Opiate Users: Deserving and Undeserving?

In her second day as a Guest Blogger, Helen Keane of Australian National University examines how “niceness” and the lack thereof shape our understandings of heavy drug use.

In the previous post I discussed the distinction between dependence and addiction. Here I’d like to raise a few issues about the psychological/behavioural model of addiction developed in pain medicine. I’ve written about this topic with Kelly Hamill in this paper.[i]

In the context of pain treatment, opiates are not dangerous illicit substances but effective and safe analgesics appropriate for long-term use in selected patients.

The At-Risk & Predisposed Individual

Because the prescription of opiate drugs is central to its clinical practice, pain medicine has developed a definition of addiction which does not implicate drugs as the primary agents of addictive disorder.Instead it constructs addiction as a psychological disorder recognisable by the addict’s out of control behaviour, her drug-focused lifestyle and her destructive patterns of drug use. The prevention of addiction in the pain clinic therefore centres on the identification of certain “at risk” and predisposed individuals, including those with a past history of substance abuse. These risky patients require extra-vigilant monitoring and surveillance if they are to be prescribed opiate drugs. Clinicians must be alert to any aberrant or suspicious behaviour such as noncompliance, aggression, erratic appointments, doctor-shopping and stories of lost and stolen medication which may indicate the development of addiction. In contrast to the improvements in functioning seen in the compliant pain patient, the life of the addicted patient deteriorates. Therapeutic medical drug use has become harmful illicit drug use.

The concern is that this account of addiction easily becomes a reiteration of the common sense view of addicts as inherently devious, deceptive and prone to criminality.  By challenging the assumption that addiction is located in the properties of certain kinds of problem drugs, the behavioural model of addiction reinforces the belief that addicts are certain kinds of problem people.

The Deserving Pain Patient

Kirsten Bell and Amy Salmon have pointed out that the legal and regulatory sanctions surrounding opiates have created an environment in which pain clinics are “virtually required” to construct oppositional categories of “deserving pain patients” and “undeserving addicts.” [ii]  In order to protect the rights of pain patients to medical treatment, do addicts have to be demonised and marginalised (yet again) as the abnormal and aberrant– those dependent drug users who are outside the realm of medical compassion? I don’t think so. One of the noteworthy features of Siobhan Reynolds’ post was her depiction of the commonality and common interests of pain patients and addicted patients. Reynolds points out that both groups are denied proper treatment by the criminalisation of opiates and both suffer from the stigma of addiction which is “wholly man made.”

Up Next– Addiction and Pseudoaddiction


[i] ‘ Keane, H. & Hamill, K. Variations in addiction: The molecular and the molar in neuroscience and pain medicine’,  BioSocieties 2010, 5: 52-69.

[ii] Bell, K. & Salmon, A. (2009) Pain, physical dependence and pseudoaddiction: Redefining addiction for nice people? International Journal of Drug Policy, 20.

2 thoughts on “Opiate Users: Deserving and Undeserving?

  1. Helen, your post reminds me of a scene in Martin Scorcese’s The Departed, which sort of deconstructs this binary (though in re anxiety, not pain, meds). As a deeply undercover cop who may or may not be losing himself in his assignment, Leo DiCaprio’s character is performing the undeserving role, but as a cop dealing with job anxiety, is officially a deserving patient. Both roles make him an Old-Fashioned Tough Guy (™) who doesn’t believe in talk therapy, so he aggressively asks the therapist and soon-to-be love interest for valium. Trained to recognize “drug-seeking behavior” as a symptom of addiction, she groans and tells him, “You know if you lied, you would have an easier time getting what you wanted.” He responds, “Yeah what’s that say about what you do for a living?” I.e., the job of the deserving patient is to spin out an “innocent” narrative of symptoms, and allow the professional to introduce the topic of medication.

    Incidentally, the therapist is played by Vera Farmiga, who played the coke-troubled lead in Debra Granik’s 2004 Down the the Bone, which like her recent success with Winter’s Bone deals with class and gender in rural drug use. In the context of those films it’s a bummer, actually, to see Farmiga playing just an object in the male costars’ relationship.

  2. Thanks for this Eoin – it’s a fine line between ‘drug-seeking behaviour’ and ‘informed health consumer’. I’m sad to say that I have seen none of the three films you mention.
    Will add them to my DVD list.

    I have read a lot about winter’s bone, heard many reviews and interviews but its distribution in Australia was patchy. If it came to our local art house it must have screened for a couple of days and I missed it.

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