Maia Dolphin-Krute
Science Journalism (this essay is part of an ongoing project, working title Opioids: Addiction, Narrative, Freedom)
Recently, I have been writing a book about the opioid epidemic. It is nonfiction, it is and is not a memoir, and I try to write as if a middle aged science journalist. In this book, I trace opioids, as a substance, internally and externally through bodies and networks of governmental, medical and industrial power. I outline the history of opioids, their role in colonization, the development of capitalism and the pharmaceutical industry, and the current opioid epidemic. This I describe as a series of events, a set of statistics, and a set of attitudes about drug addiction and pain currently being perpetuated in mainstream media. The thing, though, is that I’m not a middle aged science journalist. The position has its benefits, to be sure, mostly because I like the kind of writing that is an explanation and also that is not about me. But there are a few other things I would have and could have said if I wasn’t attempting a middle aged science journalist position.
Let’s say I’m sick. Let’s say I’m a 23-year-old woman who writes about being sick, in a way that is about biology but is not science journalism. Let’s say, given the kind of pain I have in being sick, the medications I’ve been given for it, and how much I know I could like these medications, that I can see my entire potential addiction memoir spelled out ahead of me like a prognosis, one that seems actually more plausible, definite and easily imagined than the one I currently have, which seems built mostly on a foundation of how ill-equipped medicine is to understand and care for outliers.
Let’s say I’m angry, and that this anger does and does not have to do with either being sick or the opioid epidemic. It comes and goes, or I wish it would. I try to let go. And about the opioid epidemic, my anger is mostly fear, sometimes disbelief, or how I wish some things actually were unbelievable. Fear because I do not want medicines taken away from me. Fear because the current situation exemplifies how little is understood about pain, especially chronic pain, and how to treat it and how will I live with this for the rest of my life? This is also what the disbelief is about.
There are a lot of questions here. This is something of a conflict for a middle aged science journalist, because although it’s because I’m trying to explain something in as many ways as possible, I feel like my job is actually to be answering questions. The difficulty, for me, lies in the fact that many of the things I could say as answers are their own explanations; tautologies that do and do not require a background in science journalism to expand on. See: whose pain matters? People with money to contribute to the $9 billion Americans are spending on opioid prescriptions every year so that Janssen Pharmaceuticals, and others, can put at least some of that money into “neuroscience” and developing new drugs that can then be called “neuroscience” that can then help to sell the drugs to the people with money and the right kind of pain, the pain that matters1. The pain that matters is the kind that is not a moral failure, a choice, a set of behaviors, a mental illness, a criminal activity, or a psychological or emotional state. Addiction is not the right kind of pain. The most correct kind of pain to have during the opioid epidemic is a (possibly unidentified) low back pain, arthritis or possibly fibromyalgia. The first two, and assorted injuries related therein, are the only kinds of pain mentioned in articles about the opioid epidemic and also frequently in the comments on the articles. Only once, on the page for the WBUR program “Here & Now” did I see a comment from a woman who had pancreatitis, a comment I could have made. A low-back injury is the best kind of pain to have right now because it is the most substantial: it seems like a thing, a real thing. It is not a part of a rare, unidentifiable, inadequately treated or otherwise messy illness. It’s not a disease at all, actually: it’s a healthy person’s pain, which is mostly what makes it perfect. It is substantial because it deals with bone, muscle, or posture, all of which are things visually identifiable even to a non-medical professional: this makes it seem real, and therefore manageable, not sick, still healthy. From a policy standpoint, having something like a low-back injury will be great in the coming years as opioid use is seriously restricted and the need for different forms of pain relief are recognized. Except that all that will be recognized, or at least what will be recognized first, is that which treats what seems substantial and is the right kind of pain. The pain relief that will become available will be physical therapy and related practices. This will be great for injuries and less great for disease in which ‘physical therapy’ unfortunately does not reach organs or nerves. But it was never meant to. Because people with diseases that cause pain are not pain patients. They are other kinds of patients. Who gets to be a pain patient? The people who are being treated only for pain because they have no other diseases, because actually pain patients are healthy people experiencing pain. Because they are healthy, they can and should expect their pain to be treated and end. Sick people should not expect this.
Which is not to say that an injury of this nature is not painful. But this is undeniably part of an answer to the question of whose pain matters: people whose pain is identifiable, whose pain will be profitable, whose pain fits well within the structure of Western scientific understandings of pain, whose pain makes sense to insurance companies and pharmaceutical companies.
I do work, all of the time, at imagining, and I do work to imagine myself less angry, but it is not the easiest work to do. Not when I, consistently, in almost everything I see about the opioid epidemic, hear only about pain patients whose pain fits into these narrowly defined, financially structured, concepts of the pain that matters. This is not my pain. It will not be my physical therapy.
Nor will it be for drug addicts. Because this is where the other half of the question comes into it, of how it’s not just what is and is not being called pain but also what is and is not being called desire. Wanting, in addiction, is not desire: it’s craving. Wanting, for a pain patient, even when the object of desire is identical, is not only desire but constituted as such because it is the right kind of wanting to begin with. It is wanting that moves towards the two best objects of desire: profit and “health.”
Do I get to be healthy on the days I’m pain-free? But notice even just the phrase itself: pain-free, implicitly always maintaining a relationship between pain and value. Valuable pain makes money and also knowledge and cultural products (as in medical care practices and heroic survivor narratives). Pain is also valuable when it is gone, by making more labor possible. Addicts, on the other hand, represent not only a kind of pain that has no value, but worse: a pain that actively devalues the systems it makes itself felt within. Addiction represents pain in the form of an inability to conceive of and actualize “enough:” it is endless, and the endlessness of it is its pain. But it stands in contrast to the endlessness of capitalism by producing nothing except for more of its own endlessness. Addiction is a spiral, not a true cycle. Addiction is constant negative production, in which anything accumulated is disconnected from anything that could be accumulated. Nothing is enough, because nothing lasts; nothing adds up. High is a kind of time. Because of this, because of being a presentation of not (being able to) value the values of capitalism and American culture generally (also inasmuch as it represents a failure of, among other prominent values, picking oneself up by the bootstraps) it is treated as a moral and emotional failure but not a disease. This is changing, as medical treatments for addiction become somewhat more available, but very, very, slowly. It will not happen fast enough for the 78 people who die of an opioid overdose today.
Many people choose not to live with pain. As a middle aged science journalist, I read The New York Times. As a sick 23-year-old woman who writes critical theory, I read the comments on The New York Times articles about the opioid epidemic. The number of people who comment, as pain patients, about their own fears is staggering; the number of pain patients who write comments about how they considered or would still kill themselves without effective pain relief is unbelievable. I don’t count these comments; I cannot give statistics. But they are everywhere.
And these people with pain who would rather kill themselves than live with it put the number of people who are dying of opioid overdoses into a slightly different perspective. Or not the number, exactly, but the accidental nature of an overdose death. All of these notions, of ‘accident,’ ‘overdose,’ ‘death,’ and ‘pain’ are deeply destabilized when they’re distributed around the substance of opioids, becoming, on the one hand, a more or less conscious choice, of death over pain, and, on the other, of death over pain; who, exactly, is distinguishing between the two? Whose death is an accident and whose a suicide? Of course both are equally painful for those around the deceased, but there is an admission, like an admission of guilt, in the latter and not the former.
And how do you navigate these destabilized notions while simultaneously trying to navigate more personal, biologically-inscribed, versions of them? I read the comments because potential addiction memoir or not, I want to know what it is like.
Or what it feels like. As a middle aged science journalist, I can only give you statistics. But as a sick 23-year-old woman, I can tell what statistics feel like; what the scale is. How small or large I feel or the size of my life, or my pain. The funny thing is, I would not have responded positively to a recent STAT-Harvard survey about knowing anyone involved in the opioid epidemic.2 I don’t think I know anyone. I have a friend of a friend who recently died of a heroin overdose. I have an acquaintance who is a heroin addict of some level of recovery. I have a friend who I suspect abuses the the medications she is prescribed but I don’t know this for sure and would not ask. I don’t really know anyone who is addicted to prescription medications although statistically speaking, I probably do. But I don’t know anyone who is a junkie. I don’t really know anyone who is a pain patient, either. Mostly I know people who have pain.
I don’t know any pain patients because what does that even mean? I wonder frequently whether it is doctors who say things or science journalists who say that doctors said things, and then repeat these things. Because the thing about pain and chronic pain in particular is that it is most often one of several aspects of an experience of chronic illness. I am not a pain patient; I am a patient treated for chronic pancreatitis. The friend who may or may not be abusing her medications is not a pain patient; she is treated for rheumatoid arthritis. You wouldn’t say that I’m a nutrition patient or a digestion patient, even though my medical needs include attention to issues therein. What is so different about pain?
I do work, all of the time, at imagining, and I do work to imagine myself less angry, but it is not the easiest work to do and what is so different about anger? This anger is a problem for a middle aged science journalist because of how anger makes explanations, like of science, seem shaky and unreliable, how by ‘middle aged’ I mean calm and experienced. Because there is no place for anger in medicine or in journalism, an exclusion maintained by the very existence of the scientific method and journalistic ethics. I have a conflict of interest, beyond paying $6.33 to Janssen Pharmaceuticals for pain medications. I’m interested in the opioid epidemic, and in addiction and neuroscience. I could have written a book entirely and only about that, which would have been fine except that I also couldn’t write that book because I’m self-interested. I cannot read about the opioid epidemic impersonally, as if it is only reporting. I cannot read science impersonally. And so I cannot talk about what is and is not being called pain and what is and is not being called desire without saying also: what is and is not being called (the right kind of) anger and whose anger matters and how addiction is another term for desperation, which is another term for pain, desire, and anger, how they create each other. How I’m angry because I want things, many of which I want because I’m in pain, how wanting only a few things makes me want more, like how working more makes me want more things which I have to work more to get, like a recovering addict in a recent Frontline documentary who equates living dime bag to dime bag with living paycheck to paycheck. Which is also a way of saying that it’s one thing to talk about economic disparity, globalization or the loss of manufacturing jobs when talking about the rising rates of drug abuse and death rates (for white people) generally, and another thing to talk explicitly about the anger, desire, pain and desperation of having no money, having no job, having access only to something literally called a painkiller. Whose accident, exactly, is an overdose?
If I were more of a scientist and less of a journalist, I could have more deeply detailed a neuroscientific understanding of addiction. Specifically because the science, the biochemistry, involved, is so interesting and what a different kind of description it can be to say “dopamine” instead of “systemic oppression.”
When opioids enter a body, they find themselves becoming attached to mu-opioid receptors, one of three kinds of opioid receptors in the body; morphine and its derivatives attach to mu-receptors (with different receptors producing a different set of effects, thereby creating the analgesic and euphoric properties of morphine as opposed to the analgesic but non-euphoric properties of methadone). It is as this connection, and the euphoria it produces, is made repeatedly and as it involves additional brain circuitry, that addiction can begin to form. The mesolimbic dopamine circuitry triggers drug seeking or “wanting,” while a separate system involving endorphins produces feelings of “liking.” As “wanting” and “liking” occur repeatedly, a second set of processes is triggered and becomes continually reinforced: as informed by the work of neuroscientist George Koob, these effects can be considered as a-processes and b-processes. A-processes are faster, act directly on dopamine receptors, and produce feelings of pleasure and reward. B-processes are slower, continue after a-processes have ended, and represent an attempt at bringing the body back to a homeostatic baseline. However, because a return to homeostasis always involves something of an overshoot, b-processes are actually a return to below baseline levels; this is the anxiety and depression seen after a high or in withdrawal. B-processes intensify the urge to initiate a-processes, yet because they are triggered by a-processes, this only ever intensifies the effects of b-processes. This is a way of describing the “spiraling distress” of addiction. This is a neuroscientific description of addiction’s unique endlessness: it’s endless because it becomes inscribed, via an augmentation of brain chemistry and circuitry, in the body and then, structured so deeply by homeostasis, the body continues. Habits are a function of a physical form, which is obvious outside of addiction as well. Because why do you eat at the times of day that you do? Why do you sleep an average amount every night? Why can you even say that you do anything an average amount? Because the body, in order to maintain homeostasis, has needs: needs that can be broken down by time and quantity. Food in the morning, water all day, sleep at night. And, of course, inasmuch as homeostasis applies to a huge range of biological activities, the materials and quantities needed and what they influence also include everything from temperature, light and hormones to blood sugar, blood pressure and weight. Every body has needs and many of these needs are chemical. Some of these are the right kinds of chemicals to need, and some of them are not. Some of these people who need some kinds of chemicals become the right kinds of people and some do not. But, ultimately, are you even aware of exactly all of the materials you need, everyday, and the way they are or are not supporting the homeostatic functions of your body? Do you know what you are dependent on? Which is not even to begin to include the substances a body doesn’t need but does absorb and which do or do not support homeostatic functioning. As a science journalist, I would return to that issue and also more specifically detail a relationship between homeostasis, time and materials. For now, I’ll say: “It is a biological error to confuse what a person puts in their mouth with what it becomes after it is swallowed.”3 I’ll also say: how many choices do you actually think you make in a day? Every body has material needs and every body is dependent. But some bodies make more choices available than others.
And, as a sick 23-year-old woman who writes critical theory, I would be aware of the way that the body I’m describing and the way I’m describing it indicate serious biological determinism. To which I would say: look at the way that the mesolimbic dopamine circuitry, neuroscientist George Koob and a-processes and b-processes of neuro-chemical homeostasis say, essentially, that addiction entails spiraling desperation. Biology is another way to describe.
Furthermore, saying that some bodies make more choices available than others is also a way of saying that pain, desire and anger constitute each other and some bodies have more of one than the others.
Which is also all mostly to say, that outside of statistics-as-numbers, these statistics, the “opioid epidemic,” feels like a story, a story about facts, and because it’s facts it feels like it must be true. But because it’s a story, being told about people I may or may not know, and including myself because I became a statistic the minute my doctor signed my prescription, it feels inaccurate. It feels like something heavy lying over something weightless; something that takes a different kind of sense to feel. But some something which is exactly that, a thing: because that’s the thing, the disbelief, in that I do just have this thing, in my body, and the thing is pain. And pain is a substance like any other and I cannot, quite, believe otherwise.
Notes
1. For statistics on American spending on prescription drugs see: Alcabes, P. “Medication Nation.” The American Scholar, 7 December 2015, Web. The reference made to Janssen Pharmaceuticals concerns their classification of Tramadol, a painkiller, within their class of products referred to as “neuroscience.”
2. Scott, D. “1 in 3 Americans blame doctors for the opioid epidemic, STAT-Harvard poll finds.” STAT, 17 March 2016, Web.
3. Leslie, I. “The sugar conspiracy.” The Guardian, 7 April 2016, Web.