Washington, DC—January 27, 2022The prescription opioid crisis has generated significant social suffering and public controversy, and while it is often portrayed as a uniquely American problem, rates of opioid prescribing have ballooned across the Global North. Although Big Pharma certainly played a crucial role in opioid over prescription, a complete understanding of this trend requires attention to other factors, such as the conditions that encouraged the selection of opioids by multiple fields as the go-to tool for pain management—conditions that could have future implications for the prioritizing of certain technologies to solve social problems.
In her new study “Technologies of Expertise: Opioids and Pain Management’s Credibility Crisis,” which appears in the February 2022 issue of American Sociological Review, Jane Pryma, Assistant Professor of Sociology at the University of Connecticut, broadens the view of the opioid crisis beyond pharmaceutical power in the U.S. to gain a better understanding of the conditions that contributed to the emergence of opioids as “the right tool for the job” of pain relief—and that ultimately contributed to millions of Americans’ misuse of prescription pain relievers.
Prevailing accounts of the opioid crisis paint a picture of profit-driven pharmaceutical companies that enlisted doctors to overprescribe opioids to patients in pain. But this one-dimensional depiction does not take into account the global, historical, and interinstitutional processes by which government officials, humanitarian actors, and medical experts promoted opioids for pain relief as a public health priority and patient right.
Pryma traces the formation of a global pain-management network, comparing two national contexts in “the fight against pain”: the U.S. and France.
The two are ideal for such comparison because, not only did pharmaceutical actors encourage the selection of opioids as the technology for pain management in both countries, but they were also leading national consumers of prescription opioids per capita in the early 2000s—when the U.S. opioid crisis began to take hold.
But France’s prescription opioid problem has remained on a smaller scale as compared to the U.S. To help explain this difference, Pryma first takes a close look at “pain expertise as a network, composed of multiple fields and technologies” to explain how opioids were selected as the go-to solution for pain relief. She then focuses in on the role of pain specialists in each country, and how they managed their “strategic relationships to opioid technologies differently,” ultimately insulating France from the magnitude of the U.S. prescription opioid crisis and the resulting credibility crisis for U.S. pain expertise.
The author identified and analyzed historical documents, including accounts of global health organizations and legislative and public health archives in the U.S. and France. She also identified and conducted 50 interviews with key actors in expert debates around pain management from 2016 to 2018 in the two countries, including clinical researchers and practitioners, pain-patient advocates and lobbyists, and public health and social service administrators. This group also included individuals who had been involved in interagency efforts between the National Institutes of Health, the U.S. Department of Health and Human Services, and the Centers for Disease Control, among others, who contributed to the development of pain-management research initiatives and clinical guidelines.
The author triangulated interviewees’ recollections of the history of pain management debates and policies with archival materials, media coverage, and secondary historical sources. She also asked all participants about their contemporary attitudes toward the use of opioids in pain management. Thus, the author traced the role of opioid technologies in the emergence of a global network of pain-management expertise, how pain specialists in each country responded to the opioid crisis, and what pain specialists think of the current state of pain expertise.
The author found that in both U.S. and France, opioids operated as a “linking technology,” connecting a fledgling field of pain specialists to the resources of global-health governance, humanitarian organizations, pharmaceutical companies, and public health officials. These links bolstered the legitimacy of pain specialists and established a broader global network of pain expertise. But despite deploying similar strategies to strengthen their fields, French and U.S. pain specialists used opioids as a resource to redefine their fields’ boundaries in different ways.
Both groups reported mounting pressure from healthcare administrators to treat patients quickly and efficiently, as “health administration privileged fast, standardized, and seemingly curative opioid-centric pain relief overseen by a single provider over the tailored, interdisciplinary approach of the multi-modal clinic.” When opioids proved difficult to manage, “French pain specialists leaned on their multi-modal work to reassert their professional autonomy, positioning their non-pharmacological therapies as solutions to the threat of opioids,” defending it from blame for the increasing number of opioid overdoses in France.
On the other hand, struggling to unify their field, U.S. pain specialists’ opioid optimism led to a loss of their autonomy and credibility. U.S. pain specialists struggled to maintain their multi-modal clinics through the shift to managed care. “Faced with these institutional challenges,” notes the author, “U.S. pain specialists pivoted to opioids, riskily redefining their professional jurisdiction through a claim to specialized opioid expertise.”
However, the combination of the ease with which opioids could be administered and the pain specialist field’s already weak boundaries led to the belief in the U.S. that opioid prescribing need not be a specialized practice, ultimately undermining pain specialists’ authority as experts in safe opioid prescribing and limiting the availability of nonpharmacological pain management. As evidence of the opioid crisis emerged, U.S. pain specialists could not defend themselves against the threat of the “out-of-control technology” that they had helped to promote as the tool for pain management—nor could they, as effectively, defend the needs of pain patients.
The author concludes that “the relationship between opioids and pain expertise demonstrates the hazards of addressing complex problems through silver bullet technologies.” By investing in a single tool to solve a problem, lawmakers, researchers, and practitioners limit the policy they produce and the very scope of their imagination as they consider alternative solutions. Furthermore, when professional actors select one technology to solve a complex problem, that technology constrains how experts from different fields navigate institutional obstacles to evidence-based best practices and respond with resilience to unexpected outcomes.
The way networks prioritize certain solutions to social problems has implications for the future, notes the author: “Several recent examples of technologies developed to solve vexing problems, such as self-driving cars meant to make our roads safer, vape pens promoted as a tool for smoking cessation, and even promising COVID-19 vaccines expected to end the pandemic, demonstrate that unbridled tech optimism can overtake expertise and policymaking in ways that limit how professionals can prevent, anticipate, and respond to emergent crises. “
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