Drug Stigma,Consumer Culture,and Corporate Power in the Opioid Crisis

Abstract

Recent efforts to rethink drug-related stigma have been increasingly considering the power dimension of the concept, to show how stigma formations flow top-down from governments, as well as other political or corporate stakeholders, towards the powerless and marginalised. Stigma attaches itself to the individual and collective identities of the substance-using subject. But it equally alters the multiple lives of the substance. In the US opioid crisis of recent decades, big pharma companies could be seen lobbying the medical profession and harnessing their power to destigmatise opioid painkillers, as part of wider marketing and sales strategies. This has been subsequently linked with rising opioid-related fatalities and spiralling harms among some of the most vulnerable groups. This theoretical paper locates the object-stigma of drugs between the cultural confines of ‘limbic capitalism’ (the drive to seek pleasure and meaning through consumption) and ‘palliative capitalism’ (the drive to pathologise and medicate ills attributed to the individual, but not the system). It argues that stigma should be viewed as a dynamic force which, under the guise of consumer culture and the veil of scientific rationality, can be manipulated by business elites to shift meanings around pain, pleasure, and addiction, in ways that are potentially conducive to social harms.

Introduction

In an episode of the Hulu drama miniseries Dopesick, Randy Ramseyer, an Assistant U.S. District Attorney gathering evidence to prosecute the Sackler family-owned Purdue Pharma, producer of the opioid painkiller OxyContin (oxycodone), confesses to a Federal Drug Administration (FDA) employee that he almost ended up addicted, himself, to the drug administered by doctors to manage his cancer-related pain, now in remission. In a bid to obtain information on how much Purdue top executives were aware of the damaging effects of the drug they were encouraging medical professionals to prescribe, he adds that “[…] it wouldn’t have been the disease that killed me, it would’ve been my medication. I got lucky. I just want you to think of all the kids that are not getting lucky.” The series, based on the book of the same title by journalist Beth Macy (2018), adds to a growing list of pop cultural scripts depicting the American opioid crisis of the past two and a half decades. Ramseyer's words echo the hurt left behind by a public health epidemic that by 2021 was claiming close to 81,000 lives per year in opioid overdose fatalities alone (Centre for Disease Control [CDC], 2022). But they also allude to wider entanglements of corporate-economic forces and permissive regulatory regimes, that concur to blur the boundaries between disease and medication.

This is what criminologists Travis Linnemann and Corina Medley have referred to as palliative capitalism: “a set of social relations in which legal pharmaceutical drugs and their producers, marketers, and distributors profit from treating or attempting to treat the conditions that capitalism creates”, to manage rather than cure the pain and harm it fosters (Linnemann & Medley, 2023, p. 419). Analyses informed by political economy have shown how aggressive marketing strategies by big pharma companies have met with socio-economic decline, extreme poverty, and the erosion of manufacturing jobs in the American economy, to predict higher rates of abusing opioid analgesics and resulting ‘deaths of despair’, most so in deprived rural areas and deindustrialised regions of the country (Dasgupta et al., 2018). Other interpretations have argued for the deficient regulation of sales strategies in the case of big pharma companies such as Purdue, leading to the widespread promotion and eventual diversion into illicit markets of drugs such as OxyContin, to be effectively seen as state-corporate crime, where bad policy making facilitates corporate wrongdoing and widespread social harms (Griffin & Miller, 2011).

What the opioid crisis equally points to is the blatant ease with which once stigmatised categories of psychoactive substances can be reframed and marketed in medical discourse, everyday practice and popular consciousness when moved by the influence and synergies of large companies and state-regulatory authorities. Indeed, the ‘drug dealer’ epithet is reserved for those doing their business far outside the confines of boardrooms and top management offices (Linnemann & Medley, 2023). A ‘macro-turn’ has also been gaining prominence within stigma studies, as recent theoretical contributions have been questioning the role of political and class power in defining and weaponising stigma formations against groups and social classes ritualistically scapegoated for the failings of governance (Link & Phelan, 2014; Scambler, 2018; Tyler & Slater, 2018); but equally the stigmatisation of people who use drugs and are also facing structural deprivations, owing to material status or ethnic marginality (Room, 2005; Addison et al., 2022; Alexandrescu & Spicer, 2023). Even more poignantly, is to observe how stigma determines and orders hierarchies of licit and illicit substances, separated by practices of consumption and notions of commercial value.

In this sense, Ayres and Taylor have talked about a ‘drug apartheid’ that validates some drugs as “an indicator of social competence/functionality, attracting commendation rather than condemnation” (Ayres & Taylor, 2022, p. 200). Thus, alcohol, caffeine, sugar, as well as various other performance and image enhancement drugs occupy a privileged place and are allowed their own iconography of adverts, lifestyles, carefully crafted venues, or rituals of use, in the popular imaginary of consumer capitalism; whereas other drugs are deeply stigmatised when perceived to conjure the image of classed and racialised ‘others’. Opioids have easily crossed boundaries, in their multiple forms – from the cabinets of the wealthy white affluent classes at the turn of the past century, using opium and morphine prescribed by doctors, to the shady lumpen underworld of heroin; and then into the cultural, mass-marketed mainstream of instant gratification, served by pharma-engineered drugs (Courtwright, 2022).

Taking the US opioid crisis as a point of departure, this paper considers a notion of stigma power as a malleable force mobilised by the business-politics nexus of contemporary capitalism, to change meanings and normalise practices of prescription and consumption around some classes of psychoactive drugs that can be commodified and made available on a large scale despite their established potential to inflict suffering onto those who use them. It thus locates drug stigma between consumer culture's injunction towards fast gratification, and the excessive drive to extract value from conditions that equally trace their aetiology in social, not solely biological configurations. It discusses how pharmaceutical companies would lobby doctors to prescribe and patients to turn to opioids, seeking to destigmatise and mass-market these as a response to what was deemed an untreated ‘pain epidemic’. Here, stigma reveals itself as a cultural force rooted in political economy that emanates from the disproportionate ability of the powerful to (de)stigmatise drugs and their potential uses.

In line with emerging critical perspectives, this contribution highlights the need to question the role of stigma in perpetuating social arrangements that are conducive to harm. It first explores a theoretical avenue that has recently seen macro-sociological interpretations challenging more traditional social-psychological perspectives in aiming to position the concept closer to the structural end of the analytical spectrum. Secondly, it follows the genealogy of the US opioid crisis and zooms in closer on the object-stigma of pharmaceutical and non-pharmaceutical drugs to observe how demarcations of these often fade between notions of pleasure and pain. Thus, there is an implicit need to expand existing conceptualisations to integrate a more wholistic and unified frame of understanding drug stigma, where pleasure-seeking and pain-alleviating subjectivities both draw meaning from and link back to the ideological demands of present-day capitalism – and where they feel inseparable.

Macro-Stigma and Social Harm

Substance-related conditions attract some of the most damaging forms of stigma: they often lead to or meet with social exclusion, extreme marginalisation and excessive criminalisation, low-quality healthcare provision and psychological barriers to accessing services (Lloyd, 2013; Schomerus & Corrigan, 2023). People who use drugs (primarily those deemed as ‘illicit’) have long been ritualistically scapegoated by modern society and symbolically separated from it (Szasz, 1974). From a health and disability studies perspective, addiction stigma has been seen as a malign force that needs to be neutralised, to improve the condition and quality of life of those affected by it. Whereas, from a criminological point of view, it has been considered as a mechanism of social control (Room, 2005). More recent contributions, however, have suggested that, to exploit its full analytical potential, the concept should be deployed in ways that cut across both understandings to see it as a system of social relations meant to keep people who use drugs ‘down’ in ways that equally affect their life choices and potential for development or leading a meaningful life (Addison, 2023).

A more wholistic, power-focused approach informing critical drug studies has advanced in alignment with a larger reorientation or ‘macro-turn’ within the stigma studies field itself, advocating for a clearer theorisation of ‘structural stigma’ – how stigma is shaped by and embedded within societal conditions, institutional policies and practices, dominant cultural understandings and norms (Hatzenbuehler, 2017); and further on, how stigma is embedded within power relations themselves and how ‘stigma power’ is often mobilised by the powerful (governments, political stakeholders, corporate actors or media) to direct attention towards the powerless and away from the wider injustices of the existing neoliberal order (Scambler, 2020; Tyler, 2020). This has enabled research narratives that question how class and material distinctions tie in with stigmatisation processes that flow from above, and where the powerless (the poor, the sick, the disabled, the foreign etc.) are always more likely the stigmatised rather than the stigmatisers (Link & Phelan, 2014). In proximity to drug policy, it has also meant observing the relational mechanisms at large by which “the criminalisation of a person who uses drugs can lead to greater vulnerabilities that are also amplified through axes of social inequality [of wealth, race, place etc.] impacting on their lives” (Addison et al., 2022, p. 11).

Moreover, this literature hints at lines of interrogation questioning stigma's role in perpetuating injustice embedded into social structures themselves but, further on, also in the active creation of social harms perpetrated by the powerful. In a wider sense, crime has no ontological reality and official definitions of it often steer away from the injurious actions of governments, companies, or high-status individuals (Hillyard & Tombs, 2004). Thus, deaths and other physical and health harms that result from occupational hazards and unsafe workplace conditions, food poisoning or air pollution caused by private profit-seeking organisations (Tombs & Whyte, 2015) or those derived from the (in)actions of governments when meant to protect their most vulnerable citizens (excess winter deaths or police-custody fatalities) will rarely attract prosecution but speak of the economic, social or political arrangements that produce them (Canning & Tombs, 2021). To these, other typologies add financial/economic harms (lowering the quality of life and ability to satisfy material needs), emotional/psychological harms (affecting mental health) or cultural harms (eroding identities and ways of being); but, equally, autonomy harms (that impede involvement in meaningful social activities and affect one's sense of self-worth) or relational harms (social exclusion) (Pemberton, 2015).

A social harm perspective is meant to capture “a wide range of immoral, wrongful and injurious acts that may or may not be deemed illegal but are arguably more profoundly damaging” than those that are traditionally criminalised (Muncie, 2019, p. 501). These include harms happening at the crossover between political institutions and economic organisations, that scholars such as Kramer and Michalowski (2006) loosely define as ‘state-corporate crime’ (a term encompassing not only illegal but socially injurious actions as well). Corporate entities are creations of nation-states and are maintained and supported by the ideological, regulatory, and material frameworks of free-market economies (Tombs, 2012). Corporations engage in socially harmful acts prompted, approved, or tolerated by states; or prop up the state's abusive activities themselves, for instance by supplying technology used to harm). Thus, examples as diverse as the Holocaust and the arms trade, to the corporate plundering of natural resources in occupied Iraq or the ‘war on terror’ itself have been discussed under this framework (Green & Ward, 2004; Tombs, 2016).

Large pharmaceutical companies have casually engaged in harmful behaviours ranging from the unethical to the outright corrupt: bribery, unsafe or inadequate manufacturing, price-fixing, counterfeiting, deceitful testing, and misleading marketing practices (Braithwaite, 1984; Dukes et al., 2014); benefitting from globalisation processes allowing them to ‘offshore’ clinical trials onto vulnerable populations in developing countries in ways that would not comply with regulatory frameworks in their primary, Western markets (Velut, 2021). The harms emanating from the “triumvirate of the state, medical science and pharmaceutical industry” (Rawlinson, 2013, p. 72) add to a long history of unethical human experimentation on vulnerable and unknowing subjects and echo into an increasingly medicalised society, in our times (Rose, 2007). ‘State-crafted’ stigma (of ethnicity, class, physical, mental disability, or welfare status etc.) has been the prerequisite condition for targeting groups that had been consistently blamed, typified, and dehumanised before being subjected to atrocity under the guise of medico-pharmacological knowledge (Tyler, 2020). Western pharmaceutical groups have equally been reported to test experimental drugs resulting in serious adverse effects and fatalities on former colonial populations in developing countries (Dearden, 2023).

Thus, stigma can be understood as an active force that works in the production and amplification of harms against those who use illicit substances that are not traditionally sanctioned and commodified by the state-corporate nexus of contemporary consumer capitalism itself. Then, it can be seen as one of the cultural-ideological conditions contributing to the victimisation, denigration, and dehumanisation of those at the harmful end of unethical or outright abusive medico-pharmacological practices. Moreover, a macro-oriented perspective on drug stigma can equally highlight the active role of large-scale organisations and state structures in shifting meanings and perceptions towards normative acceptance of some drugs, rather than others. This is often favoured by the laissez-faire, non-interventionist approach of governments and by the actions of multinational pharma companies (Moynihan & Cassels, 2005). The advertising and promotion of certain pharmaceutical drugs, often under misleading pretences, does not reflect a market dominated by the best products in scientific terms, nor by those most in tune with public health needs (Dukes et al., 2014).

Moving forward with the state-corporate crime paradigm, Griffin and Miller (2011) focus on the marketing of Oxycontin by Purdue Pharma to propose that the US opioid crisis should be seen through this theoretical lens; though they nuance their argument away from usual conceptualisations of the state as an active facilitator of widespread harm, towards this being seen more as a ‘regulation deficiency’, where despite good intentions to protect the public from the highly addictive potential of the drug or from diversion into unsupervised use, poor policy design and implementation failed to prevent decisive action being taken that could have saved thousands of lives. Purdue's ultimate bankruptcy resulting in a multi-billion-dollar settlement would validate Griffin and Miller's view that enforcement authorities could eventually act decisively against the company when the scale of harms inflicted became too significant to ignore, though the opportunity to do this effectively had been arguably missed at multiple points (Keefe, 2021).

The role of ‘stigma power’ in the production of harm is conceived through the power to stigmatise (people who use drugs, certain classes of drugs and their use themselves, such as opioids) ‘from above’ – by the state and law enforcement, political or business elites. The opioid crisis and the marketing of strong painkillers by big pharma raises questions about the ability to displace stigma or to destigmatise and normalise some (previously vilified) drugs altogether, in pursuit of sales targets and in denial of responsibility for ensuing harms. Seeing stigma this way also invites conversations about a long line of deceitful commercial practices and unfettered influence of the pharmaceutical sector but also about how state-corporate power can oversee and actively push cultural shifts that equally reshape notions of pain and pleasure – in a consumer-enabled, medicalised society increasingly intolerant of any discomfort where “ideas of health and illness have transformed in such a way that it has become thinkable that every adult should be taking a preventative cholesterol-lowering drug and every troubled adolescent an antidepressant” (Dumit, 2012, p. 21). The paper progresses to discuss such drug-related stigma (and de-stigmatisation efforts) in relation to larger concepts of comfort and suffering moulded by contemporary consumer capitalism.

The Opioid Crisis: A Brief History

It is estimated that over a million people have died from a drug overdose in the US since 1999, with opioids being responsible for about three quarters of yearly fatality numbers at the beginning of the current decade (CDC, 2023). This has been attributed to a large set of factors, ranging from a ramped up corporate-driven supply of medical opioid painkillers (Van Zee, 2009; Sherman, 2017), to a cultural repositioning towards the liberalisation of opioid prescription among pain doctors (Lembke, 2016; Jones et al., 2018; McGreal, 2018), to further on worsening economic conditions in post-industrial areas with low welfare provision witnessing ‘deaths of despair’ (Dasgupta et al., 2018; Pierce & Schott, 2020). Other scholarly and investigative accounts have specifically looked at the introduction, prescription, and subsequent diversion of the Purdue Pharma drug Oxycontin (Cicero et al., 2005; Keefe, 2021). Since its release in 1996, the vigorous promotion of the strong oxycodone-based medication has been correlated with rising overdose-fatality rates (Compton & Manseau, 2019; Alpert et al., 2022), as well as a wider transition towards illicit substitutes such as heroin and fentanyl following Oxycontin's reformulation and more stringent prescription conditions, for those frequently using this and other medical opioids (Powell & Pacula, 2021).

Eventually declared a national public health emergency in 2017, by the Trump administration (Haffajee & Frank, 2018), the opioid epidemic is generally seen to have unfolded in three waves of overdose mortality: the first one debuting in the 1990s and bringing a tripling of opioid prescriptions by the early 2010s; a second one witnessing a rise in heroin-related deaths potentially fuelled by new barriers in prescription; and a third one driven by the appearance of highly potent synthetic opioids, mainly fentanyl analogues (Ciccarone, 2019). These successive stages coalesce towards reconfigurations in supply. Quite specifically, the third wave beginning around 2013 appears to have created a significantly heightened risk environment around fentanyl produced cheaply in China and circulating within the heroin supply or having the potential to contaminate it, oftentimes leading to fatal outcomes among buyers (Ciccarone, 2017; Mars et al., 2019; Jenkins, 2021).

Cutting through these intertwining developments, at root-level remains the initial prescription drive spearheaded by Purdue Pharma in the pharmaceutical sector. Following the launch of OxyContin, the company monitored and targeted doctors and areas with high numbers of chronic-pain patients. These would receive frequent visits from sales representatives, be constantly exposed to branded merchandise and enjoy all-expenses paid trips for product-focused symposia where they would be encouraged to prescribe the drug beyond the traditional cancer-related pain sphere, opioids had been routinely assigned to (Van Zee, 2009). Purdue also advertised its drug as non-addictive due its slow-release period of 12 hours, a claim equally challenged by independent tests finding shorter release times, in practice, and by those using it recreationally who would crush, dissolve, or simply ingest the pills in higher doses (Meldrum, 2016). A ‘cultural shift’ within the medical body against the ‘under-treatment’ of pain was spurred on by the company in its promotional messaging, including the brief anecdotal and empirically irrelevant Porter and Jick (1980) commentary to the New England Journal of Medicine that allowed it to estimate a risk of addiction of ‘less than one percent’ (Van Zee, 2009).

States with lower threshold regulations and less restrictive prescription policies primarily targeted by Purdue as lucrative markets for OxyContin have noticeably experienced significantly higher opioid-related mortality rates more than two decades after its introduction (Alpert et al., 2022). An affiliated entity of Purdue's, alongside three of its top executives, pleaded guilty in 2007 for the misbranding of OxyContin in a deal with federal prosecutors that resulted in penalties of about $600 million, but the company's management continued to pursue its tried and tested marketing strategy, downplaying the harmful potential of its most profitable product (Keefe, 2021). Furthermore, its subsequent 2010 reformulation of the drug adding chemical barriers to prevent the crushing, breaking, or dissolving of the (slow-release opioid) pills has been found to stimulate the growth of illicit markets further leading to prescription user transitions to heroin, fentanyl, and even other, non-opioid drugs, then linked with rising overdose fatalities (Powell & Pacula, 2021).

Eventually, faced with the tragic proportions of the steadily cumulating public health crisis, the US Centre for Disease Control (2016) would ultimately update its prescription guidelines away from opioids in the non-palliative treatment of chronic pain or towards lower dosing (Ramin, 2020). Purdue itself would face a barrage of litigations from thousands of lawsuits initiated by state authorities and victim groups affected by the opioid crisis, eventually declaring bankruptcy in 2019 and later agreeing to collective payments of up to $6 billion; though shielding the Sackler family owners (estimated to have extracted well over $10 billion from the business, to add to their personal wealth) from any further liability (Smyth & Indap, 2023). Prestigious universities, museums, and art galleries have been untangling themselves from Sackler money funding scholarships, libraries, display wings and exhibitions, cutting ties with the family's charitable arms (Adams, 2023). What remains, still, is a story of corporate greed where one company's financial traction could reshape a whole medical profession's relation with, and a larger population's habits of using, a heavily stigmatised category of drugs. Along with the commercial success of OxyContin, a wider sense that the meaning of opioids had changed, “from a dangerous medicine of last resort to a household object and standard for treating pain” began to solidify (Sherman, 2017, p. 594).

Stigma and Pleasure

To follow the altering contours of drug stigma, some of the wider factors that impact the political economy of drug manufacturing, distribution, and control, must be considered. One such driving force behind historical processes of stigma formation around state-sanctioned and prohibited substance use has been the advent of global consumer culture, largely driven by the neoliberal West's influence. As the sociologist Zygmunt Bauman would observe, this has entailed structural changes, chief among which we find “the fashion in which people are trained to meet the demands of their social identities” by engaging in and actively displaying their consumption practices, by their willingness to “play the role of the consumer” responsibly (Bauman, 2007a, p. 24). Where good citizenship is defined by the ability to be a measured pleasure-seeking (and pain-avoiding) consumer who enjoys her choices in rational and ethical ways, those who fail to do so by (mis)using drugs in harmful or addictive ways are most likely to face the stigma of failed, excessive, or compulsive consumption (Ayres & Taylor, 2020).

People who develop harmful habits of using drugs thus fall at the wrong end of what Ayres and Taylor (2022) point to as being the ‘drug apartheid’. This arbitrary division, enshrined in now century-old prohibitionist laws (Taylor et al., 2016), is further enforced by norms of consumption that see some psychoactive substances celebrated and ritualistically promoted as they emanate symbolic and cultural capital; whereas others are inevitably relegated to the lower tiers of the consumer society and pinned onto the identities of defective or ‘flawed consumers’ (Bauman, 2007b). If stigma ‘spoils’ individual and collective identities by projecting or amplifying discrediting attributes onto them (Goffman, 1990), the stigmatisation process best operates around ‘low-status’ substances embedded into practices that go against socially approved norms of legitimate consumption and sit outside commodified arenas endorsed by states and markets (Ayres & Taylor, 2022). Further on, those substances closer to the privileged end of the spectrum and the consumerist rituals they accommodate are equally entangled into forms of social harm production, even if ‘destigmatised’ in comparison to those more likely to attract the ‘drugs’ label.

Critical drug scholars such as the historian David Courtwright have suggested that economic organisations have, throughout modernity, increasingly tapped into the biology of addiction to target pleasurable behaviours and commodify the human experience. He refers to this as ‘limbic capitalism’, “a technologically advanced but socially regressive business system in which global industries, often with the help of complicit governments and criminal interests, encourage excessive consumption and addiction. They do so by targeting the limbic system, the part of the brain responsible for feeling and for quick reaction, as distinct from dispassionate thinking” (Courtwright, 2019, p. 19). Thus, the synthetic isolation of heroin and cocaine, the addition of fats, sugars or salt into ultra-processed foods, the very algorithmic architecture of online gambling or social media platforms, are all normalised forms of scientifically engineered practices of excessive consumption.

As the neurologist Anna Lembke suggests in Dopamine Nation, her account of how contemporary societies of abundance flood the brain with reward stimuli, “supply has created demand as we fall prey to the vortex of compulsive overuse” (Lembke, 2021, p. 21). Opioid addiction sees the brain tilting the pleasure-pain balance towards the side of pain, due to dopamine deficit and craving (the neurotransmitter associated with reward and motivation) following repeated exposure to the drug. But it also fits into a larger pleasure economy that encourages dopamine depletion and constant craving towards other commodified objects of ‘junk’ consumption, such as fast-food, news, gambling, the smartphone itself etc. In a sense, flooded and overstrained with stimuli, all are now addicts, in need of ever “more reward to feel pleasure and less injury to feel pain” (Lembke, 2021, p. 61). Supply has also tampered with dominant notions and definitions of intoxication – those labelled as ‘addicted’ are held to be morally liable for their inability to engage in restrained, measured, civilised consumption, without questioning the wider systemic, hyper-cultural injunction to overconsume (Ayres & Taylor, 2020; Ayres, 2022).

Stigma then sits at the junction of structural forces that push for new boundaries and normalisation drives in substance use. Corporate-driven consumer culture seeping into medical practice has made the notion of pain unacceptable – the prerequisite of pleasure is the neutralisation of pain, at other historical times seen as an opportunity for growth and spiritual enlightenment, now anathema to modern life (Lembke, 2016). The patient herself has increasingly come to be seen as a consumer feeding back satisfaction ratings on the quality of care and opting for the quick fix of a pill, more financially cost-effective to satisfy health insurance companies and more psychologically comfortable than laborious physical therapy or lasting lifestyles changes (McGreal, 2018). The story of OxyContin starts with Purdue expanding the consumer logic to unexploited market segments, such as the non-cancer pain market. “We will cure the world of its pain”, Richard Sackler's fictionalised character (Purdue's CEO credited with the success of the drug) exclaims in the Dopesick series. Then, OxyContin's permeation is attributed to a certain (destigmatising) promise of whiteness, an implicit promise broken by the company to uphold “an affluent white zone of clinical narcotic consumption” kept safe, sealed, and segregated from underclass and racially othered illicit substance markets – a respectable supply of clean opioids for suburbia unlike that of the inner-city streets (Hansen et al., 2023, p. 121).

Ayres (2022) draws on philosopher Slavoj Žižek's (1991; 2019) work to show that within the ideological fantasy of consumer capitalism, desire is insatiable and the pleasure that follows it ephemeral; desire is kept perpetually open by the subject to mask the void of meaning and fulfilment, bordering on ignorance. This is eventually a desire not to know, a fetishistic disavowal that extends to the arbitrary distinction between the stigmatised substances sought by the powerless and those sanctioned by state and capital, peddled by and to the affluent. Žižek (2014) also observes that affluent consumers choose to buy needlessly expensive things to make their life meaningful and pleasurable – not only the Starbucks coffee but a coffee ethic promising fair trade or eco-sustainability in the harvesting of the beans. Politicians and crime control agencies now openly shame the same middle-class ‘coffee hypocrites’ who also snort cocaine at the weekend, turning a blind eye to the violence, exploitation, or ecological damage to the Andean rainforest, down the illicit drug's global supply chains where the coca leaf is sourced (Greenwood, 2015).

What is less seriously questioned is the very rationale of the ‘war on drugs’ that fuels transnational organised crime by making heroin, cocaine, cannabis high profit-margin dark commodities; and that creates threats of illicit ‘drug dealing’ typically excluding those in business suits or white coats. These cater ‘precision medicine’ engineered under the guise of science for a ‘protected segment’ within the opioids market for privileged consumers, who benefit from comprehensive care, as they benefit from the ethical and symbolic assurance that theirs is the clean, rational, morally sanctioned type of substance use. In the first stages of the opioid epidemic this group could still linger in denial as companies such as Purdue would primarily over-saturate white blue-collar, rural and small town areas with oxycodone (Kentucky, West Virginia, Maine, Pennsylvania), before it would become obvious that suburban housewives and college students would equally fall victim to what had previously been labelled ‘hillbilly heroin’ (Hansen et al., 2023).

Authors such as Fraser et al. (2017, p. 199) have suggested that “addiction is a means by which contemporary liberal subjects are schooled and disciplined in the forms of conduct and dispositions required to belong, and to count as fully human”. Through its language and biopolitical designations, they suggest, stigma is materialised for those rendered through it as slipping outside the sphere or autonomy and rationality. Addiction stigma delineates spaces of abjection for the confinement of groups historically positioned as residing outside such normative spheres, at the intersections of class, race, and other lines of marginality (Seear, 2020). But glimpses into it can reveal cracks in the signified, ideological order in multiple ways (Žižek, 2019). First, in the realisation that harms from above, such as those emanating from the excesses of corporate power, can extend to everyone, even to those at the privileged end of the drug apartheid, habitually assured and protected by the veil of scientific rationality assigned to legitimate pharmaceuticals. But equally in how the ontology of addiction is in a way, a refusal and retreat from the ideological order itself. This is where in a libidinal economy of endless choices and consumer fantasies, the fixation for the drug and the drug alone leaves the subject desiring no more (Bjerg, 2008).

Stigma and Pain

A de-stigmatisation momentum around opioid-based painkillers for mass consumption, leading to the last decades’ crisis, also punctuates post-industrial society's increasingly complicated relationship with pain and the larger biopolitics of its management via drugs. Accordingly, the recontouring of opioids and addiction's place within medical and cultural discourse plays a significant part. These are also processes driven by shifting notions of stigma. Courtwright observes that in a dawning phase of opioid addiction in the US, in the late nineteenth century, those labelled as addicts would mainly be female and come from the middle and upper classes using morphine and opium medically. By the middle of the next century, these would be replaced by the figure of the nonmedically using lower class young male, largely aided by the advent of heroin and the pushing of the drugs trade underground by law makers through incipient pieces of prohibitive legislation (such as the 1914 Harrison Act) and by zealous enforcers such as those of the Federal Bureau of Narcotics – the more modern Drug Enforcement Administration's predecessors. Conservative physicians would be increasingly reluctant to prescribe opioids to an ever-thinning pool of iatrogenic (medically acquired) drug habits, pushing the locus of addiction “from the office and parlor to the desolate piles of urban debris” (Courtwright, 2022, p. 110).

A certain prescription conservatism then emanating from class-laden stigma would last well into the post-war decades, later strengthened by the home return of heroin-addicted Vietnam war veterans. This began to be challenged by a steadily growing pain reform movement within the medical profession, that Purdue and other big pharma suppliers would encourage to their own ends. Historian David Herzberg (2020) observes that the rehabilitation of a ‘white market’ of legitimate opioid medications could only be achieved by funding pain societies and journals, propelling pro-opioid medical voices as ‘key-opinion leaders’, and trying to co-opt regulatory and professional bodies by underplaying the risks of overdose and addiction in their wider communications to health experts but also to the larger public.

Thus, withdrawal symptoms could only be attributed to ‘pseudoaddiction’, caused by inappropriate and insufficient pain relief in patients that only called for the administration of more opioids. Industry-funded pain experts such as Dr Russell Portenoy would emphasise that opioids were effective in the treatment of any form of chronic pain and that no dose was high enough. By his own later admission, the goal was that “we had to destigmatise these drugs, we had to bring them from the cold into mainstream practice” (Catan & Perez, 2012); and then, “because the primary goal was to destigmatise, we often left evidence behind” (Moghe, 2016). By the turn of the century and less than half a decade since OxyContin's introduction to the market, pain would be classified by the Joint Commission on Accreditation of Healthcare Organizations in its 2001 standards, as a ‘fifth vital sign’ (alongside heart rate, temperature, respiratory rate, and blood pressure) requiring to be measured by patients on a scale of 1 to 10 and for treatment providers to calm it by any means available (Lembke, 2016).

How big pharma manipulates medical practice and the reputation of drug products to create or cash in on demand is a symptom itself or a wider systemic malaise, for criminologists Linnemann and Medley (2023). They also cite the example of ‘pharma bro’ Martin Shkreli, the hedge fund manager and pharma executive who in 2015 raised the price of the potentially life-saving drug Daraprim by 5,000%, to then achieve media fame as ‘the most hated man in America’, along with a prison sentence for (a separate case of) investment fraud (Larson & Hurtado, 2023). Shkreli's actions were then individuated in the news and social media cycles as pertaining to a loathsome and easily despisable character, but they can be equally read as an external manifestation of internal contradictions exposing a larger socio-economic system that tolerates price rigging and profiteering within a commodified healthcare circuit, but then expects ethical behaviours from those involved in it for fast gains. Linnemann and Medley, drawing on Mark Fisher's (2022) notion of capitalist realism, see this as another outburst of the underlying harm that the ideology of free markets needs to continually disavow as personal flaws rather than systemic pathology. They further refer to this and to the opioid crisis as instances of palliative capitalism. As they explain, this is “a system that transforms suffering into profit, seeking not to ameliorate individual conditions, but to manage them indefinitely” (Linnemann & Medley, 2023, p. 422).

The circular logic of this is one where poverty, lack of public investment, community breakdown, environmental degradation and deregulation, fuel conditions pertaining to mental and bodily health that then large conglomerates in the health market can propose palliative responses to, that are never more than temporary fixes for lasting harms, drawing surplus value from suffering without questioning the system's deeper dysfunctions, in the first place. Opium itself and its many preparations have always found themselves in those places inhabited by the ‘left behind’ in moments of technological disruption, change and disconnection (Sullivan, 2018). From the squalor of Victorian slums filled with the rurally displaced, industrial poor, to the present-day demise of industrial heartlands, along with the dissolution of community and retreat from common meaning, in atomised societies coagulating at best into digital tribes around culture wars, where ‘everyone feels alone’, the poppy's pharma-grade derivates tap into the deficit for another key-neurotransmitter that affects quality of life as much as bodily pain: oxytocin. This flows most organically from love, friendship, meaningful connections and the feeling of belonging, but its chemical arousal also passes through the brain's opioid receptors. Those finding it this way, not by choice, introduced to it not by ‘ruthless’ street dealers, but by peers, doctors and pharmacists, could tap into a deeper, collective pain: “It may be best to think of this wave [of opioid addiction] therefore not as a function of miserable people turning to drugs en masse but of people who didn’t realize how miserable they were until they found out what life without misery could be. To return to their previous lives became unthinkable” (Sullivan, 2018).

That opioids with their numbing, soothing and insulating qualities, would once again find fertile soil in a globalised yet disjointed universe where corporate capital and new technologies ripple through the social fibre and concur to offer palliative fixes to the ills they tend to instil themselves, reads like another instalment of a distinctly modern story. Behind it, a closer look at the object-stigma of drugs and addiction reveals that “stigma is entirely dependent on social, economic, and political power – it takes power to stigmatize” (Link & Phelan, 2001, p. 375). Equally, it takes symbolic power to destigmatise when the interests of corporate-business elites call for it. Here, we can see how a potentially well-intended de-stigmatisation drive from medical workers and pain reform activists is hijacked and amplified by the economic and political forces of industry to manipulate and disseminate biased knowledge, catalyse sales, and push for deregulation. In the reframing of pain as an intolerable and easy-to-fix condition by physicians, with the right tools becoming available, stigma is then essentially transferred from the pharmacological object of the drugs to the care providers refusing to engage with the new pharmacopeia available to them, to look after pain-riddled patients.

Stigma and symbolic power transpire through the hierarchies of prestige and shame that are produced and maintained within the social sphere, from above. Those who can stigmatise or destigmatise must make sure they are able to deflect labels away from their own selves and actions. The Sacklers’ concern to be involved in charitable work and sponsor art collections and museums all over the world while effectively using drug money generated from thousands of opioid deaths plays into larger efforts to whitewash the family's name and push it onto the ‘respectable’ side of the drugs divide (Keefe, 2021). The Sackler name would sit on public art buildings, schools, and hospitals as “a morbid symptom – not unlike a rash or boil” (Linnemann & Medley, 2023, p. 425) that reminds how at the core of ‘American dream’ the large fortunes and industrial empires of business dynasties have been built not only in the (old and new) opium trade, but equally in the brutality of colonialism and slavery, land expropriation or decimation of native populations (Reiss, 2014; Desmond, 2019). If corporate big pharma can pretend to sit on the legitimate side of the divide, and if the killings, violence, and corruption are mainly attributed to the darker side of the dealers, cartels, and drug lords that haunt the imaginary of the endless war on drugs, here we observe that the two alleged opposites branch into and stem back from the underbelly of the same game.

The separation lines that push the acceptable and intolerable drug dealers apart weave into what the political scientist Paul Rogin (1988) has long recognised as the public spectacle of political demonology. This is the ideology-driven, ritualised demonisation of the traditional enemies of the political order. These (foreigners, impoverished and revolting workers, or organised criminals; political agitators, infiltrators, or radical reformers) are constantly called onto the scene to give weight to narratives of imminent danger that saturate the news and entertainment media, their said extremism a call for a permanent state of war and crisis. However, others’ inherent extremism (that of governing elites, corporate businesses, or the state itself, its military, and police) fits much more naturally into the same political core – that can casually arrest, imprison, and brutalise perceived enemies, even under the shallow shield of human rights and essential freedoms it affords its subjects. The political theology of a perpetual end of the world, Travis Linnemann (2022) suggests, mobilises the necessary and casual violence of the state and its defenders, against the brutal and savage violence of those typified as the threat in the war on drugs or tough on crime policies. That the drug dealers are to be found in the streets rather than in corporate suites becomes a self-evident truth in the fight against monsters.

Conclusions

Here, this paper has sought to look at the US opioid crisis by reflecting on notions of stigma mediated by corporate power, and pendulating between pleasure and pain. Stigma power transpires through the various forms of knowledge making and resulting harm that has followed an industry-driven liberalisation of opioid painkillers. Stigma appears as an active force behind efforts to suggest that the problem is ‘elsewhere’, away from the conveyor belts of large pharmaceutical companies pumping out mass supplies of products known by them to be potentially damaging. It is shaped by the ideological demands of a consumer culture geared towards fast enjoyment and gratification; and a commodified medical arena where pain is treated as a lucrative, endless profit stream to be tapped into by large business organisations. Stigma power then inevitably reveals itself to be enmeshed in systemic arrangements and structures of political influence, capital ownership and cultural persuasion where the powerful are capable to frame definitions of problems and evade responsibility for behaviours conducive to harms.

This aims to shift the perspective on the object-stigma of drugs towards a larger, macro-lens by understanding the stigma power emanating around drugs in multiple ways. First, the power to stigmatise and destigmatise some psychoactive drugs over others, in line with profit imperatives (Taylor et al., 2016; Ayres & Taylor, 2022). While opioids appear as an evident case study to consider, further developments in other markets where previously illicit and stigmatised psychedelic or cannabis products are commodified and expanded into lucrative industries, for example, could also prompt critical interrogations of potential harms as they inevitably become integrated into big pharma portfolios and marketing machines. Second, the power to deflect own stigmatisation by harnessing resources and symbolic capital to situate drug-related problems away from the responsibility of powerful stakeholders, by hiding behind the veil of rationality (tweaking ‘the science’ to misrepresent the risks) and ‘whitewashing’ big pharma companies’ image (Courtwright, 2019; Keefe, 2021; Linnemann & Medley, 2023). That “regulatory deficiencies occur when the government fails to protect individuals from societal harm despite good intentions” (Griffin & Miller, 2011, p. 223) and that perpetrators of harm such as Purdue and other large corporate companies are able to steer themselves away from the stereotypical drug dealer image to routinely avoid state controls, widens the lens towards institutional and structural arrangements that casually allow big businesses free reign over vulnerable customers and the markets they reside in (Green & Ward, 2004).

And then third, individualising the problem (personal responsibility to not ‘misuse’ situated with consumers) to ignore the systemic roots of drug problems, maintain the drug policy status-quo and existing hierarchies of stigma, where substance-use identities intersect with other marginalised identities to frame vulnerable individuals and groups as blameworthy for any harms resulting from (licit and illicit) drug markets (Room, 2005; Lloyd, 2013; Hatzenbuehler, 2017; Addison et al., 2022). A historical fixation with the ongoing war on drugs together with a neoliberal discourse of personal responsibility overlap to pin down drug-related harms onto supposed individual problems and bad choices, oftentimes ascribed to those situated, in class and status, at the fringes of the rational society. In all these forms, drug stigma inevitably falls back onto and amplifies the power disparities and inequalities of the social world.