.

5.11 When Regulation Is Gone, the Market Takes Its Place Few can explain the emergence of medicinal cannabis in the absence of substantive evidence of its efficacy. It has been astonishing to witness the impact of the arrival of legal recreational cannabis legislation in the United States after decades of a war

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on drugs. These changes are thought to only have occurred after a substantial period where cannabis was available as medical marijuana. After over a decade of an epidemic of prescribed opioids in the USA, cannabis has emerged as a likely replacement. Remarkably safe compared to oxycodone and fentanyl, cannabis has the potential to be the next major pain reliever. This neurosignature is driven by capital. Bradford and Bradford (2016) reported that once a state medical cannabis law in the US was implemented, the use of prescription drugs fell significantly. They found that implementing an effective medical cannabis law led to a reduction of 1826 daily doses for opioid pain relief filled per physician per year. John Stewart, ex CEO at Purdue Pharmaceuticals and now medicinal cannabis company “Emblem” is now seeking to promote cannabis as an alternative to prescription painkillers. The profits earned by “Emblem” will come from the opioid crisis that Purdue was instrumental in creating (https://www.bbc.com/news/worldus-canada-38083737). In 2018 Australian cannabis company Auscann is employing similar marketing techniques to Purdue—medical liaison teams—to educate doctors about the use of medicinal cannabis. The capitalisation of pain sufferers is being mapped very carefully in Australia. Auscann has two of Australia’s leading drug policy advisors, former Liberal MP Mal Washer (and head of Alcohol and Drugs Council of Australia) and Professor Alex Wodak on its board and its medical advisory team. Former Liberal WA Attorney General Cheryl Edwardes is also on the board at Auscann. The markets are poised. In North America, cannabis is being readied as the alternative to oxycodone. In Australia it may well be the replacement for codeine. Judging from the licensing arrangements between Big Pharma and Australian state governments, the state is also readying itself for a production boom.

5.12 Conclusion As noted in previous chapters the magic is not in the commodity codeine or its replacement. The magic is in commodity pain. How easy it is for GlaxoSmithKline to create new pain, the “life headache”, and to insert its old product Panadol into the position of life-giving remedy. “Fitzy”—Ryan Fitzgerald—the celebrity (no relation to me) who was the key talent in the Panadol “Switchoff” campaign was pure affect when the campaign video footage showed him reconnecting with his kids in the Panadol “reconnection house”. At the heart of the vulnerability of OTC self-medication is the centrality of affect in framing pain. As noted in Chap. 3, the affective economy is the source for connection with the world around us. The OTC medication story should remind us that pain has a broad codification: the incapacity to connect with people around you, managing the brokenness of the social structures that bind communities, and the pain of a broken heart. There is more than one type of pain that pain relief is contracted to fix.

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This is why emotions are important, and why affect is central to understanding OTC consumption. If an OTC medicine offers the promise of giving life, who wouldn’t take it, on the chance that it might connect us with life. When we are not able to traffic in the affects to enable us to go beyond ourselves, to become-other, life itself is at stake. This is the appeal of the promise. This is the contract implicit in the purchase of the pain relief drug. The Panadol marketers were right on the money—they are absolutely right to focus on metonymic substitution. People will invest in the chance that the event derivative will deliver life. This is the scarey part of the OTC story. The marketers are more connected to the potential of life than our government regulators. This is why medical science only gets it half-right when the response focusses on reducing access to opioids like codeine. The government response, to penalise those offering the futures contracts for difference (CFD), misses the demand for pain relief. The demand is situated in the risk mitigation that the contract attempts to achieve. Modern medicine languishes far behind the derivative logic of modern capital. Regulation of OTC medicines reveals this failure. Being situated in the linear causal medical pain model, public health does not have a language to attempt to find a cultural explanation for the widespread consumption of OTC medicines. This is the best it can do.

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Chapter 6

Etched in the Skin: Pain, Methamphetamine Violence and Affect

Beyond the direct effects of substance abuse, perhaps its most damaging result is addiction itself. The compulsion of addiction makes drug use the most important purpose in an addict’s life, leading them to pursue it at any cost and treat anything else as secondary. Self-neglect becomes normal – an accepted cost of continuing to use drugs. And the consequences of addiction can remain etched in their very skin for years. The pursuit of a drug habit can cost these people everything – their friends and family, their home and livelihood. And nowhere is that impact more evident than in the faces of addicts themselves. [Source: https://www.rehabs.com/explore/faces-of-addiction/]

For some, faces provide a window into pain. For others, pain-filled faces have been a media exemplar for profound suffering. More recently, websites such as “faces of meth” and “faces of addiction”, emerging either from police or the drug rehabilitation industry, trace the changes in drug user faces over time, graphically illustrating the pain of extreme degeneration. Another exemplar of facial pain can be found in the cultural arena, through the blockbuster film series of Lord of the Rings. Andy Serkis, the actor playing Gollum, explained that he based his character on the figure of an addict: I had to find something very real to play that part and for me it was all about that ring and addiction, the whole schizophrenia and pathological lying. I play him pretty much as if he was an addict. It controls him and he craves and obsesses over this thing. [Source: https://www.nme.com/news/film/the-hobbit-star-andy-serkis-i-play-gollumas-if-h-875835#lqLqdSMg5OiylZv3.99]

In 2018 when giving a seminar to nurses, one nurse approached me with a business idea: “What about demonstrating to kids how much harm drugs do by showing them photos of before and after faces of meth users”. My response at the time was diplomatic; “It has already been done, maybe try another angle”. The power of the image of the pain-filled addicted drug user face is not just an abstracted image. It is a business opportunity.

© Springer Nature Singapore Pte Ltd. 2020 J. L. Fitzgerald, Life in Pain, https://doi.org/10.1007/978-981-10-5640-6_6

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As noted in the introduction, there are numerous sources of pain for drug users: the drug itself, the pain of addiction and there is also what to do about the pain of living for those in marginal social positions (Singer 2001). As noted in the New England Journal of Medicine, the identification and treatment of chronic pain has sharpened over the past 10 years, but so too has the opioid overdose rate (Olsen and Sharfstein 2014). Pain comes in many guises, we tend however to focus on the face of the drug user as a powerful index to pain. As noted by rehabs.com (see above), pain is etched into the skin. In semiotic terms, the face is both form and content. Having previously analysed the tendency of news print media to black out the faces of drug users (Fitzgerald 2015a, b), in this chapter I am going to explore the obverse: the drug user face as an index for pain. Here I will examine the faces of methamphetamine users as part of the cultural pain neurosignature for methamphetaminerelated violence. I have chosen to look at methamphetamine-related violence because the faces of methamphetamine users have been central to intensifying public fear about methamphetamine both in the USA and Australia. The central argument flowing from this analysis is that the indexical mark of the face in the cultural pain neurosignature is inherently valuable because it produces pain. It functions like a derivative because the value of the face-as-sign is linked directly to the risk it poses to the body politic and to the future pain it will produce. In order to describe the social consequences of this cultural pain neurosignature, I will conduct a deep case study of faces in pain, the “Montana Meth Project” website and the pain and suffering associated with drug use. Specifically, I will examine how the focus on pain associated with the ice-violence neurosignature had material consequences in Australia. The drug scare that underpinned Australia’s supposed ice epidemic was premised on pain. I will explore the idea that Australia’s ice epidemic was not an epidemic of ice-methamphetamine, but an epidemic of pain. The neurosignature redefined the pain and a slew of harm ensued. The cultural neurosignature articulated the problem as methamphetamine. However, no-one noticed that perhaps there was a deep cultural concern about pain. Whilst my focus will be on the appearance of faces in materials from the 2005 “Montana Meth Project”, I will contextualise the use of faces with illustration from other drug-faces sources, such as “Faces Of Meth” and “Faces Of Addiction” websites.

6.1 Faces of Meth The Faces of Meth (FOM) website was the brainchild of Deputy Bret King from the Multnomah County Sherriff’s office. In December 2004, he shared mug-shot photos of repeat offenders, and used these to educate young people about the dangers of methamphetamine. “Faces of Meth” has been trademarked, however the gallery of photos is available for free download and media news websites have reproduced the images

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Fig. 6.1 An image from the “Faces of meth” collection in Multnomah county. Source https://www. youtube.com/watch?v=ZvmvmazxHag

under their own banner (https://www.heraldsun.com.au/news/photos/image-gallery/ 6de3d35339f303a3cf1a58845f0f018f?sv=f6749a194b2341fbf8b1d378e20bfcc0). There were also spin-offs such as the 2009 Face2Face software application. Submitted photos are “tweaked” with the software to model what happens to someone’s face after methamphetamine use. The Mendocino County Sherriff’s Office, the producer of the application (https://www.youtube.com/watch?v=_CafSPMLHjY) originally sold the software for over $3000. Now the company involved specialises in rendering digital material for retail 3D statuettes from submitted photographs (Fig. 6.1). Linnemann and Wall (2013) observe that the Face of Meth (FOM) photographs (http://www.mcso.us/facesofmeth/main.htm) resonate with existing cultural anxieties about ‘white trash’. The abject figure of the meth user in FOM emerges primarily because the images disturb identity, system and social order (Thomas-McGill 2017) “FOM locates meth users outside community, outside law, outside reason, outside bourgeois conventionality”. The genre of the shot (mug shots) gives the images authenticity and the framing of these people as “meth users”, reduces the complexity of their lives down to meth use. The FOM mugshots simultaneously demonstrate the capacity of the Sherriff’s office to capture and control the meth user and reinforce the power of the state. According to Linnemann, the FOM images enable the state to “govern through meth” (Linnemann 2012) and reproduces a specific racialized subjectivity (Linnemann and Wall 2013; Tchoula et al. 2017).

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6.2 Faces of Addiction The next website (https://www.rehabs.com/explore/faces-of-addiction/) is perhaps an exemplar of the capacity for capital to be mobilised through the face of pain. The website, rehabs.com, which receives more than 5 million consumers each year (https://blog.recoverybrands.com/consumer-insights-holidays/), is operated by Recovery Brands, and owned by American Addiction Centers (ACC). ACC also owns a suite of other drug treatment industry websites including Rehabs.com, Recovery.org, DrugAbuse.com, ProjectKnow.com, and a digital marketing platform called ClientReach (https://www.bloomberg.com/research/stocks/private/snapshot. asp?privcapId=328949504). According to rehabs.com: The pursuit of a drug habit can cost these people everything – their friends and family, their home and livelihood. And nowhere is that impact more evident than in the faces of addicts themselves.

The face of the drug addict becomes a site for capitalisation. The visible presence of pain is a touch point for investment. Here, the catastrophic health effects of drug abuse are plain to see, ranging from skin scabs to decayed and missing teeth. While meth is often seen as one of the most visibly destructive drugs, leading to facial wasting and open sores, various other illicit drugs, and even prescription medications can cause equally severe symptoms when continuously abused.

The point of difference for the Faces of Addiction website is the animation of change over a period of time and the attribution of the drug offence to the graphic (Fig. 6.2). Online, the right-hand mugshot morphs between still photos to show the transformation over time. The transformation shot is frankly quite creepy, as it erases the limitation of the mug shot. The transformation creates a continuity over time, giving the impression that you are seeing more than what can be captured in the split-second mug shot. Somehow the animation provides an overview on the life of the mug in the shot. If we thought the still image mugshot instantiated the power to capture, control and “govern through meth”, the animation accentuates the level of control by pretending to extend control over the time between the photos. The still shot always implied that there was a remainder, something outside the facial mug shot that was beyond what could be understood in a one-off photograph. Medical photographer Hans Killian (in the next section) attempted to capture that which is left out by the lens in that split second. The animation implies an absolute power to “govern through meth”. In the next section I will examine the background to reading faces in terms of pain. I will then deepen the understanding of the relationship between pain and drug use by reviewing some dominant theories for how pain is understood in the life of drug users. The point of this broader review is to demonstrate how a face condenses the multiple dimensions to pain that may be apparent in the life of a drug user. After this I will go to the case study of “the Montana Meth Project” and demonstrate the concrete manner in which the face of the Ice addict became mobilised in Australia’s Ice epidemic.

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Fig. 6.2 Facial transformation of a methamphetamine user from faces of addiction (https://www. rehabs.com/explore/faces-of-addiction/)

6.3 Faces and Pain Bilbo Baggins, the hero of the tale of J. R. R. Tolkein’s The Hobbit, was a humble hobbit, who carried an evil ring of power for several decades. Long after passing the ring on to his nephew Frodo, Bilbo still desired the ring, to the point that when he encountered it decades later, his face transformed into that of an evil monster. The desire for the ring transforms him from a gentle old man to a pain-filled beast. The pain of unrequited desire never goes away, and culturally we anticipate that even our most interior of desires can be read in the face. Historically, medicine has a strange ambivalence when confronting pain, both valuating it as a useful tool but also denying the painful experience (Barras 2014). One of the most important medical contributions to understanding the face of pain was in 1934. Dr. Hans Killian, an anaesthetist and surgeon, published a volume of patient photographs entitled Facies Dolorosa: Das schmerzensreiche Antlitz (The Countenance in Pain). The work consisted of sixty-four portraits of mostly terminally ill and dying patients. Facies Dolorosa conveys a tension between scientific observation and humanist art (Primavera-Lévy 2011). His patients included children, men, and women of all ages who displayed a range of emotions: composure, silent suffering, apathy, reproach, struggle, and acute pain. Killian was trying to express what he called “das Unwägbare” [the imponderable] as essence, as force. He grouped the images into 9

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segments: (1) Ill people virtually untouched emotionally (2) The experience for the disease reflected in the face (3) Goiters (4) Pale faces (5) facies Dolorosa (6) Narcosis (7) Drowsiness and consciousness (8) Emaciation and (9) Sequential images from different stages of disease (Primavera-Lévy 2011). Primavera-Lévy (2011) believes the essential humanity sought in Killian’s images realised a quest, consistent at the time in Weimer Germany, for a sense of shared human exposure to vulnerability and a mark of deep connectedness. The objective in these images was to capture not just what was apparent in the fragment of time in which the image was composed. The aim for Killian (1956) was to capture that which transcended the moment, that which escapes the visible. Benjamin (1999/1936) called this the auratic. Prima-Levy refers to it as the remainder, the suffering countenance, that which is left after that which is captured by the lens in that split second. For Primavera-Lévy (2011) Killian was at least partially successful: Contemplating the countenances in Facies Dolorosa, it is hard to deny that KIllian is on the scent of aura. Killian’s images of patients at the brink of death enduring irreproducible pain compellingly simulate duration and singularity.

Interestingly, Primavera-Lévy (2011) is connecting pain to an ontology outside of time. Although thoroughly humanist, the location of countenance outside of time and the body, but somehow located and indexed though the body perhaps points to the kind of ontology for pain suggested in Chap. 2. Killian resisted the historical urge, rooted back to Hippocrates, Aristotle, and Galen to try and diagnose disease by physiognomic facial features (Luger et al. 2016). Killian instead urged a greater awareness of the patient through appreciating that which was apparent beyond the disease. The urge to look beyond the body to the auratic was however overtaken by another urge. The drive to diagnose and define through reading the face for pain chose another path that had its roots in an earlier physiognomics. There are multiple ways of encountering an image: both through the forms in the frame, and through the content which is semiotically connected to that which is in the frame. A significant clinical arena is devoted to objectively measuring changes in facial appearance and correlating that with levels and types of pain. Although dementia patients (Kunz et al. 2007; Oosterman et al. 2016) and neonates (Grunau and Craig 1987) were primary targets for such analysis, the automated facial recognition of pain has proceeded to a high level of sophistication (Prkachin 1992, 2009; Prkachin et al. 2004; Prkachin and Solomon 2008; Atee et al. 2017, 2018). The objective measure of facial pain involves a number of active units in the facial active coding scheme (FACS): brow lowering, cheek raising, tightening of the eyelids, wrinkling of the nose, raising of the upper lip, pulling at corner lip, horizontal stretch of mouth and parting lips (Atee et al. 2018). The automation of pain measurement in the face is highly specific and reproducible. A clinician with an iphone and an AI can read pain from a face (Atee et al. 2017). The problem with reading the face for pain however, is that any number of environmental, physical or psychological forces could be causing these objective changes in musculature. In the next section I will briefly review the relationship between pain

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and drug use to put together a list of culpable forces that can transform the face into an indexical marker for pain.

6.4 Pain and Drug Use Bourgois (1996), Singer (2001, 2004, 2006), Singer and Page (2016) trace the pain of suffering of individual illicit drug users through to oppressive social structures that exploit those at the edges of market economies. Singer (2001) coined the term “oppression illness” to describe the accumulated pain from: chronic traumatic effects of experiencing racism, classism (disdain and mistreatment of the poor and working class) and related oppression over long periods of time (especially during critical developmental periods of identity formation), combined with the negative emotional effects of intense self-disparagement associated with being the enduring target of social bigotry… it is a product of the impact of suffering from social mistreatment and at some level believing one does not deserve anything better/ They have internalised their oppression and blame themselves for being poor and socially ostracised.

Social processes are internalised and manifest in risk behaviours and attitudes, and to some extent become located in the physical body. During the 1990s and 2000s, these commentators asserted that the physical outcomes of the corporeal impact of oppression illness was HIV and hepatitis C infection among injecting drug users. Here pain and suffering were causes of drug use and a driver of the demand for pain relief. In this framework, pain has its social origins in the structural violence of modern capitalism (Fig. 6.3). There is also a literature that examines the relationship between chronic pain and “non medical” drug use through the pain of chronic injury (Manchikanti et al. 2006). Although there is an extensive literature describing the physical and psychological pain of withdrawal from drugs, I will focus on more existential accounts of

Fig. 6.3 The relationship between structural violence, illness and drug use. Political economy of inner-city drug injection. Adapted from Singer (2001)

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pain, and pain focussed on affect. There is a strong sense that the suffering of addiction/dependence has an ontological quality, i.e. it stands as distinct from other forms of pain and the suffering is felt across a number of dimensions of the self. Deleuze and Guattari (1987: p. 283) use the addict as an exemplar of a botched body. A body that has emptied itself out of its structures, the things that keep a self together and able to function in the world. In an attempt to become-other with the world too much, the drug addict attempts to lose itself in the world, to the extent that it cannot be-in-the-world (Fitzgerald 2015a, b: pp. 7–12). Deep suffering results from this kind of becoming-other. McLeod (2017) refers to this kind of becoming as occurring within a Becoming-Indeterminate assemblage. There is great suffering and pain here as the body loses its way in the world. There is some evidence also to suggest that drug use causes deficits in the ability of drug users to recognise pain in the faces of others (Fernández-Serrano et al. 2010). Polysubstance users had significantly poorer facial affect recognition than non-drug users for expressions of anger, disgust, fear and sadness. The extent of specific drug use predicted poorer affect recognition: heavy cocaine use predicted poorer anger recognition, and duration of cocaine use predicted both poorer anger and fear recognition. It should be noted that this was a small study with numerous methodological complexities, however the overall results are notable (FernándezSerrano et al. 2010).

6.5 Cultural Pain of Addiction Culturally, the pain of addiction sits somewhere beyond physical and emotional pain. It has a deeper and most pervasive quality associated with the loss of self. As noted at the beginning of this chapter, Andy Serkis the actor who plays the creature “Gollum” in Tolkein’s Lord of the Rings movie corpus, modelled his portrayal of the character on an addict: Gollum is entirely based on the notion of addiction. The way that the ring pervades him, makes him craving, lustful, depletes him physically, psychologically and mentally. It was important to find something very real to people watching in this day and age. You feel sorry for him but you hate him. Gollum has a weak personality and isn’t able to cope with the power of the ring. (source: https://www.telegraph.co.uk/culture/film/film-news/9737923/ The-Hobbits-Andy-Serkis-Gollum-is-based-on-addiction.html)

Not being able to cope with the force of power depletes the individual psychologically and mentally. This pain is far deeper than other types of pain. In a drug ethnography from new Mexico, Garcia (2010) focusses on how certain forms of loss, compelled by historical and social conditions, lead to a local “ethos of melancholia”, that results in heroin addiction and death. One of the drug users in the study asserts: Es que lo que tengo no termina [It’s just that what I have, has no end]. (Garcia 2010: p. 71)

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For Garcia (2010) unfinished grief and historically-situated pain are a feature of heroin addiction and Hispano life. The specificity of the conjunction between local Hispano conditions and the experience of addiction suffering are poignant. The work of mourning commemorates the “singularity of death while insisting on the inevitable repetition of it” (Garcia 2010: p. 73). Garcia refers to the descanso memorials which bring death to life, similar to the graffiti memorial in street drug markets in other contexts (Fitzgerald and Threadgold 2004). Garcia extends the mourning into a Freudian melancholy subjectivity. A feature of this melancholy is the unending quality of the experience of loss, how loss becomes permanently embedded in the drug user through insomnia, a heavy heart, injection scarring and abscesses. Addiction is an historical formation and an immanent experience. For Garcia, the melancholic drug user is stuck in affect and incapable of sublimating the pain of past loss so that he may love meaningfully in the present (Garcia 2010: p. 109). The weight of the biomedical model of addiction as a chronic relapsing condition, can “bury us beneath the weight of that which does not end” (Garcia 2010: p. 77). These wounds in which the future, the present and the past co-mingle through the force of recurring need, the need to score heroin, the need to get high, the need to find a vein. (Garcia 2010: p. 93)

For Garcia, the pain of the past becomes embodied in both corporeal practices and the disparate techniques used to govern drug-using bodies. The pain of drug addiction extends well beyond the physical body.

6.6 Iteration of Suffering and Pain in Treatment Modalities In her analysis of the narratives of 12-step drug treatment, Summerson-Carr (2010) examines the role of affect in the drug treatment narratives that confer recovery and wellness. In this drug treatment modality, Summerson-Carr observes that, like the Christian confessional tradition, “secrets keep you sick”. The naming of sins is thought to heal the sinner. However, when addicted, secrets are thought to hide themselves from the confessant as well as the confessor. Denial, anger and shame hide the truth and produce the pain of addiction. The addicted speech act is one which fails to penetrate hidden truths. Recovery and wellness are achieved when these “truths” are liberated and the drug user sees themselves and narrates their own life in the same terms as the therapist (SummersonCarr 2010: p. 133). In an analysis of another 12-step drug treatment program, Chen (2010) describes two types of related suffering in addiction. Primary suffering can drive an individual to drug use. Over time, the effects of addiction worsen, causing secondary suffering (Fig. 6.4). Chen (2010) defines this secondary suffering as “the unbearable suffering of drug addiction e.g., the ‘hitting bottom’ that forces one to reassess his life and

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Fig. 6.4 Suffering as a motivation for treatment: A conceptual model. Adapted from Chen (2010)

seek help… a multidimensional phenomenon affecting all aspects of one’s physical, emotional and social existence”. For Chen (2010) the 12-Step program offers a practical way to cope with suffering through a process of surrender. The act of surrender sets in motion a conversion experience, which involves self-change including reorganization of one’s identity and meaning in life. Accounts of the pain of addiction are ubiquitous and tend to emerge from the drug treatment sector, often in the form of 12-step testimonials. However, following from Summerson-Carr (2010) there should be an awareness that narratives of the pain of addiction need to be situated within the context of their production. Summerson-Carr (2010) observes the ideological work involved in forming the language of experience in “talking cures”. The metalinguistic labour in 12-step drug treatment models redefines the self and its experience of pain in affective terms. For example, the metalinguistic tool “HOW” (Honesty, Openness, Willingness) is used by therapists to guide and sanction drug user behaviour. The pain of recovery is increasingly defined in terms of the language of the therapeutic model. The “sins of the past and the residual shame of the present” are cast within narrative plotlines and prescribed modes of speaking (O’Brien 1998). As a consequence, studies that report on the pain of addiction from people undergoing this kind of treatment need to be understood within the terms of the treatment model. A good example is the study of “pain resolving” by Kim-Lok et al. (2016) among Malaysian drug treatment patients. According to these patients, pain was the primary concern of those in treatment. Seeking instant pain relief and “honesting” predominate during the recovery process. Painful experiences are events of abandonment, rejection, loss, non-approval, betrayal, humiliation, abuse, aggression, and punishment. These painful experiences cause emotional pain in the form

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of feelings of worthlessness, inadequacy, un-belongingness, insecurity, emptiness, low self-esteem and hopelessness. Painful emotions such as shame, fear, guilt, anger, resentment, anxiety, and depression ensue (Kim-Lok et al. 2016). What is apparent is that the origins of pain configured in this drug treatment speech genre are social. Yet, the pain is experienced and narrated as an individual attribute. The pain of drug use has a number of dimensions, with only a few of these are related to the drug itself. Most of the pain acknowledged in the literature and in drug treatment, is pain emerging from the social self or through registers that are inherently social and emotional in origin. Social pain threatens fundamental social needs (Eisenberger 2012; Karos et al. 2018). Focussing on the drug and individualising the pain erases the contribution of the social (Das 1995). This raises very important questions about what we see when we see pain-filled faces of drug users. What is the pain that we are seeing? From the point of view of Singer and Bourgois, to reduce the pain of drug use to the substance itself is a violent reduction of the complexity of life and an erasure of the economic and social forces that enforce oppressive structural conditions. The face then becomes even more important not as a window into pain, but as a distraction from the structural sources of pain. In the next section I will explore the primary case study—the use of pain-filled faces in The Montana Meth Project.

6.7 The Meth Project The Montana Meth Project began in 2005 in Montana through the donations of software engineer Thomas Siebel. The project was targeted at teenagers and through the use of graphic TV ads and billboards, aimed to reduce methamphetamine use in Montana. It has been reported that after its apparent success, seven other states adopted the campaign and it broadened to be called “The Meth Project”. In 2007, on evidence of its success, the State of Montana expended over $1 m to support the campaign (http://www.montanakaimin.com/news/evaluating-the-effectiveness-ofthe-montana-meth-project/article_39f61954-ac5a-11e6-b695-bfd686efc470.html). Reportedly, with over $5 million of funding from Thomas Siebel, during the first 6 months of the campaign over 60,000 min of radio and TV ads and 150 newspaper advertisements pages were purchased (https://library.cqpress.com/cqresearcher/ document.php?id=cqresrre2006060200). Meth users were portrayed as dangerous, violent, dirty, out of control, and as victims of sexual violence (Erceg-Hurn 2008). Evaluations of the Meth project are not very positive (Erceg-Hurn 2008). A 2008 impact evaluation reported that around 50% of teenagers in the study believed the project materials exaggerated meth risks and “caused a threefold increase in the percentage of teens who believe that using meth is not risky”. The report also suggested that any changes in methamphetamine use indicators would be more likely be due to the 2005 commencement of measures enshrined in the Federal Combat Methamphetamine Epidemic Act, which restricted the sale of methamphetamine precursors (https://www.deadiversion.usdoj.gov/meth/index.html).

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A 2010 evaluation of statewide self-reported methamphetamine use patterns in states with, and without the meth project, found little effect of the project (Anderson 2010). The evaluation noted that methamphetamine use was on the decline during this period in states with and without the Meth Project. Overall a follow-up analysis found no effect of the meth project on methamphetamine use. There was a statistically non-significant effect of the campaign on white high school students, but not on other ethnicities (Anderson and Elsea 2015). The Meth Project engaged high profile film directors to create their graphic advertisements. Darren Aranofsky, a Hollywood director (whose films have received a Sundance award and several Academy Award nominations) directed eight television ads, including Deep End, Desperate, E.R., and Losing Control in 2011 and Boyfriend, Mother, Friends, and Parents in 2007 (http://www.methproject.org/ action/recognition.html#partners-link). Between 2005 and 2006, celebrated English director Tony Kaye directed the first eight ads for the Meth Project, including Bathtub, Laundromat, and That Guy (http:// www.methproject.org/action/recognition.html#partners-link). Damaged and distressed faces were a strong feature of many of the TV Ads. In some cases, the faces were young and in other stories the faces were old and haggard. The TV advertisement entitled “Bathroom” directed by Tony Kaye was particularly graphic. In this piece, a young girl was having a shower and hallucinated a stream of blood in the water at her feet. She screams when she sees a figure of her future self. Haggard and dishevelled in the bath, the future self tells her “don’t do it, don’t do it”. The TV advertisements gather their power not just from the graphic depictions, but in the Shakespearean narrative structures. “Bathtub” for example does not even refer to meth during the piece, rather the focus is on the horror of the scene, a young girl seeing her future self, talking back to her. It is only in the closing frame does the project branding close the narrative. Up until the final frame, the bloodied-up girl could be there for any reason. The bloodied-up girl is actually an index for meth. Without the pre-existing context, this advertisement could have been for anything, risky driving, risky sex, risky anything that results in a pain-filled beaten up bloodied face. The cleverness of the ad is that it creates a visual narrative puzzle that is solved by the final frame of the piece. The blood and the bloodied-up face of the drug user carry the affect of regret through the narrative, and the visual narrative closure establishes the indexical link between pain and meth use. Interestingly, short 1–2 s segments of a number of these Meth Project TVadvertisements appeared in an Australian TV news item in 2015. Except this time, the vision from “bathroom” was not branded as part of the Montana Meth Project. What was included was the bloodied-up face of the young girl (Fig. 6.5) and the scabbed-up, dirty faces of scarey methamphetamine guys. The watermarks on the SBS TV news item can be seen in upper left and right corners of the frames. I will return to the citation of these Montana Meth project images in a subsequent section.

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Fig. 6.5 Re-contextualisation of the bloodied up bathroom girl from Montana into an Australian TV news item. Source “Australia’s Ice epidemic”: The feed SBS television (25 March 2015). https://www.youtube.com/watch?v=AkH4rDpwStE. Source Vision from the meth project, YOUTUBE compilation showreel “Not even Once”, “Bathtub” (2005) director Tony Kaye. https:// www.youtube.com/watch?v=uGiAxwgrF_k. Note the Australian TV network watermarks

What is apparent is the saturation of pain across these images of meth faces. Whether it be Faces Of Meth, Faces of Addiction or the Meth Project, these sources of cultural material provide a key for indexing pain to the face of meth. Historical analyses of the media presentation of methamphetamine epidemics (Parsons 2014) would have us believe that methamphetamine has a special link to poverty and whiteness (Ayres and Jewkes 2012; Linnemann and Wall 2013). In the UK, in the wake of a fake meth epidemic, Ayres and Jewkes (2012) suggest that the British media constructed its own hyper-reality through the “ice epidemic” reporting. Central to this was the creation of the image of the violent meth user. In the USA, Parsons (2014) observed three distinct methamphetamine scares in the USA: the “speed freak” alarm of the late 1960s and early ‘70s, the “ice” epidemic in 1990, and the “crystal meth” epidemic around 1995. There is a long history of portraying methamphetamine users as crazed and violent. These cultural residues powerfully shape expectations of what methamphetamine does to people and remains a ghost in the cultural pain machine.

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6.8 Your Face on Meth Mustafa Atee developed the automated pain recognition app Painchek™ as part of his Ph.D in Western Australia. The app is a sophisticated multidimensional app for handheld devices to be used in clinical settings (Atee et al. 2017, 2018; Hoti et al. 2018). It is designed to detect pain among non-verbal populations who cannot easily articulate their pain, such as dementia patients. Only one dimension of the app is of interest to this chapter. Using the camera on a handheld device, a facial image is analysed by a pain recognition algorithm to estimate pain levels through the visual appearance of facial musculature. The app measures changes across nine facial “action units”: brow lowering, cheek raising, tightening of eyelids, wrinkling of nose, raising of upper lip, pulling at corner lip, horizontal mouth stretch and parting lips (http://www.painchek. com/wp-content/uploads/2018/03/PainChek_DTA_For-distribution1.pdf). The app was developed using a machine learning process through exposure to thousands of facial images. In this section I will examine the pain levels in faces from the various web-based resources discussed earlier. In clinical use, the app engages multiple data sources to produce a pain estimate. Facial recognition is just one of these data sources. I will not try to estimate the level of pain experienced by the people in the images in the above websites. I will however explore the readability of pain in the images. The facial pain module of Painchek™ is perhaps one the best ways to provide a measure of the pain readability of a facial image, given what we know about the limitations of reading pain in faces. Mugshot images from the Multnomah County Sherriff office website, the faces of addiction website, and other sources of before-and-after images were assessed using Painchek™ . The results are expressed in three ways. The first is to express how many of the images contained a visible development of pain after drug use. The second way data is expressed is to measure across the pool of images the aggregate pain recorded before and after drug use. According to the Painchek™ authors, facial expressions are readily accessible, are highly plastic, and are believed to be the most specific, encodable form of pain behaviour in humans (Williams 2002). The scoring of the facial domain are comparable to an existing scoring system—the Abbey Pain scale. There are two primary observations to be made about this cohort of website faces. An average of 23% of before-drug-use images scored above zero, meaning that 77% had no evidence of pain in their face. Suggesting both that this cohort of images were not pain free and/or that the detection limits of the algorithm has a baseline of positive detections at around 23% of the cohort, regardless of whether this means pain was present or not. In terms of the cohort, this is not unsurprising as these are mugshots of offenders under arrest. There must be some discomfort involved. The second observation is that the pre-drugs estimate of pain is consistent with published results for a sample of dementia patients at rest (Atee 2018), whose automated facial scores were 1.7 ± 0.7 (mean ± standard deviation).

6.8 Your Face on Meth Table 6.1 Results of the Painchek™ assessment of website images before and after drug use

153 Facial pain analysis Source

Before drug use (%)

After drug use (%)

Count of individuals with score >0 on painchek after drugs Faces of meth (8 images)

2/8 (25%)

4/8 (50%)

Faces of addiction (13 images)

4/13 (31%)

5/13 (38%)

Face of addiction video (18 images)

4/18 (14%)

9/19 (47%)

Average over all images

23%

45%

Sum of painchek scores >0 on painchek across group of images Faces of meth

2

4

Faces of addiction

4

5

Face of addiction video

4

9

Total over all images

10

18

The change in pain can be understood in two ways. To what extent did the postdrug use images have detectable pain markers. When examining the total pool of images, regardless of the website, 45% of images had a pain score greater than 0. Only two patients had a high facial pain score of 3 (Table 6.1). Summing scores across all images in the cohort, the aggregate pre-drug pain was 10. The total pain score after drug use across all the images nearly doubled to 18. This brief analysis, albeit using a facial recognition tool that was not meant to be used for cultural analysis, gives an indication of what can be perceived in these images in the faces of meth, and faces of addiction online materials. Painchek™ analysis suggests that pain was perceived to a far higher extent in post-drug images than in pre drug images. Pain indicators were nearly doubled in the post-drug images than the pre-drug images. This is a complete dataset. I am not extrapolating the impact of these images to other images. When Painchek™ assesses the pain in these images, this is what it finds (Table 6.2). When specific characters in the Montana Meth Project were examined, the highest pain-filled image was that of the screaming girl in “Bathtub”. Images in this particular movie were re-cycled ten years later in an Australian news media coverage of a methamphetamine epidemic.

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Table 6.2 Highest ranked pain images, using Painchek™ in the Montana Meth Project showreel (https://www.youtube.com/watch?v=uGiAxwgrF_k) Scene/character

Timecode (min.sec)

Painchek™ facial pain assessment score

Montana meth project https://www.youtube.com/watch?v=uGiAxwgrF_k “Bathtub”—screaming girl

2:56

5

“Bathtub”—scabby vision of the future girl

3:00

3

“meth not even once”—scabby lips girl

3:27

2

“stop looking at me”—baby crying

5.51

5

“this wasn’t supposed to be your life”

6:01

2

6.9 Meth Epidemics Parsons (2014) asserts that a number of methamphetamine epidemics in the USA have been drug scares. The process of constructing drug scares involves the creation of “folk devils” (either in forms of youth gangs, Asians, Mexican cartels or greedy prescribing doctors), and a transformation of the drug user from just “deviant” into something monstrous. Murakawa (2011) asserts that a feature of the methamphetamine epidemic was a focus on the physical monstrosity in the faces of meth users. This transformation of the drug users it is argued, changed drug policy and policing practices, resulting in high levels of drug consumer arrests (Parsons 2014). For less critical historians of drug trends, methamphetamine epidemics emerge out of very specific social circumstances (Farren 2010). Sometimes these epidemics are media constructions, sometimes they emerge from social pathology (such as war and impoverishment) and sometimes as a product of drug market changes. Post-world war II epidemics in USA and Japan emerged from widespread access to the substances and prior exposure during wartime (Weisheit and White 2009: p. 36). In the USA, it was medically prescribed from 1959–1962 after medically treating heroin users with methamphetamine (Kramer et al. 1967). The emergence of methamphetamine epidemics does not however follow a “natural” course. Crop eradication in Hawaii created an opportunity for asian distributors to distribute methamphetamine more widely in Hawaii (Joe-Laidler and Morgan 1997). Hawaii in the 1980s, San diego in 1989, and Michigan and Iowa in the 1990s, all had specific “surges” (Weisheit and White 2009; Parsons 2014). Overall there was a migration of methamphetamine from California to Illinois and Missouri over this period (Weisheit and White 2009: pp. 41–44).

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6.10 The Australian Ice Epidemic In 2015, mainstream news media announced, citing research from the Federal Government and leading law enforcement agencies, the that there was an Ice epidemic in Australia. On April 8, 2015, The Australian Prime Minister Tony Abbott declared this to be the worst drug problem Australia had ever experienced (https://www.smh.com. au/politics/federal/prime-minister-tony-abbott-says-ice-is-the-worst-drug-problemaustralia-has-ever-faced-20150408-1mgi7u.html). The key evidence for the epidemic was the survey results from the National Drug Strategy Household Survey published by the reputable Australian Institute of Health and Welfare (AIHW). Table 6.3 shows the data at the time, as it was expressed in the survey report. Table 6.3 Reproduction of a table showing the frequency of use of the different forms of methamphetamine, according to National Drug Strategy Household Survey (NDSHS) Frequency of use

2007

2010

2013

At least once a week or more

13.0

9.3

15.5#

About once a month

23.3

15.6

16.6

Every few months

27.9

26.3

19.8

Once or twice a year

35.6

48.8

48.0

All recent meth/amphetamine users

Main form of meth/amphetamine used—ice At least once a week or more

23.1

12.4a

25.3#

About once a month

24.3

17.5*

20.2

Every few months

20.7

23.1*

14.3

Once or twice a year

31.8

47.0

40.2

Main form of meth/amphetamine used—powder At least once a week or more

7.7

2.9*

2.2**

About once a month

22.9

13.8

16.6

Every few months

31.6

29.0

20.0

Once or twice a year

37.6

54.4

61.2

Source Australian Institute of Health and Welfare (AIHW) AIHW (2014, Table s.20). a AIHW online data table was accompanied by a note that the 2010 estimate of 12.4% has “a relative standard error of 25 to 50% and should be used with caution” * Estimate has a relative standard error of 25 to 50% and should be used with caution. ** Estimate has a relative standard error greater than 50% and is considered too unreliable for general use # Statistically significant change between 2010 and 2013 (a) For non-medical purposes (b) Used in the previous 12 months Note Base is recent users of meth/amphetamines

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The Australian Criminal Intelligence Commission (ACIC) released a report on 25 March 2015 describing the methamphetamine market in Australia. The ACIC report reported a doubling of the number of ice users in Australia. News reports accompanying the ACIC report focussed on the doubling of the number of ice users. The headline in the News Corporation newspapers was ice use doubled. This was reiterated through an animation of a line graph showing the doubling of the number of ice users in a TV news item on the national SBS TV news and current affairs program, “The Feed” (https://www.youtube.com/watch?v=AkH4rDpwStE). The central claim of the “ice epidemic” in the ACIC report was that between 2010 and 2013 the percentage of survey respondents reporting weekly ice use had gone from 12.4 to 25.3%. The number of ice users had doubled. The data was cited and recited in print and TV news. Reading the AIHW table at the time however, a very different conclusion could have been drawn. Taking into account the previous data point from 2007, the percentage of weekly ice users in 2013 had returned to 2007 levels. Importantly the 2010 estimate had a very large standard error (between 25 and 50%). The 2010 estimate, according to the AIHW footnote “should be used with caution” (AIHW 2014, Table s.20). The apparent doubling was not a doubling at all, it was return to levels previously recorded in 2007. Even the AIHW in 2019 in its most recent fact sheet about methamphetamine, still do not account for the level of use in 2007: While overall recent meth/amphetamine use declined between 2013 and 2016, the proportion of the total population using crystal/ice remained relatively stable between 2013 and 2016 and has increased since 2010. (AIHW 2017) https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia/contents/ drug-types/meth/amphetamine-and-other-stimulants

For some reason the Federal Government and the ACIC chose to ignore two things, (1) the 2007 data point and (2) the caveat placed against the 2010 estimate by the AIHW. According to this data, there was no epidemic, this was business as usual. Other areas of the NDSHS results suggested important trends. Whilst there was an increase in methamphetamine-related harm, there was no evidence of increased methamphetamine use. The results suggested that there was a reduction in methamphetamine use overall in Australia over the period, when there was meant to be a methamphetamine epidemic. What the AIHW report did not include was an awareness that driving methamphetamine harm may have been a change in the style and focus of policing of methamphetamine markets and in particular methamphetamine users. Methamphetamine policing skyrocketed from 2011 in Australia, with a doubling of the number of methamphetamine arrests nationally between 2011 and 2018 (Fig. 7.3). The harms associated with methamphetamine also rose over this period with higher level of emergency room presentations, methamphetamine violence and aggression. There are two dominant theses for methamphetamine related harm. The first thesis is that it is the intrinsic activity of the drug that causes aggression and therefore the harm. The first thesis is dominated by first responder testimony and narratives. The

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evidence that methamphetamine has itself caused the epidemic of pain and violence sits in the zone of storytelling. The second thesis, is that the increased policing of retail drug users since 2011 caused the increase in violence and therefore increased harm. This alternative explanation emerges from two meta analyses and policing statistics that together, provide a strong source of evidence. The second argument goes something like this: Increased levels of retail market policing causes increased systemic violence. This combined with higher levels of high purity methamphetamine, which is known to increase agitation, have resulted in the epidemic of methamphetamine-related harm. The choice of interpretation then sits between first responder narrative and systematic/macro evidence. The more compelling policy story, the one the public and policy makers believed was the first story. A problem with both stories is the nature of the evidence and the speaking positions of the storytellers. Personal testimony of police, ambulance officers and drug users was complemented by case studies from psychologists and alcohol and drug clinicians. The most compelling expert evidence came from the Australian National Drug and Alcohol Research Centre (NDARC), which claimed that it had the strongest evidence that ice caused violence. It is worth examining the NDARC evidence and the basis upon which the facts of ice-related violence became incontrovertible truth in Australia.

6.11 Ice—Related Violence Goldstein’s (1985) tripartite relationship between drugs and crime has been reviewed extensively and is still held as a robust framework for thinking about the drug-crime nexus (Bennett and Holloway 2009). According to Goldstein’s drug-crime nexus, violence associated with drug markets is related to (1) the psychopharmacological properties of the drug (physical and psychological effects of drugs on violence); (2) the economic compulsion of the addicted drug user (violence as the means for financing illicit drug use) and (3) systemic violence (violence arising from disputes within illegal drug markets) associated with the drug market (Goldstein 1985). The key source of the NDARC argument about ice-related violence comes from the work of McKetin et al. (2014), who report on the risk of violence in a sample of methamphetamine-dependent users in drug treatment in two Australian cities, Sydney and Brisbane. They report that when using for 1–15 days, violent behaviour was increased 2.8 times compared to when they were not using methamphetamine. The odds of violent behaviour were further increased by higher doses in the previous month, psychotic symptoms (22–30%) and alcohol consumption (12–18%). For McKetin et al. (2014) the question was constrained to only include two factors that may contribute to violence: methamphetamine or predisposing pre-morbid risk factors (such as antisocial personality disorders or conduct disorder). McKetin

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Fig. 6.6 Theoretical relationship between methamphetamine use and violence. Adapted from McKetin et al. (2014)

et al (2014) framed the problem: “It is not clear from these studies whether methamphetamine use causes violent behaviour or whether people who use the drug are otherwise predisposed to violence”. Figure 6.6 adapted from McKetin et al. (2014) describes these relationships. In the original heuristic diagram explaining the link between amphetamine use and violence, the arrowhead line connecting methamphetamine use with behaviour is dotted and is annotated with a question mark. A second dotted line linking psychotic symptoms with violent behaviour is similarly annotated. Lines that are not annotated indicate causal relationships. There are a number of conceptual gaps in this framework from McKetin et al. (2014). The first is the implication of causality. Whilst there is some discussion of dose in the text, like many simplifications, there is no mention of dose in the figure or degree of influence of the factors involved in the relationships. Dose is crucial in any discussion of effect. In this figure, there is no accounting for dose. The citation for the dose-related increase in psychotic symptoms in response to methamphetamine is from the same study cohort (McKetin et al. 2013). It should be noted that the 2013 study whilst establishing a causal relationship between methamphetamine and psychotic symptoms also reported that frequent cannabis use and frequent alcohol use (i.e., 16 days in the past 4 weeks) also independently increased the odds of experiencing psychotic symptoms. Dose dependence was established through reference to their own 2013 study in which they used the same two dose categories used in the 2014 study in the same MATES cohort. The authors acknowledge that evidence in the literature of a causal linkage is lacking because the existing evidence is derived “entirely from case reports and cross-sectional studies”. McKetin et al. (2014) reported that the risk of psychotic symptoms increased with an increased frequency of methamphetamine use (>16 days in the last month). They

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also reported that the addition of frequent cannabis and/or alcohol use (>16 days) increased the probability of psychotic symptoms to between 61 and 69%. Although the authors reported an inability to determine whether methamphetamine-induced psychosis predicted future psychotic symptoms, there was little capacity to monitor whether the same could be said of this cohort, i.e. whether prior use may have sensitised the cohort to a heightened vulnerability to methamphetamine-induced psychosis. The cohort was a heavy (median use 8 days in past month), long-term (median length of use = 13 years) drug-using cohort of dependent users, so there is a strong likelihood that they had experienced psychotic symptoms previously. In short there is a very limited opportunity to compare the results of this study to the broader population because it is a convenience sample of heavy chronic users. The same limitation could be applied to cannabis use. Clinical data suggests that prior experience of psychotic symptoms can predict future cannabis-induced psychosis among chronic users. This sample was a heavy cannabis using sample (median use of 20 days in the last month). As an aside, observing dose dependent effects of cannabis when co-administered with methamphetamine is very complex, as cannabis is often used to mitigate the psychotic symptoms from heavy amphetamine use. McKetin et al. (2014) suggest that using a case-control or “within-subject” research design “eliminates confounding by pre-existing individual characteristics and other time-invariant factors” (McKetin et al. 2014: p. 799). Whilst this type of design certainly enhances the capacity to control variables, it is an overstatement to suggest that it “eliminates confounding”. One difficulty with the design which is not widely acknowledged is that the apparent invariant factors may not be so invariant. It has been a feature of the clinical and neuroscience literature for some time that stimulant users may be susceptible to “sensitization” to psychotic symptoms, i.e. that continued exposure to stimulants increases the likelihood of future psychotic reactions to the drug (Strakowski and Sax 1998; Strakowski et al. 2001, 1996; Boileau et al. 2006; O’Daly et al. 2014). What might be an apparent strength of the design may actually be a confounder, as the outcome (psychosis) they are measuring in the 2013 study may be time-variant based on their exposure to the substance over the course of their drug use, rather than as a function of the dose they are using in the course of the study. The second conceptual gap is the erasure of setting from the relationship. There is no acknowledgement of the importance of setting in shaping the effects of a substance. Certainly, the earlier “risk environment” literature (Rhodes 2002; Strathdee and Bastos 2002) provides a counterpoint to this highly individualised and decontextualised account of the relationship between drug and behaviour. Indeed as Rhodes (2002: p. 85) suggests: a shift in focus towards the ‘risk environment’ as a unit of analysis and change helps to overcome the limits of individualism characterising most HIV prevention interventions as well as to appreciate how drug-related harm intersects with health and vulnerability more generally.

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The framework from McKetin et al. (2014) is a step backward from recognition over 10 years earlier that highly individualised accounts of the relationships between drug and behaviour can be misleading and not helpful in producing effective interventions. A closer examination of the study is worthy as the claims of the relationship between methamphetamine use and violence are substantial. The sample was drawn from both a community-based drug treatment program and clients of a needle and syringe program. This was a sample of long term, older, heavy methamphetamine users. The study consisted of data collection over three non-contiguous one-month observation windows over a 3-year period. Participants were on average 31.7 years of age, had been using on average for 13.1 years, with 79% injecting the drug. Psychotic symptoms occurred in 60% of the sample, a participant was 6.2 times more likely to report violent behaviour using methamphetamine compared to when they were not using the drug. At higher dose levels (more than 16 days of use in the past month), users were 15 times more likely to report violence. In their unadjusted regression analysis, 12 out of their 16 variables in their model were statistically associated with increased risk of hostility, including alcohol use, low dose cannabis use, ecstasy use, heroin use, benzodiazepine use and being unemployed. This would suggest a more generic set of contributing factors to the reported violence. Although the investigators have chosen two dose categories to approximate dose dependence, the dose categories they have chosen are very wide (1–15 days and 16 or more days of using in the past month). The rationale for these categories is not provided and therefore the two doses are really composite of a wide variety of patterns of use. The median level of use across the whole sample was 8 days in the past month. It is not clear why they chose not to compare the median use and preferred to divide the sample into two dose categories, demarcated at double the median level of use, potentially obscuring what happens at lower dose levels. A more complete dose—effect curve would have been preferable, with at least 5 dose levels. The designation of 1–15 days of use as “low use” is also at odds with the pattern of methamphetamine use most commonly reported in population samples. The IDRS reports annually on methamphetamine users at NSP services. The average median number of days used for this population is 36.5 over 6 months, equating to approximately 6 days per month (Stafford and Breen 2016: p. 21). The upper threshold for the low use category in McKetin et al. (2014) is two and a half times the median dose used in the general NSP population, suggesting that the “low dose” category is not a low dose, rather it is only low in relation to the higher dose used in their study. The consequence of this segmentation of the sample is to overstate the relation between violence and amphetamine use. There is no doubt that at high doses methamphetamine is associated with hostility and violence. However, caution does need be applied to interpreting the results of McKetin et al. (2014) and extrapolating the results to a broader population of methamphetamine users. There is also an opportunity cost to this study in failing to identify what happens at lower doses. Setting a high lower dose with a binary category is an artifice that has little relevance to population levels of consumption.

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Looking more broadly, a recent systematic review finds only some parts of Goldstein drug-crime violence nexus are supported in the empirical literature. McGinty et al. (2016) found that there was only strong evidence for one of the three elements in Goldstein’s framework. Selling illicit drugs was consistently associated with perpetration of violence toward others (McGinty et al. 2016). Evidence for the direct psychopharmacological effect of drugs was inconclusive, as was evidence of economic compulsion. In their review McGinty et al. (2016) noted that McKetin et al. (2014) was a study with a high risk of bias. In summary, this detailed examination of the two studies by McKetin et al. (2013, 2014) was conducted as an illustration of the very real limits to what can be known about the causal effects of psychoactive drugs within this population. The critique focussed on the difficulties of attributing causality in a multi-causal setting and the empirical pitfalls of generalising too widely to the general population of methamphetamine users when studying a highly dependent cohort. Finally, this analysis should generate caution for readers when they read academic work that asserts causality and dose-dependence to drug effects in complex multicausal settings. McKetin et al. (2013, 2014) were published in well-credentialed journals and are widely recognised authors funded by national funding bodies. So this research is about as good as it gets, unfortunately. This should put cross-sectional, observational and case study research into some context. If these controlled and highly technical studies using accepted epidemiological designs cannot tease out the complexities of the drug-crime-violence nexus, it should put grave doubt into the capacity of research designs with less credibility to provide convincing evidence. The take home messages from this analysis of the epidemic in Australia is that the epidemic of ice-harm may have been iatrogenic. That is, the increased level of market disruption at a retail level placed more pressure on the market and more violence ensued. Rather than ice causing more violence and pain it was national methamphetamine strategy and anti-drug policing that created the pain. The causes of this are unclear. Several factors stand out as notable. The increased visibility and scientific framing of meth users as violent and needing to be controlled, must have weighed into the minds of police and policy makers. The political framing of the epidemic as the worst Australia has ever experienced also pushed the hyperbole further. This will be examined further in the next chapter. It is for this reason that the epidemic needs to understood as a cultural pain neurosignature. The cultural pain neurosignature enabled meth-pain to be configured as derived from the violent body of the meth user. The distorted and damaged faces became self-evident facts of the harmfulness of meth. All the other sources of pain, and all the other contributing factors to the violence (which empirically are more substantive), were erased by the dominant cultural pain neurosignature which placed the individual face of the meth user as centre of the epidemic. Instead, the epidemic neurosignature itself was causing the pain. The list of participants in the ice-pain cultural neurosignature is extensive:

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• Australian state police for increasing the arrests of meth users between 2011 and 2018; • The ACIC for not including the 2007 AIHW data point and overstating the “epidemic” in their 2015 report; • The AIHW for not rebuking the ACIC and popular news accounts of their NDSHS data; • The SBS TV news producers in 2015 for citing the Montana Meth Project images as documentary evidence of what a meth user looks like (they did not include a banner that the images were dramatisations); • Australian Prime Minister Tony Abbott for overstating the scope of the “epidemic”; • The NDARC researchers who overstated the significance of their 2014 cohort study; • The expert reviewers for the academic journal who did not pick up on the research design problems with the 2014 NDARC study; • The news reporters and editors who gave minimal air-time to counter arguments about the supposed “epidemic” (Lee 2014, 2017; Fitzgerald 2015a); • Members of the drug treatment services sector who received additional funding on the basis of the “ice epidemic” and then subsequently did not challenge the federal government about the “epidemic” claims. The Australia ice epidemic was not just as “drug scare” that existed in the media. There were multiple participants, and different forms of capital were mobilised.

6.12 The Ice-Violence Cultural Pain Neurosignature The SBS news item mentioned earlier (“Australia’s Ice epidemic”, The Feed SBS television, 25 March 2015, https://www.youtube.com/watch?v=AkH4rDpwStE) is perhaps the most dramatic illustration of the cultural pain neurosignature linking methamphetamine to violence. The news item is a wonderful example because it draws on ghosts, it recruits participants from beyond the direct Australian arena of ice-related violence and it communicates pain. Not just through the faces of ice users, but pain is communicated also through the faces of those engaged in solving the problem. Readable pain is mobilised from that of the user to that of the policy manager and police officer (Table 6.4). When the faces of the key visual talent in the SBS new item “Australia’s Ice Epidemic” from SBS News program “The Feed”, were assessed with Painchek™ , the news piece was awash with indices of pain. Although the CEO of the Australian Crime Commission, the Federal Minister for Justice and the local police inspector all have readable pain, the standout was the face of an actor playing the part of a violent ice user punching and lashing out in a hospital emergency room. The most pain-filled image was actually not a documentary image. This dramatized image of

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Table 6.4 Painchek™ facial pain assessment scores, for characters in the SBS news item coverage SBS—“The Feed”, Australia’s Ice epidemic Talent

Timecode (min:sec)

Painchek™ facial pain assessment score

SBS—“The Feed”, Australia’s Ice epidemic https://www.youtube.com/watch?v= AkH4rDpwStE Chris Dawson, CEO Australian Crime Commission

0:04 0:58

2 2

Trevor Ashton, Inspector Victoria Police

0:40

2

“Meth addict going crazy!!!” (you tube extract)

0:42

0

Violent man from public TV advertising campaign

0:44

4

Stella Stuthridge, Victorian Magistrate

0:49

1

Scabby faced guy on meth—Montana meth project clip

0:47

1

Michael Keenan, Minister for Justice

1:03 1:59

2 2

Source https://www.youtube.com/watch?v=AkH4rDpwStE

the violent man from an Australian public drug information campaign scored most highly on Painchek™ for pain. Along with the pain-filled faces of those in the Montana meth project, the cultural pain signature extends pain beyond methamphetamine users to a range of third parties engaged with the methamphetamine story. The SBS item didn’t just communicate misleading partial data about the “ice epidemic”. The visual items within the story, included ghost grabs from the dramatisations of the Montana Meth Project a decade earlier; an Australian television drug information campaign (based on the Montana Meth Project) and a random video grab from YouTube depicting a delusional ice-affected man from somewhere in the USA. The problem with the coverage was that the SBS news item did not declare the origin of the clips. Dramatic re-enactments produced by celebrated Hollywood directors were passed on as factual material. The distressed girl in the bathtub scene was there, as were the scabby guys in the shadows. The footage of the delusional man in a cell with wild eyes was unsourced (https://www.youtube.com/watch?v= WoRc0UHjHkA). The image of the dishevelled girl taken from the Montana Meth Project movie “Bathroom” is even more interesting. Not only is it an actor playing a dishevelled meth user. The character within the original plotline is actually an hallucination of a future image of a dishevelled meth user. The image of the pain of the meth user is overladen with fictive power. What was once fiction, has now been transformed into a documentary visual account. The most extreme rendering of pain is not from a “real” meth user, but of an

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Table 6.5 Parameters of the cultural meth pain neurosignature Parameter

Cultural meth pain neurosignature

How normal is re/defined

Normal is that we can read from the face Meth users are violent Meth users are in pain and outside of pain—meth users are zombies. They do not know what depth of pain they are in

How the various parts of a painful body are integrated

Body is out of control

How pain is communicated socially

We only learn about the pain of meth through non-user testimony

Positioning pain beyond time—pain is ongoing

Meth users as out of control Zombies—outside time

How the owner of the neurosignature is an expert about this particular pain

Government owns the neurosignature

How the pain sufferer becomes part of the community

Only way is to be reformed Meth users cannot be part of the community Pain is ubiquitous The meth user’s pain is shared by the people around them

actor (Table 6.4). The pain level of the real meth user is low compared to that of the violent actor in the hospital setting. The ice-pain cultural neurosignature has indexed ice use to violence, through dramatization. The ice-pain cultural neurosignature has created a copy of the real and inserted it and activated pain in that copy to produce an affect above that in the non-dramatised copy (Table 6.5). I will now articulate the feature of the ice-pain cultural neurosignature according to the parameters (Fig. 6.5) established in Chap. 2.

6.13 Cultural Pain Sensitization Central sensitization in neuromatrix theory occurs when there is an aberrant neurosignature that dominates interoceptive processing. All signals that are somewhat related to the cultural pain message about a drug, get misinterpreted to require a pain response. In the extended cultural neuromatrix theory, the same principle holds. The central sensitization occurs in the cultural arena, whereby cultural materials, such as the image of the face of the drug user becomes an indexical mark that stands for pain. Drug scares are where a dominant cultural pain neuromatrix overreaches with the impulse to protect the body politic. Linnemann and Wall (2013) assert that the pain and humiliation of drug use and imprisonment became commodities in methamphetamine drug scares. Chambliss (2001) suggests that the imagery used in the “this is your face on meth” campaigns from the 1980s equated working-class, “rural whites” to poor, urban non-white

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minorities. By indexing one racial group to another, the campaign incited class and race anxiety, mediated by methamphetamine (Linnemann 2016). This anxiety fuels investment in punitive drug laws. At an individual level, the functional outcome from central sensitization is the transformation of pain into a new/expanded/different type of pain, pain1 , pain2 , pain3 etc. …. into a series. The pain neurosignature reads the indexical markers for pain1 in the interoceptive system and repackages that energetic debt extracted from the field of relations into a new pattern—pain2 . This new pain, a neuropathic pain, has a wider and more intense character. I misinterpret pain2 , and localise the pain differently. Instead of being situated at the site of the irritation at cervical disc between C5–C6, the pain is being felt in my shoulder and my arm. I take oxycodone to try and minimise the pain. It does for a while, but I can still feel the pain in my shoulder, knowing that there is nothing wrong in my shoulder but perhaps something is wrong at the C5–C6 joint. I see my musculoskeletal doctor who suggests we perform surgical procedure called a radiofrequency neurotomy to stop any irritation at C5–C6. The procedure zaps the medial branch bundle adjacent to the disc at C5–C6. For 6 weeks aberrant pain messages are sent to my shoulder, neck, arm and to other parts of my neck. The pain neurosignature picks up the irritation at C5–C6 and tries to make sense of it. The procedure has irritated the whole area, and is read by the brain as a threat. The pain neurosignature sends messages out to the dermosome in my shoulder and back, indicating more pain, this is pain3 . On the other hand, the medical branch bundle is no longer sending messages to the neuromatrix that there is something wrong at C5–C6. I take pregabalin to try and manage the neuropathic pain arising from pain3 . This new pain starts at the neck and creeps up the back of my head and cripples my thoughts with a massive headache, this is pain4 . The pregabalin starts producing myoclonic jerks in my arms and legs. Large uncontrolled jerks, that scare the hell out of me, this is pain5 . I have to stop running because of the risk of the jerks. Pain3 makes no sense to me, I take increasing doses of oxycodone to try and manage the pain, whilst also managing my job, this is pain6 . Increasingly, I have to sleep 1–2 h in the middle of the day because I fatigue from trying to manage my pain. I start to put on weight because I eat when I am in pain, and I have stopped running. After another 6 weeks, I have put on 5 kg. I seek a clinical review from my musculoskeletal doctor who sends me for a MRI. The MRI report shows degenerative changes in my cervical spine around C3–C4. It also reveals a small brain tumour. Two neurosurgeons are engaged to interpret the indexical markers on the MRI and advise on strategies. Here comes pain7 , the anxiety produced by the prospect of my future being limited to months rather than decades. This is how pain gets transformed. As the indexical markers are read, interpreted and reinserted into the neuromatrix, the pain gets transformed. The original energetic debt has been repackaged six times, the pain has spread, intensified and changed in character. The pain now has different names, it is sharp, stabbing, electric, dull, aching and black. My body parts are being put together differently each time a new pain emerges. Maybe the tumour is driving the aberrant messages. Maybe the sensitization is getting worse. Maybe I actually have a new lesion in the cervical spine. I have to work out how to talk to my employer about this, do I down-play it. Should I take

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time off work? Should I work harder to finish things off because I may only have a few months to live. Time has to be configured differently. Is this the new normal. One neurosurgeon said it will only get worse from here because of the degenerative changes. At the level of my mind-body neuromatrix, this is what I think happened to me. Pain, indexed though markers, was transformed to different sites and had different qualities. As pain was newly indexed, a new pain emerged. Pain1 begets pain2 which then begets pain3 . and then pain4 etc. … Each time I investigated, the health costs increased. I now start making decisions about the future in terms of the pain. I start making decision about my present in terms of how much I should invest in the now, rather than in an uncertain tomorrow, or next week. Should I start a new research project, with the risk that I won’t be able to execute it because of my pain. In which case should I start hedging my bets and do something else now, just in case everything goes wrong and I end up unemployed and unemployable. As the pain is transformed, so too, I start making bets in the present, based on future risks. If I invest my energy here, maybe it will pay off because I may not be able to do “X” next year. Maybe I should take my leave now, cancel all my research and go travelling with my family because I may not be able to do it in two years. At a social and institutional level, the transformation and smudging-over of pain into new types of pain is apparent. Increased anti-drug policing produces a greater demand for prison beds. Prison is criminogenic—it produces a new cohort of future criminals. Increased policing of drug offenders in Australia creates a higher demand for diversion and court-mandated drug treatment services. The increased courtmandated demand for drug treatment has placed pressure on existing drug treatment services. Voluntary drug treatment patients are secondary to those who have courtmandated treatment places. Voluntary patients have to wait, while court-mandated places are filled. The pain of not getting access to treatment when it is needed is significant. Drug treatment is often dependent on “windows of opportunity”. If a drug user is not able to get access to treatment when they need it, it can delay stabilisation and increase harm. A perverse outcome from this affective economy is to increase the pain for those seeking treatment by increasing wait times for voluntary drug treatment patients. This is the machinery of drug panics and moral panics. This is how it works. The face of meth, indexes pain and mobilises affect, primarily with an objective to protect the body politic. This analytic has the potential to enliven the moral panic discourse to provide a new set of interventions because it opens up the list of those who are culpable.

References Anderson, D. M. (2010). Does information matter? The effect of the meth project on meth use among youths. Journal of Health Economics., 29, 732–742. Anderson, M. D., & Elsea, D. (2015). The meth project and teen meth use: New estimates from the national and state youth risk behavior surveys. Health Economics, 24(12), 1644–1650.

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Chapter 7

Regulating the Cultural Pain Neuromatrix

The pain of drug epidemics, moral panics and the pain of addiction, are three obvious examples where an a-signifying semiotics has driven the propagation of cultural pain from drugs. This poses great challenges for regulators. The sensitised brain neuromatrix responds to bodily threats (like affective content or pre-motor interoceptive messaging) with aberrant pain messages. The pain messages originating from the brain, disproportionate to the nature of the threat, are less-than-conscious and not amenable to cognitive intervention. An a-signifying semiotic process transmits the signaletic material as packets of information across neural circuits. The information is not subject to cognitive evaluation. There flows an informational amplification as the packets of information recruit previously uninvolved neural circuits into the pain response, amplifying the pain message even further. For the individual with a chronic C4 disc injury in their neck, they feel the pain grow across the neck, shoulder and around the back of the head. They feel fatigue and their visual tracking and proprioception fails. Over time the overall body becomes incapacitated when the neuromatrix is sensitised. There are parallels with the cultural pain neuromatrix. As we have seen with the amplificatory modulation of a cultural pain response to “evidence” of a codeine epidemic, elements of the cultural pain neuromatrix seemingly saw threats to the Australian body politic from North America and responded with a cultural pain response (Fig. 7.1). Similarly, the almost automatic acceptance of “evidence” in the methamphetamine violence relation, saw a cultural response to a threat to the population from violent methamphetamine users. Evidence at the level of a prospective cohort study, population survey, documentary news program and ultimately from police funding programs was accepted as truth. The “evidence” instead of being rigorously evaluated, seemed to feed into an automated spiral of evidence that generated a cultural neurosignature to ensure the protection of the body politic (Fig. 7.2A). The crucial difference between the brain neuromatrix and the cultural pain neuromatrix is the degree to which there is conscious control over the flow of interoceptive messaging. We are happy to accept that there is virtually no conscious control over

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Fig. 7.1 A-signification in the up-scheduling of codeine, creating a spiral of cascading demand risk

Fig. 7.2 Automaticity in the a-signification in the “ice epidemic” neurosignature producing A the violent methamphetamine user refrain and B the face of pain control

the flow of interoceptive messaging in sensitised pain patients. It is a different matter however, when it comes to whether there is a cultural subconscious over which there is no control. Although a century ago, structural sociologists and anthropologists such as Emile Durkheim and Claude Lévi-Strauss may have asserted some autonomy to culture, there are few that would assert that culture now operates autonomously and without conscious engagement from its constituents. Here is the key difference and the key point of deploying the analogy of the cultural pain neuromatrix. The deployment of the cultural pain neuromatrix has revealed the seemingly less-than-conscious manner through which we enable cultural pain responses when we feel there is danger to the body politic. When there

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is a perception of threat, partial truths and spurious facts pass through into the public imagination relatively unchallenged. Increasingly in this global “technosphere” when “fake news” has emerged as a paradigm of political practice, it is never more important to ensure that cultural pain responses (such as increased surveillance, coerceive powers, exclusionary legislation and punitive law enforcement), are actively scrutinised. The consequences of a cultural pain response to a threat to the body politic will be the exclusion or punishment of a segment of the population. This cannot ever be automated or left underexamined. The risk is that these “immune” responses to a threat, become amplified to then become autoimmune responses. The cultural autoimmune response, when we misrecognise and hack off healthy parts of the body politic under the belief we are protecting the general body politic is widely accepted as the basis for failed states and fascist regimes (Rabinow and Rose 2006; Esposito 2008/2004; Campbell 2006a, b). The cultural neuromatrix framework highlights those moments when the autoimmune pain response, itself causes pain. It also highlights that cultural pain responses are not autonomous. We have a part to play in reducing pain. Rather than using pain to govern the population, either through benign neglect, market rhetoric or through an autoimmune response, we have other regulatory options. Having examined several different policy arenas through which pain has been intimately connected to drug use, this chapter will reflect on the challenge of regulating pain, not at an individual level, but pain as it relates to how the cultural pain neuromatrix engages with drug markets, the body politic and ultimately to capital. We have already examined how pain as a commodity works hand-in-glove with affective economies. We have also seen how pain was the commodity that mediated between the opioid epidemic and the rise of medicinal cannabis. We have also seen how important pain is to methamphetamine markets. Looking across these cases studies however opens up a line of thought about some deeper principles through which to consider regulating drug use associated with pain. A starting point with reflecting on the deeper regulatory principles is to focus on the refrains arising from the cultural neuromatrix that organise machines, resources, policies and practices. In this chapter I will outline a set of principles that require government to assert a role in regulating the cultural pain neuromatrix. Although pain itself may be beyond regulation, at least the cultural pain neuromatrix can be a site for regulation.

7.1 Pain: Applying the Cultural Neuromatrix Theory The cultural neuromatrix theory takes the medical theory of the neuromatrix and extends it into the cultural arena. What is perhaps most salient in this move is the model of pain that is deployed through the transformation. I have deployed a model of pain that is focussed on chronic pain, central sensitization and the a-signifying processes underpinning it. There are some important differences between the model of pain in Melzack’s neuromatrix model and the cultural neuromatrix model of pain.

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The most profound difference in this transformation is the involvement of affective economy, and in particular how this relates to markets. Also, underpinning the cultural neuromatrix theory is a cultural theory of the origin of germinal life. Borne from the philosophy of Deleuze and Guattari (1987) and subsequent affect theorists such as Massumi (2017), pain as an object emerges from fields of potential. This energetic theory is scale independent. It can operate at the level of the individual body or at the level of the socius. This is perhaps a point where those not familiar with this branch of continental philosophy may find the theoretical material difficult to reconcile with orthodox cartesian models of pain. The necessity for basing the cultural theory on what is called non-representationalist theory (Thrift 2007), is that these theories of life have been specifically developed to enable connections to be drawn between the operations of capital, embodied practices and cultural life (Barnett 2008). Whilst we are happy to accept that there is virtually no conscious control over the flow of interoceptive messaging in sensitised pain patients, we are not so comfortable with the prospect of there being no conscious control over the cultural pain neuromatrix. Assertions of a cultural subconscious that evades some form of conscious control are now limited to Jungian psychotherapy (Yakushko et al. 2016). Culture extends beyond the individual through social collectivities. It is inherently social, and few would assert that culture now operates autonomously and without conscious engagement from its constituents. As noted earlier, a-signifying semiotic processes enable cultural machines to background the semiotic work that is being undertaken to propagate, produce and reproduce pain across cultural milieu. The most that can be done is to ensure that we have a conscious engagement with the cultural conditions under which we experience, transform and generate cultural pain neurosignatures and the social and political context of their reception.

7.2 Pain: Signifying and a-Signifying Semiotics Traditional Saussurian semiotics focusses on the relation between the observable sign (signifier) and the meaning (signified). Correspondence is arbitrary and comes about through cultural convention. In its simplest articulation, the word object (in this case the word p-a-i-n) will correspond to the signified—the concept of “pain”. Together, they form the sign “pain”. In French, pain is expressed as douleur, in German schmerzen and Italian has three terms for pain dolore, male and sofferenza (Palka 2014). Most word signs are arbitrary, however there are different types of semiotic relations (metaphoric, metonymic and indexical) that bear different kinds of relationships between the different elements of pain signs. According to post structuralist semiotics, meaning arrives not just through “cultural conventions” but through the deployment of power that privileges certain meanings and sign systems over others. Meaning is not simply a series of differences between alternate signifieds. In this framing, the effect of a sign emerges not just

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from the framework that is used to understand the sign, but the capacity of the sign to operate within the usual framework of signifier|signified. When signs operate outside this kind of semiotic operation, it is called an a-signifying semiotics. The key to a-signifying semiotics is that the sign does not connect to a signified in the traditional sense. The sign is referred to as a signal. It is a part sign. It achieves effects through connecting with other part-signs under certain conditions. Part signs, through automated processes do not have a negotiated semantic dimension. Part signs enable material processes in the world by engaging with algorhythmic, calculative and machinic processes to achieve machinic semiotic outcomes (Guattari 1995; Lazzarato 2006). This machinic register captures and activates “pre-subjective and pre-individual elements (affects, emotions, perceptions) to make them function like components or cogs in the semiotic machine of capital” (Lazzarato 2006). Genosko (2008) refers to the materials of a-signification as “signaletic matter”. It is the information transmitted without necessarily having semantic content. A-signifying signs “automate” dominant significations, they normalize, construct invariance and consensus. Signaletic matter for example is essential to the authorisation and identification of mobile device users. In themselves a-signifying signs have no meaning, but they are essential to making things happen. The unique code on a magnetic strip on an access card identifies an individual and enables access to buildings. That same access control information is used to enable a printer to print out hardcopies of reports. The information assists in actualising the virtual identity of an individual. Because the individual can be actualised through a wide range of a-signifying signs, in different ways, the versions of the individual can referred to as a “dividual”. A dividual is an informational diagram pointing to the actualization of a virtual entity (Deleuze 1995). A-signifying machines automate the production of dividuals. Repetitive machinic signaletic stimuli are the stuff of the infocapitalist technoverse (Massumi 2017; Sampson 2017). It is the automaticity of a-signification that poses the greatest challenge for pain management. At the individual level, a-signification is pivotal to central sensitization responses. Neurosignatures that independently or less-than-consciously recruit parts of the neuromatrix into pain messaging are at the heart of aberrant central sensitization. This is what makes central sensitization so hard to treat as it is mostly insensitive to cognitive intervention. At a cultural level it is the automaticity of asignification processes that makes it hard to intervene and change a refrain. For example in the case of the codeine scare in Australia, there was an a-signification process that automatically linked risk data from one machinic process (a growing chronic pain population) to another (the USA opioid epidemic) to form an elliptical process resulting in upscheduling (Fig. 7.1). There is of course little direct evidence to link codeine availability to changes in oxycodone, fentanyl and heroin consumption in Australia. As noted by the economic modellers, there was insufficient data to estimate the actual population of at-risk codeine users in Australia. Deep analysis of mortality data of codeine associated deaths revealed that mental health and intentional harm were the most prominent factors predicting codeine mortality, however these factors did not feature in the

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Government response to codeine. However, as noted in Chap. 5, this didn’t stop the narrative for up-scheduling codeine. Mediating the machinic process was the movement of affect. Mobilising fear was an essential affective strategy in this immune response of the cultural pain neuromatrix to protect the population from itself. The evidential ellipsis (where partial evidence became linked to actions), served to collapse the complexity of the opioid epidemic from a multicausal system into a single causal chain. According to the lay refrain, it was the risk of addiction that caused the opioid epidemic and as opioids are addictive, we should therefore upschedule codeine to protect Australians from the risk of an opioid epidemic. Rather than manage the complexity, the discourses condensed the risk into the material metaphor, of an explanatory cultural neurosignature. In the case of the OTC analgesics, the codification of drugs as OTC, renders the pain that they address as frivolous. It also renders the strategies used to market the OTC drugs more powerful. The strategies are mixed semiotic: signifying and a-signifying in their function. The capacity of panadol to maintain its prominence in the market is not just because of the category code capture, but because of the narrative work to enable Panadol to point towards lifestyle malaise. The marketers did not even try to attach pain relief to paracetamol, in fact they used a metonym to achieve this outcome. But because they know that the mechanisms that enable pain relief are both significatory and a-significatory, they can afford to market the drug without even connecting it to pain. In fact they connect it to life and allow the pain cultural neuromatrix to connect the rest of the dots and amplify affect to achieve the outcome. The search for signification is one of the errors we make when we think about cultural pain neurosignatures. We tend to codify an OTC pain reliever in terms of whether it can relieve pain and whether it can cause addiction. The real message here is that the focus on significatory processes that result in pain relief will always leave an excess. Pain relief is rarely a pure significatory process. Especially when it comes to OTC drugs, the relief comes from a wide range of sources, the drug is really just an indexical vehicle that points towards feeling better. Not just a placebo, the OTC drug is a powerful mechanism for pain relief without drugs. In the case of the methamphetamine violence cultural neurosignature, asignification also played a central role (Fig. 7.2). As noted in Chap. 6, the movement of affective truth from the Australian Institute on Health and Welfare (AIHW) to the ACIC report on methamphetamine drug markets, through to Australian government Public TV commercials, news limited print media headlines and an SBS TV “ice epidemic” news item was automated. The error in data interpretation between the AIHW report and the ACIC report was never corrected in mainstream media, nor was it corrected by the stakeholders involved. The reported “doubling” of ice addicts mobilised fear across the Australian community and was deployed by Australian federal politicians for maximum political effect. Also automated in the process was the inclusion of affective pain-filled faces from the Montana Meth project. Again, the mixing of fictive dramatisations and unattributed YouTube footage into a documentary news item was an automated process, with little accountability or opportunity to dispute the connection between the sign and its meaning.

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The outcomes from the Australian methamphetamine “epidemic” were painful. The most profound outcome was the mobilisation of law enforcement to arrest more amphetamine users. The distinction here between users and traffickers is important. To a far greater extent over this time period, law enforcement focussed on arresting methamphetamine users (Fig. 7.3). In the State of Victoria, Australia’s second most populated state, methamphetamine use/possess offences grew by 350% over a 10 year period (from 1632 to 7346). Cannabis use/possess offences grew by 150% (from 5600 to 8649) per annum. In drug criminology, drug offences are called policegenerated offences, i.e. changes in the number of drug arrests reflect changes in policing rather than a change in the “natural” prevalence of the crime. Methamphetamine trafficking offences increased by 135% over this period (from 789 to 1853), whereas cannabis trafficking offences dropped 6% over the same period. Whilst there are some State-to-State differences, the overarching focus of Australian drug policing on methamphetamine users rather than traffickers (or other drug users) has produced a profound effect on Australian society. The cultural belief that methamphetamine users posed a violent threat to the body politic may have been the cultural refrain at the heart of this change. This kind of policing response in the past would have been called a moral panic. Moral panic frameworks tended to try and find explanations for moral panics in conscious political conspiracies, the symbolic expression of deep cultural anxieties or as moral panics being themselves performative cultural scripts (Cohen 1972; Wright 2015). The difference with analysing this event in terms of a cultural pain neurosignature is in finding the source of response in an a-signifying process focussed on a response to threat. The danger of a-signification in cultural pain neurosignatures is the contagious propagation and perpetuation of refrains that create pain. This is how chronic pain is reproduced at a cultural level.

Fig. 7.3 Drug offences recorded in the State of Victoria, Australia between 2009 and 2018. Black lines show annual changes in the number of methamphetamine offences. Green lines show annual changes in the number of cannabis offences. Data Source Victorian Drug Statistics Agency. Solid lines show use/possess offences, dashed lines show trafficking offences

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7.3 The Face of Pain Control In 2015, using a Deleuzian analytic framework called Faciality, (Deleuze and Guattari, 1987: p. 178), I explored how drug photography produces drug user subjectivity (Fitzgerald 2015: pp. 83–84). The framework from Deleuze and Guattari (1987) that I refer to is an abstract combination of two processes: subjectification and desubjectification. The forming of subjects—subjectification—is achieved through a heterogeneous series of semiotic relations, what I have called in this current work, a neurosignature (Figs. 7.1 and 7.2A). The a-significatory spiral is productive. It produces ways of being in the world and material outcomes. As we have seen with the OTC codeine and methamphetamine neurosignatures, both of these cultural neurosignatures produced significant outcomes for codeine (OTC up-scheduling) and methamphetamine users (more police arrests). On the other hand, the white plane of consistency—the space outside the two black holes of subjectification is the space outside subject formation (Fig. 7.2B). This space of differentiation and becoming-other is the space of de-subjectification. Together these two elements form (parodically in Fig. 7.2, section B) the “face” of an abstract machine of faciality (Deleuze and Guattari 1987: p. 181). These two semiotic regimes combine to form what is called the Face of pain control. Deleuze and Guattari refer to the mixing of different semiotic regimes together to produce an overarching politics, where “The face is a politics” (Deleuze and Guattari 1987: p. 180). The Face defines zones of possible signification and fields of virtual potentialities. In 2015 I was concerned that drug users needed a face, and needed to control the abstract machine of Faciality. In this work, the neurosignatures form the black holes of subjectification. The white wall of consistency, from which pain emerges is a de-subjectivised space. It is through the neurosignatures that subjects are formed. How these subjects are formed is entirely up to how we control the emergence of different cultural pain neurosignatures. We have a choice to allow neurosignatures to emerge that amplify pain, or to facilitate pain neurosignatures that relieve pain. What we need is a Face of pain control that attends to the social production of subjectivity through pain produced both by the cultural pain neurosignatures and by the engagement with pain outside of these neurosignatures. The abstract machine of pain control is the model through which to consider how to regulate the cultural pain neuromatrix.

7.4 The Deployment of Biopower One phenomenon that was most stark in the case studies is the degree to which unmeasured pain is erased. If pain is not measured, it does not exist. For those who are self-managing pain they are left to the mercy of the OTC advertising markets. These markets can make the most outrageous claims about the efficacy of their

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medications. Those with un-measured or unmeasurable pain are left behind. Judging by the consumption of OTC analgesics, at the level of the population this constitutes a substantial proportion of the population. Those that cannot manage pain are left behind in bare life. The rest of the population are given the opportunity to manage pain. In fact it is the responsibility of the citizen to monitor and manage their pain. A good citizen does not get stopped by pain. A good consumer will not be slowed down by pain. Those who aren’t able to manage their pain will get placed on registers, even though the logic of the analgesia may be ill-founded. In the twelve months prior to codeine being up-scheduled, the Pharmacy Guild of Australia, in collaboration with the Commonwealth Department of Health, implemented a compulsory process of recording consumer names and drivers licence information on a database when they purchased over the counter codeine. This strict compliance regime is also known as third party policing and network governance (Mazzerole and Ransley 2004). The monitored population are then subject to the risk of a wide range of forces. This unspecified risk of being subject to force is at the heart of the disincentive, the hurdle that is placed between the pain relief seeker and the relief itself. Leaving segments of the population that live in pain unable to access legitimate pain management is a deployment of biopower. Capital flows most readily from this segment as they consume a high volume OTC pain relievers with little benefit.

7.5 The Role of the State Taking into account the political, semiotic and cultural processes in framing pain, there are a range of regulatory options for the state. Rather than draw on pragmatic regulatory frameworks (such as Braithewaite’s responsive regulation), I will instead draw some philosophical options developed from the case studies examined here. Many of the orthodox pragmatic frameworks tend to exclude the State as a contributor to pain. I will pose four more abstract regulatory option for regulating the cultural pain neuromatrix.

7.6 Guardians (Methamphetamine) The case study of methamphetamine reveals what happens when the state assumes the role of guardian and participates in the production of pain. The case study reveals how pain gets produced by a cultural pain neuromatrix. The refrains were deployed by a diffuse range of actors, including the state, who produced and reproduced pain. These refrains also obscured the mechanisms through which pain is produced. The Australian Government was the owner of the methamphetamine pain neurosignature. The Australian Prime Minister, Minister for Justice, and the CEO of

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the Australian Crime Commission all positioned themselves as guardians. The Australian population needed to be protected from methamphetamine and the violent methamphetamine user. The guardians recruited a wide range of resources to mobilise affect and through this communicate the pain associated with methamphetamine. They cause pain. They create a dominant cultural pain neurosignature for the interoceptive work that produces a Face in pain. This cultural neurosignature persists today. The cultural neurosignature transforms meth user’s faces into a condensation image, whereby it condenses all the complexity of the “ice epidemic” into a single image of pain. It also erases the other sources of pain such as unemployment, poor education, poverty, physical hardship and hopelessness. As Roche and McEntee (2016) noted in their review of the factors that contribute to methamphetamine use in rural settings, the higher proportion of young people using methamphetamine in rural areas is related to lower educational attainment, low socio-economic status, higher unemployment and isolation. Instead, the methamphetamine pain neurosignature refocuses attention to the violence and pain created by the drug itself. Although pain was never mentioned, Government ensured that pain was the entry point for illegal drug strategy into the politico-economic milieu. Pain is a valuable commodity in the context of a debate about national leadership. It becomes the basis for policing tens of thousands of methamphetamine users across Australia. Within a twelve-month period, the politico-economic milieu produced two national inquiries and a rolling media machine, that fed media stories from around Australia to the broadcast news agencies every week for 12 months. This is the machinery of drug panics and moral panics. This is what can happen when Government is the guardian of the cultural pain neurosignature.

7.7 Wolves of the Marketplace One regulatory position for governments is to leave the regulation of pain relievers to the marketplace. Whilst this may seem like an odd position to examine in terms of traditional opioid analgesics, it is not so strange a proposition when considering OTC analgesics and medicinal cannabis. In terms of the gross volume of pain relievers to be consumed, OTC and medicinal cannabis constitute a significant proportion of pain relief medications in North America. I will start with examining the regulatory refrains that currently underpin the economics of medicinal and recreational cannabis markets. As noted in Chap. 5, OTC analgesia is perhaps the least regulated pharmaceutical arena. The advertising marketplace is wild in its claims and the wolves of capital stake out their claims with great intensity. Similarly, the wolves of capital are rapacious in the illegal cannabis markets, with high levels of violence and competition. Transitioning illegal cannabis markets to legal markets is a complex task. The legal appropriation of illegal recreational cannabis markets has added significant complexity to the policy arena. It appears from some US states that there have been

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separate policy imperatives underpinning the transition of cannabis from an illegal recreational substance to a legal temptation good. Central to this transition has been the establishment of medical cannabis markets, to serve both a medical need and to act as a transition point for converting illegal cannabis markets into legal markets. By using case illustrations, I will examine two regulatory refrains within the cannabis policy arena: that cannabis is a “normal” commodity and these markets involve disparity of opportunity. These refrains organise resources, mobilise affect, institutionalise ways of being in the world and structure politico-economic machines. They are by no means the most important refrains or organised into dominant or less dominant forces. They are important illustrations of how central regulation is in the flow of capital. The cannabis arena is particularly revealing as it serves as a counterpoint to the flows of capital in the oxycodone epidemic. In the oxycodone epidemic, the demand for pain relief was directly manipulated by capital, and the State was left to pick up the regulatory pieces after the worst public health disaster in over a century. Here in the cannabis arena, the State, through refrains rooted in a different political discourse, is creating market conditions that directs the flows of capital through pain. The United Nations Office on Drugs and Crime (UNODC) in 2018 estimates 192 million people using cannabis at least once in the past year. US and Canada are the major economies where cannabis use is most prevalent (UNODC 2018: booklet 3, p. 42). In the United States, the number of daily users of cannabis has almost doubled over the period 2006–2016 (Center for Behavioral Health Statistics and Quality 2017). In all US states that have legalised recreational consumption, the policy pathway to legalisation has been through the use of cannabis to treat pain via medical cannabis laws (Center for Behavioral Health Statistics and Quality 2017: p. 52). Use of cannabis for pain relief has been an entry point for the widespread use of cannabis as a temptation good. Although market analyst reports are as much advertising as they are reflective of reliable information, the content is worth examining. Grandview Research estimates that the US legal cannabis market size in 2016 was estimated to be USD 7.06 billion; medical cannabis is the largest marijuana segment and by 2025, the medical cannabis segment will be valued at USD 100.03 billion. It is estimated that in 2016 North American consumers spent $6.9 billion on legal cannabis, an increase of more than 30% from $5.1 billion in 2015 (https://cogencegroup.com/an-introduction-to-theoregon-marijuana-industry/). The cannabis consumer industry is projected to be larger than some other popular consumables. According to Arcview Market Research, overall cannabis consumer spending in North America was estimated at $53.3 billion in 2016, of which 87% was spent outside legal channels. The compares to US craft beer sales ($22.3 billion) (https://www.brewersassociation.org/statistics/national-beer-sales-productiondata/) and US wine sales ($38 billion) (https://lizthachmw.com/2016/02/06/state-ofthe-us-wine-industry-in-2016-trends-and-statistics/).

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7.8 A Normal Commodity Market It is impossible for states to control the flows of capital associated with pain. Pain markets operate because the flows of capital are national and international. The composition of cannabis exchange traded funds (ETFs) for example, reveals the international character of pain financial markets. Cannabis price modulation occurs because of state-federal policy conflict, not according to the legal status of the substance (Dioun and Haveman 2015, 2017). In a study of price variation across seven US states, prices in legal licensed regimes were 23% lower than in legal unlicensed regimes. Price patterns are driven by “uncertainty derived from conflict among legal regimes created by different levels of government, rather than by uncertainty derived from legality or illegality at any single level of government” (Dioun and Haveman 2017). Although cannabis and the financial proceeds from cannabis are prohibited under US federal law, the cannabis market has already been integrated into North American financial markets. Capital has felt the modulations and adapted to the presence of this new configuration of pain. The cannabis ETFs that aggregate the performance of cannabis stocks, already include investment from Philip Morris and British American Tobacco. To rephrase a paracetamol marketing campaign, when regulation is gone, markets takes its place. This cannot be an end point in a discussion of the regulation of pain. It is not enough to leave pain and its regulation up to markets. In its analysis of the Oregon cannabis market, the Oregon Liquor Control Commission (OLCC) (2019: p. 20) reflected that the market model for recreational cannabis was designed to have less of a regulatory imposte than other US states with recreational cannabis legislation. Not only did the legislation reduce regulatory controls (such as licensing costs), it also opened the local cannabis industry up to non-residents to encourage investment from outside Oregon. The legislation also did not put a cap on the number of producer or retailer licenses granted. This model was located more along the free market end of the market regulation continuum (Caulkins et al. 2015). The refrain that organises policy, legislation, producer licensing and consumer behaviour is that the cannabis market will behave like other commodity markets (Oregon Liquor Control Commission 2017). This refrain is evidenced in OLCC documentation that purported that the cannabis market will behave like the hops market (Oregon Liquor Control Commission 2019: p. 20). Part of the normal operation of a market is that there is an “equilibrium” between supply and demand. Oregon cannabis legislation requires that a report be completed every 2 years on the market “equilibrium” between cannabis supply and demand (Oregon Liquor Control Commission 2017: p. 3). In 2017, the OLCC asserted that it was impossible to ascertain directly whether there was equilibrium in the market because of empirical difficulties in measuring the market (Oregon Liquor Control Commission 2017: p. 6). Instead, the report suggested that price and “the market mix of goods” would be used as proxies for the demand for cannabis.

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The amount spent on cannabis products rose from $450,000 to $2,225,000 over the 12 months of 2016, with the greatest increase occurring in the last 3 weeks of December 2016. Consumption jumped from around $850,000 in the first week of December to over $1,500,000 in the last week of December. The vast majority of consumption (71%) was in the form of “usable marijuana”. Extracts and oils represent a smaller proportion (18%). The report noted that because different products can be converted from usable marijuana it is difficult to estimate the actual mix of products being consumed. According to Oregon licensing data, the vast proportion of cannabis expenditure is for recreational reasons, although the proportion of expenditure by cannabis patients has remained relatively consistent over the past six years since the expansion of the recreational market. In 2018, Oregon “patients” expended approximately USD $5 million per month on cannabis representing around 10% of the cannabis spend. This is not to say that only 10% of the cannabis is being used for medical purposes, as consumption is indexed in this data purely through the type of customer that is paying for cannabis through licensed retailers. Patients are also allowed to grow up to 12 plants themselves (https://www.oregon.gov/oha/PH/DISEASESCONDITIONS/ CHRONICDISEASE/MEDICALMARIJUANAPROGRAM/Documents/PlantLimit-Chart.pdf). There is little data indicating what proportion of cannabis consumption is for pain relief. As noted in Chap. 4, cannabis is being used to relieve pain at a number of levels, not just the remediation of physical pain. The Oregon Public Health Division (2016) estimated that there were 78,045 registered medical marijuana patients in Oregon. Overwhelmingly the primary indication (93%) for use was severe pain. The Behavioral Risk Factor Surveillance System (BRFSS) reported that 23% said they used medical marijuana in the past 30 days (Oregon Public Health Division 2016). Lin et al. (2016) estimate that 17% of those using cannabis use it for medical reasons. Compton et al. (2017) suggest that 9.8% of all cannabis users were medical users. Compton et al. (2017) also estimated that 78.8% of medical cannabis users live in states with medical cannabis laws. They also suggest that 21.2% of medical cannabis users gained access to cannabis either through doctors or were “self-medicating problems with cannabis”. Although the regulatory system has moved from managing the medical cannabis market to the recreational cannabis market, a number of indicators suggest pain relief is still present in cannabis consumption regardless of the regulatory mechanism that is in place. Oregon has a long history of illegal cannabis production and integration of cannabis production into the economic life of the state (Marks 2019). In 1973, Oregon was one of the first US states to decriminalise cannabis possession. In 1998 it introduced a medical cannabis program. In late 2014 it authorised the recreational consumption of cannabis. The number of patients registered on the Oregon Medical Marijuana Program (OMMP) has declined substantially from 71,191 in 2015 to 28,177 in 2019. The median age category of registered patients is 40–44 (Oregon Medical Marijuana Program Analysis Unit 2019).

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According to the Oregon Liquor Control Commission (2019) the intention of legalising recreational cannabis was to transition illegal production into a legal market. The balancing act in cannabis policy for Oregon legislators involved encouraging previous illegal producers to join the licensed production system and maintain a balance between supply and demand. As noted in public news media there has been a long connection between the medical market and the illegal market: “The medical industry thrived on the black market,” (https://www.oregonlive.com/marijuana/2018/11/oregpm.html). Before the legalisation of recreational use, the demand for cannabis was articulated through the medical market. Even in 2019, after several years of a legal, regulated recreational cannabis market, the governance of cannabis policy is managed across seven government agencies, Oregon Health Authority, Oregon Liquor Control Commission, County and City law enforcement, Oregon State Police, and the Oregon Department of Revenue (https://www.oregon.gov/olcc/marijuana/Documents/Marijuana_ StateAgencyResourcesByTopic.pdf). The equilibrium between supply and demand is now articulated through the auditing of the delivery of wet weight equivalent of THC to the consumer: By reconstructing each step of the supply chain from the item as sold back to its originating input material, this methodology is able to convert the THC value of the final product to the initial wet weight of its source material. The difference between the actual wet weight harvested between July 2017 and June 2018 and the estimated wet weight equivalent of THC sold over the same period is the degree of equilibrium between supply and demand within the OLCC recreational marijuana market. (Oregon Liquor Control Commission (2019): p. 17).

Seemingly as a consequence of low market constraints, in 2017–2018 licensed Oregon producers created an oversupply of cannabis. Between July 2017 and June 2018, demand represented 50% of supply. It was estimated that at the beginning of January 2019, Oregon producers had enough cannabis in storage to last 6.5 years (Oregon Liquor Control Commission 2019: p. 1). The Oregon Liquor Control Commission described the market theory underpinning the policy options facing the Oregon legislature: A market in which supply and demand are not in equilibrium does not typically prompt a policy response from state or federal authorities. Although it may cause private losses to individuals or businesses, “creative destruction” is generally viewed as an inherent risk of entrepreneurial activity and investment. The Oregon marijuana market was established with such creative destruction in mind. Low barriers to entry were created in an effort to incentivize transition to the recreational market, with the expectation that Oregon’s long-standing tradition of robust marijuana production would persist. By bringing this production into the legal, recreational market it was for the first time directly measurable and observable. The recreational market is living up to expectations of booming production and declining consumer prices that cut into the illegal market while also experiencing rising tax revenues. Meanwhile, the Legislature’s lifting of Oregon residency requirements in 2016 for owners and investors in OLCC marijuana licensees has provided access to capital for businesses and helped ensure liquidity. This has created a business dynamic similar to tech start-ups— many businesses are able and willing to weather losses today for the prospect of large profits

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tomorrow. Oregon businesses build a brand and establish legally licensed outposts in other states and the state benefits from an emerging growth industry. (Oregon Liquor Control Commission 2019: pp. 20–21)

As a response to a market that is seemingly out of equilibrium, the Oregon Liquor Control Commission 2019: p. 1) placed a moratorium on the issuance of new cannabis licences for producers and retailers. In the popular press however the impact of the cannabis glut was being discussed in different, more personal terms as a wipeout of small scale providers and a boom time for multinationals. According to the Oregon—Idaho High Intensity Drug Trafficking Area (OIHIDTA) (2018), (an initiative of law enforcement agencies unsympathetic to legal cannabis laws), impoverished communities that were heavily engaged on cannabis production face “critical economic risk” from collapsing cannabis prices. Counties such as Jackson, Josephine, and Lane and were particularly at risk. The policy regime was structured around a refrain that the cannabis market would act like any normal commodity market, even to the extent that it would invoke the trope of “creative destruction” to justify the rapacious effects of free market rationality on economically vulnerable communities. Cannabis policy was no longer structured around the categories of legitimate or illegitimate use, it was about mobilising resources to enhance the flows of capital driven by the spectre of pain. Anti-alcohol activists have for some time claimed alcohol is no normal commodity (Alcohol and Public Policy Group 2010). The claim is made because alcohol consumption produces a range of harms that go beyond the individual consumer, and therefore the State needs to regulate the commodity. The market alone cannot be trusted to effectively regulate consumption. This line of argument is similar to that used by Caulkins in relation to cannabis as a “temptation good”. The commodity is not harmful enough to prohibit it, however, there are sufficient costs and harms that require the State to regulate the affordability, availability and accessibility of the commodity (Alcohol and Public Policy Group 2010). Shapeshifting cannabis is again posing difficulties.

7.9 Disparity of Opportunity Within the entrepreneurial rhetoric of the expanding cannabis marketplace is a refrain focussed on a “disparity of opportunity”, i.e. not everyone has the same opportunity to benefit from the cannabis market. There are strong media claims that the cannabis industry is now being “whitewashed” (https://www.theguardian.com/society/2018/jan/15/legal-cannabiscalifornia-black-incarceration-virgil-grant) because people with criminal histories are excluded from the cannabis industry. Most states with legalised recreational cannabis programs have exclusion criteria that limit those who are able to get licenses to participate in the legal market. One of those exclusion criteria is the presence of a criminal record. The disproportionate number of African Americans

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with drug offenses (between 2000–2017 they accounted for 40% of cannabis arrests) disporportinately discriminates against African Americans. Also alleged is a concentration of retailers in low income areas, which creates a “disparity of opportunity”. As reported in the Washington Post in 2017 (Jan and Nirappil 2017), Jesce Horton founder of the Minority Cannabis Business Association asserts that black and hispanic communities that previously were overrepresented in the criminal justice system for cannabis offences, are now excluded from the new cannabis licensing system: “It’s really a slap in the face to communities who have been targeted,” Horton said. “A lot of people see these as racist regulations. These are fear-based tactics by legislators who are more than willing to go along with the business interests sitting in the room.”

According to media reports of Oregon Office of Economic Analysis, the retail cost of a gram of cannabis fell from $14 in 2015 to $7 in 2017 (https://www. oregonlive.com/marijuana/2018/05/oregon_to_pause_accepting_mari.html#incart_ river_index). As reported in the Oregonian: Now, marijuana prices here are in freefall, and the craft cannabis farmers who put Oregon on the map decades before broad legalization say they are in peril of losing their now-legal businesses as the market adjusts. (https://www.oregonlive.com/marijuana/2018/05/glut_of_ marijuana_in_oregon_is.html)

In the same media report, it was alleged that the California Growers Association was suing to block regulations that will drive out smaller providers. A lawsuit mounted by CGA against the California Department of Food and Agriculture was however dropped in January 2019 (https://mjbizdaily.com/california-marijuanagrowers-association-drops-suit-mega-farms/). The California Minority Alliance, Georgia Minority Alliance and Ohio Minority Alliance are NGO’s that have emerged from concerns about disparity of opportunity to participate in the legal cannabis market (https:// www.californiaminorityalliance.com/chapters). Although Ohio’s medical marijuana law requires businesses whose majority owners are Black, Hispanic, American Indian or Asian to receive preference in awarding cannabis industry licenses, a 2018 case asserted that the “minority set asides” were unconstitutional (https://www.the-review.com/news/20181116/minority-set-asides-in-ohiomedical-marijuana-law-declared-unconstitutional/1). The law specified that 15 percent of all licenses to enable participation in the medical marijuana arena be awarded to businesses owned by a racial minority. Section 3796 s16(c) of the Ohio Medical Marijuana Control Program specifies that previous cannabis trafficking or use/possess offences cannot be used to disqualify an applicant from gaining a licence. What used to be concerns about civil rights and the mass incarceration of minorities through drug law enforcement are now transformed into concerns about the right to enter into a marketplace (Wacquant 2009).

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7.10 The State as Spectator (The North American Opioid Epidemic) The North American opioid epidemic is perhaps one of the most clear examples of what happens when the state stands by as a regulatory spectator. Although the recent proliferation of US State litigation cases against the opioid industry suggests now that the State is no longer watching, it is a post hoc response to a public health emergency. Friedman et al. (2019) goes further to suggest that the US health care system has participated in the development of opioid-using populations who may not previously have engaged in this type or level of opioid use. What became evident in the development of the US opioid epidemic, and perhaps the most damning critique of the role of government was the bundling together of multiple pains into opioid consumption. The pain of the many maladies that afflicted small communities became bundled together into a contract that was then itself trafficked. Commodity pain shapeshifted with little appreciation by government. The pain was predominantly blamed on irresponsible prescribing. As noted in Chap. 3, the drugs work, they provide a relief from the pain, but not necessarily in the medical sense. Opioid medications were the investments made to manage the risk of pain, writ large. Debts were bundled together into more complex derivatives, and the risk of the system started to spiral. Pain had become the hidden commodity at the heart of an epidemic that was killing thousands of Americans. There are however no regulatory controls on pain and its derivatives. Pain will continue and the affective economy will drive the movement of affect through networked assemblages. Because the focus of government is primarily on restricting access to pharmaceutical pain relief, both through tighter scheduling of opioids and the prosecution of the pharmaceutical industry, the pain relief market will continue to burst through the regulatory shields that are primarily focussed on post hoc litigation. The demand for pain relief remains unsatisfied. This is not only at the level of the individual There is a cultural explanation for the piling up of social and structural malady into pain tranches. The cultural pain neuromatrix has become sensitised to the presence of the shapeshifting commodity pain.

7.11 The Gardener In a curious discussion of pain in language, Heidegger (2001/1959), asserted that pain is a site of Being. Pain reflects the thresholds that produce the distinctive rifts that mark Being-in-the-world. Pain holds together the mark and the ground upon which life is inscribed. Pain is the intensity that is drawn out of a field of potentials that is the source of life. For me, pain is an energetic debt of Being. If pain is that which is indexed to energetic debts, extracted from fields of life potential, no market should have access

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to that. The State, as best as it can, should be fully aware of its own limitations, and attempt to be the gardener of life, a gardener to the field of potential. The state needs to provide for and tend to the manner in which we culturally draw on that field of potential. The state needs to be involved in tending to the neurosignatures that actualise affect into material outcomes. At a collective level, truly interdisciplinary clinical teams should be empowered and funded to support those in chronic pain. At a cultural level cultural pain sensitization needs to be acknowledged. Pain cannot be individualised as it has been shown, in the case studies in this work. We can avoid the amplification of cultural pain if we delink capital from the modulations of commodity pain through amplificatory pain neurosignatures. The dynamic field of potential will continue to create opportunities for capital to extract value. Derivatives will continue to be drawn together. The gardener needs to tend to the field, plant those structures that will produce fruit and be prepared to eradicate those matters that become unruly and dangerous. The gardener should be driven by two principles, no one should get left behind and markets cannot control access to life. As noted in Chap. 3, we can approach the method by which commodity pain is exploited by considering it not as a commodity with a use value, but as a commodity that is forever exchanged (LiPuma 2017: p. 37). The logic of the derivative is a time dependent wager on the volatility of value; it creates the division and reassemblage of capital; and is an amalgamation of different forms of risk into an “abstract cipher that functions as a social mediation”. The cultural pain associated with codeine and methamphetamine each posed a threat to the body politic. The pain derivative was a drug scare and moral panic (Garland 2008). For policy makers, an attack on the body politic can take many forms, terrorism, biological infection, radicalism, loss of Christian faith, climate change, recession or even homophilia. Many of these threats can provoke an “immune” response to protect the body politic. For consideration here is the derivative focussed on a fear of attack from drugs. The abstract cipher mediates the risk to the body politic. There are two contemporary philosophical writers on autoimmunity that I wish to examine here as a way to better understand immunitary logic, Jacques Derrida and Roberto Esposito. The two are not together coherent, however they both contribute substantially to thinking about how to respond to autoimmunity as a pain derivative. Esposito agrees with Derrida on some points but disagrees with Derrida on the relationship between immunity and community (Campbell 2006b: p. 53). The first discourse emerges from the work of Jacques Derrida (1981). Derrida asserted in his discussion of the literary pharmakon, that there was a link between allergy, autoimmunity and the pharmakon. The pharmakon possesses the attribute of being both cure and poison. Subsequent scholarship discusses the technical debates regarding conflation of allergy with autoimmunity and the origins of selfhood (Timár 2017; Haraway 1991, 2008: p. 316). However the relation that Derrida was examining was “the essence of disease because it highlights the defensive immune aggression which threatens both the organism and its invader irrespective of the pathogenic character of the latter” (Timár 2017: p. 75).

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Derrida noted that by virtue of the action of immune responses, we can see the excess of life beyond the living, which “invites death into life” (Mitchell 2017; Timár 2017). The relation of death in life, connects with other philosophies of immunity (Campbell 2006). In a more direct engagement with the politics of immunitary thinking, Derrida later commented on the incompleteness of democracy and the inherent tensions between democracy and sovereignty. As has been noted by Bharucha (2014: p. 58): Derrida highlights the inner mechanisms of terror that disrupt the apparatus of immunity itself. With violent irony we are propelled to engage with the phenomenon of a “living organism” protecting itself ‘against its self-protection by destroying its own immune system … ‘Protection in other words, becomes a lethal form of destruction that can no longer be ascribed to the machinations of the state alone. Rather there are invisible elements at work within the existing apparatus of a cultural system that operate with their own suicidal logic. The agencies of autoimmunity are not just camouflaged enemies, but perfectly at home in their site of destruction, domesticated … by the very system they plan to destroy.

The co-existent relation of death in life resonates with the philosophy of immunitas, espoused by Italian philosopher Roberto Esposito (Esposito 2008; Campbell 2006). Esposito sees immunitas as a foundational tension with modernity and goes further to articulate an engagement with biopolitics as a response to this tension (Esposito 2008, p. 52). Esposito fashioned an affirmative biopolitics—bios—from the existence of two co-terminous political imperatives emerging from the writings about biopolitics after Foucault, Negri and Agamben (Campbell 2006). Esposito suggested that there are two dominant impulses in an affirmative biopolitics. The first impulse is for communitas. This impulse is to extend an obligation of munus, the sharing of a gift to those other than the self. This gift of life is a radical openness. The political consequences are to open borders, to facilitate and celebrate the possibilities of “a contagion caused by the breakdown of individual borders and the mutual infection of wounds” (Esposito 2010/1998: p. 124). This radical communitas, is held in concert with a second drive, immunitas. Communitas is co-terminus with the imperative for immunitas. The modern body politic attempts to protect itself from the vulnerability of communitas by foreclosing on openness. Immunitas is an exemption in the face of disease, it is a condition of untouchability: “life be it single or common would die without an immunitary apparatus” (Campbell 2006b: p. 52). The idea of the modern subject who enjoys civil and political rights is itself an attempt to attain immunity from the contagion of the possibility of community. Such an attempt to immunize the individual from what is common, ends up putting the community at risk as immunity turns upon itself and its constituent element. (Campbell 2006, p. 5)

According to Esposito, one of the terrible “dispositifs” of Nazism is the conjunction of normativization and nature. Nazism asserts that the biology of Otherness becomes conflated with a “natural” and unchanging component of life in the body: “Life and norm are held together in a knot that can be cut only by annihilating both” (Esposito 2008: p. 184).

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One of the answers from Esposito, in an effort to construct an affirmative biopolitics is to ensure that life and norm are never vitalised to presuppose each other. This captures the imperative from Derrida, to scrutinise the compulsion for selfprotection of the body politic and to expose those less-than-conscious agencies of autoimmunity. A second answer from Esposito lies in how we attain “great health”. In this regard Esposito returns to Deleuze. Here are two principles to structure the regulation of the cultural pain neuromatrix: markets cannot control access to life and leaving no-one behind.

7.12 Markets Cannot Control Access to Life The great health for Nietzsche is not to maintain itself in its present state, but to be open to the roll of the dice, to the chance of both disaster and of transformation. In related ways both Deleuze and Esposito see this as the way forward out of the subjectifying and individualising tendencies of the modern state (Esposito 2008/2004: p. 193). This is not a radical liberalism. On the contrary this is an imperative to see the great health in our being of others. We are not separate to the world around us. We do however need to wake up each morning with enough of ourselves to function in the world. Markets cannot control and determine the capacity for citizens to engage with the world through pharmaceuticals, yoga, pilates, or taking psychoactive drugs. We have seen the consequences when the market is left to control access to the chemicals that determine life in pain. An oxycodone epidemic and soon, an unconstrained cannabis capitalisation binge will give evidence to what happens when the market controls the access to life.

7.13 Leaving No One Behind We have observed an illustration of a form of the a-signifying tendencies of sensitised neurosignatures to enable the conflation of life with norm. An extreme example of this is the production of the violent methamphetamine user. Here the norm became naturalised. This occurred through a sloppy prospective cohort study, and through an almost automatic cascade of evidential ellipses. This enabled the public spruiking of an epidemic. This advocaacy involved the citation of a time series made from two frequency estimates, and the pasting in of a visual narrative of dramatisations into a primetime documentary news item on broadcast television. Naturalising the embodiment of drug pain as a norm is a technique for leaving people behind. This is the first principle for a regulation of the cultural pain neuromatrix. The delicate balance between dissolving with the world around us, be it through whatever means, and being held together with black holes of subjectivity needs to be of our making. The populace, the citizenry, the voting public, an anarchosyndicalist collective, whatever form the collective may take, needs to be involved

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in the balance between choice of affect and the production of the neurochemical self that is constrained by whatever pain relief neurosignatures may be operating. The face of pain control needs to be participatory. How we build that face is another question.

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Lazzarato, M. (2006). “Semiotic Pluralism” and the new government of signs. Homage to Félix Guattari. Transversal Texts. http://eipcp.net/transversal/0107/lazzarato/en. Lin, L. A., Ilgen, M. A., Jannausch, M., & Bohnert, K. M. (2016). Comparing adults who use cannabis medically with those who use recreationally: Results from a national sample. Addictive Behaviors, 61, 99–103. LiPuma, E. (2017). The social life of financial derivatives: markets, risk and time. Durham, Duke University Press. Marks, S. (2019). A letter from OLCC director Steve Marks: Oregon’s public policy approach to support legal Marijuana production and the state’s abundant supply: The course for seeking the right balance. In Oregon Liquor Control commission (2017) 2019 Recreational Marijuana Supply and Demand Legislative Report. Portland: OLCC. Massumi, B. (2017). Towards a politics of dividualism. Multitudes, 68(3), 77–87. Mazzerole, L., & Ransley, J. (2004). Third party policing: Prospects, challenges and implications for regulators. Canberra: Australian Institute of Criminology. Mitchell, P. (2017). Contagion, virology, autoimmunity: Derrida’s rhetoric of contamination. Parallax, 23(1), 77–93. Oregon Liquor Control Commission. (2017). 2019 Recreational marijuana supply and demand legislative report. Portland: OLCC. https://marijuana.oregon.gov. Oregon Liquor Control Commission. (2019). 2019 Recreational marijuana supply and demand legislative report. Portland: OLCC. https://marijuana.oregon.gov. Oregon Medical Marijuana Program Analysis Unit. (2019). Oregon Medical Marijuana Program statistical snapshot, 04/2019. Oregon Health Authority. Portland: Public Health Division. https://www.oregon.gov/oha/PH/DISEASESCONDITIONS/CHRONICDISEASE/ MEDICALMARIJUANAPROGRAM/Documents/OMMP%20Statistic%20Snapshot%20-% 2004-2019.pdf. Oregon-Idaho High Intensity Drug Trafficking Area (O-IHIDTA). (2018). An initial assessment of Cannabis production, distribution, and consumption in Oregon 2018-an insight report, First edition-updated version. Salem, Oregon. https://static1.squarespace.com/static/ 579bd717c534a564c72ea7bf/t/5b69d694f950b7f0399c4bfe/1533662876506/An+Initial+ Assessment+of+Cannabis+Production+Distribution+and+Consumption+in+Oregon+2018_ OR-ID+HIDTA_8-6-18.pdf. Oregon Public Health Division. (2016). Adult behavioral risk survey. Oregon Public Health Division. https://www.oregon.gov/OHA/PH/BIRTHDEATHCERTIFICATES/SURVEYS/ ADULTBEHAVIORRISK/BRFSSRESULTS/Documents/2015/marijuana15.pdf. Palka, A. (2014). “What is Painfulness?” A comparative study of pain in English, Polish and Spanish. In A. Lyda & G. Drozdz (Eds.), Dimensions of the word (pp. 47–83). Newcastle upon Tyne: Cambridge Scholars Publishing. Rabinow, P., & Rose, N. (2006). Biopower today. BioSocieties, 1, 195–217. Roche, A., & McEntee, A. (2016). Ice and the outback: Patterns and prevalence of methamphetamine use in rural Australia. Australian Journal of Rural Health, 25(4), 200–209. Sampson, T. D. (2017). Cosmic topologies of imitation: From the horror of digital autotoxicus to auto-toxicity of the social. Parallax, 23(1), 61–76. Thrift, N. (2007). Nonrepresentational theory. London: Sage. Timár, E. (2017). Derrida’s error and immunology. Oxford Literary Review, 39(1), 65–81. UNODC. (2018). World drug report 2018 (United Nations Publication, Sales No. E.18.XI.9). Vienna: UNODC. Wacquant, L. (2009). Prisons of poverty (expanded edition). Minneapolis: University of Minnesota Press. Wright, S. (2015). Moral panics as enacted melodramas. British Journal of Criminology, 55(6), 126–1245. Yakushko, O., Miles, P., Rajan, I., Bujko, B., & Thomas, D. (2016). Cultural unconscious in research: Integrating multicultural and depth paradigms in qualitative research. Journal of Analytical Psychology, 61(5), 656–675.

Chapter 8

Conclusion

You cannot regulate pain. What you can do is regulate the activity of the cultural pain neuromatrix. Specifically this can be done by placing limits on the somatic amplification of pain, by refrains operating across three milieux, the individual, the cultural, and the politico-economic. The principles structuring the regulation of the cultural pain neuromatrix are leaving no-one behind and markets cannot control access to life. It is crucial that the right target is identified when trying to address the problem of pain. When pain became the fifth vital sign in the United States, a refrain was created that operated across all three milieux. The refrain enabled an indexical line of sight between pain-as-felt, pain-as-measured, pain-as-treated, pain-as-commodity, pain-as-an-industrial-segment and pain relief as a political objective. This refrain amplified pain beyond a simple aggregation of the suffering of individuals. There was so much to be gained from treating pain, that the treatment of pain then became institutionalised by the refrain. The distribution of opioids saturated the population, such that it was almost impossible to conceive that the population could consume that much pain relief. Harm ensued. As the epidemic of opioid prescription gathered momentum and itself started to create pain, the markets looked for other pain relievers. The seed of the pain relief refrain had already been planted, except this time, some of the pain relief needed to address the pain caused by existing pain relievers. Cannabis was a perfect vehicle for the next pain relief refrain. Led by the markets, cannabis was transformed from a hazardous substance, to a remedy, not just for the pain of individuals, but as a remedy for the oxycodone epidemic. In Oregon, a state where the cannabis market was not sufficiently controlled, the refrain amplified cannabis production levels, such that Oregon in two growing seasons produced enough cannabis to supply Oregonians for six and half years. This glut has forced prices down, resulting in the destruction of artisan cannabis production and the creation of investment opportunities for the multi-national cannabis industry.

© Springer Nature Singapore Pte Ltd. 2020 J. L. Fitzgerald, Life in Pain, https://doi.org/10.1007/978-981-10-5640-6_8

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The response from Oregon was to deploy two different bright and shiny economic refrains—“creative destruction” and “market equilibrium” to manage the pain of the 2018 Oregon cannabis glut. The pain from the pain relief refrain became an economic pain and the response of government was to blame the “market” and overzealous producers. At no point are the connections made between the less-thanconscious-refrains that have been operating underneath these two pain refrains. When explaining the need to put constraints on the Oregon cannabis production market, Oregon administrators noted that the original reason why few constraints were placed on cannabis producers, was to ensure that the legal market could supplant the illegal cannabis market. In both cases the somatic amplification of pain was caused by a pain refrain. Each refrain was market-led. The refrains operate at the level of individuals, culture and the political-economic system. Pain at its source is an element of life, but the amplification of pain needs to be understood at a cultural, political and economic level. This is where Tom Price, the ex-US Secretary of Health got it wrong. It is not the moral weakness of individuals that led us into a North American opioid epidemic. It is not the inevitable weakness of individuals in the face of pain relief. We are blind to the operations of refrains, because we do not see the organization of pain as linked to markets through a diffuse cultural neuromatrix. Capital has its eyes on the mechanisms that direct the flows of life. And strangely, when it comes to political economy, pain gives life. Pain is very productive. It mobilises affects, which then get translated into economic capital. Ontopower has established the conditions for pain to be a commodity that keeps on giving. Modern capital will seek to connect the affective economy to pain through affects. Biopower operates to give advantage to those forms of life that are productive and to confer a bare existence to those forms of life that are non-productive. Market-led refrains are the central mechanism through which capital organizes and amplifies the affective economy. Refrains are also the pathway through which we can avoid the amplification of pain through refrains. The challenge for States is that the cultural pain neuromatrix does not recognise boundaries, it is diffuse and operates at a less-than-conscious level. Capital knows this and exploits it. At the heart of the challenge for a life in pain is to recognise when our immunitary logic, the logic to try and protect the body politic, itself creates pain. It is an autoimmunitary logic that is the threat to life. In trying to protect life we can inadvertently threaten that very life that sustains us. In 1971 Melzack and Torgensen mapped out the domains of English language used to describe pain. They came to the conclusion that: The fact that there are so many words to describe the word pain lends support to the concept that the word “pain” is a label which represents a myriad of different experiences, and refutes the traditional concept that pain is a single modality which carries one or two qualities.

They also noted that our pain experiences are not as narrow as our “symbolic verbal categories”. Although Melzack and Torgerson (1971) were seeking a scientific account of the language for pain, there seemed even in 1971, to be an openness to

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an ontology of pain that exceeded the categories of our understanding. Somewhere between 1971 and 2019 we lost our way in making sense of pain, at least at a cultural level. It seems scientific pain is now encountering the genetics of brain function. The quest for analgesia has now extended to finding genes that code for pain-free living. The recently-discovered “genetic disorder” in a 66-year old woman who feels little pain, has altered fear and memory symptoms and a “non-anxious disposition” is caused by a FAAH-OUT pseudogene microdeletion (Habib et al. 2019). The finding was interpreted to open the way to genetic interventions to design a pain-free living. The paper has received extensive global attention in science and international news including the New York Times, Wired magazine, Then Huffington Post and NBC news (https://www.ucl.ac.uk/news/headlines/2019/mar/womannovel-gene-mutation-lives-almost-pain-free). Examination of the low pain sensitivity tests supplemental to the paper reveals however that the patient was hypoalgesic in only 2 of 11 sensitivity tests. The very characterisation of her condition as a genetic disorder, and the search for others in the population with similar “disorders” should ring alarm bells regarding the naturalisation of the normative. This finding should challenge geneticists, neuropharmacologists, social scientists and theoreticians to examine the naturalised categories we use to think through pain. The quest to make sense of pain will continue. Life in pain is never easy. We should just try and make it a little easier.

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