1 / NEW USES FOR OLD THINGS
AT THE TIME OF THIS WRITING, IT IS ESTIMATED THAT MORE THAN
500,000 people have been treated with buprenorphine for opiate dependence.1
In the United States, nearly 16,000 physicians have completed the required training that allows them to prescribe the medication to their patients. Since its approval in 2002, buprenorphine has quickly become the frontline agonist treatment for opiate withdrawal symptoms and replacement therapy for opiate dependency in America. In 2010, the approval of a new delivery system in the form of a Suboxone dissolving film has made buprenorphine an even more appealing treatment option for both patients and physicians alike.2
When I began my study, I was primarily interested in the clinical effectiveness of buprenorphine. Does the pharmacotherapy work
to mitigate the symptoms of withdrawal and dependency for adolescents addicted to opiates, whether it be heroin or opioid narcotic analgesics (prescription painkillers) or both?3
Specifically, I sought to understand what goes into defining a working
therapy on the side of young patients, especially after their time in closely monitored clinical environments came to an end. My concern has never been to identify why drug abuse persists, or why periods of abstinence from drug use are often punctuated by crises of other sorts. Instead, I want to grasp how value is derived from a therapeutic tool, in this case a pharmaceutical intervention. Slowly, it was the afterlife
of a therapy that drew my attention; how a “therapeutic career” is lived alongside and comes to characterize continued illicit drug use, relapse, and bouts of institutional presence and disappearance.
AT THE MARGINS OF KNOWABILITY
In nearly every study since 1992, the long-term outcomes of individuals treated with buprenorphine as a replacement therapy have been described
as unknown, representing a major research limitation. 4
In the conclusion of a Cochrane report on the use of buprenorphine to manage opioid dependency, the authors suggest that the limitation is not an artifact of existing research methodologies, but a challenge to the analytical possibilities inherent to addiction research.5
The nature of drug addiction does not lend itself to straightforward forms of knowing
(the combination of circumstance, motivations, neurobiology, and other unaccounted factors).6
Certainly within addiction medicine and the recovery community, the idea of “curing” addiction is far from the established nomenclature used to describe successful outcomes resulting from treatment. But at the same time, there is
some conceptualization of success at play when it comes to pharmacotherapy. Time is one aspect that narrows the idea of success (Does abstinence from drug use occur between given points in time?), and personal forecasting is yet another aspect (Is what was hoped for as a future—by researchers, physicians, patients, parents, and family members—realized?). The answers to both questions, however, are as elusive as they are illusionary. The limitations, in part technical and in part aspirational, are as much an epistemological problem as a clinical question: What are the limits of knowing
when it comes to assessing whether a treatment works? Where would these limits begin and end?
Some recent scholarship in medical anthropology addresses these otherwise long-standing debates regarding pharmaceutical intervention. Jõao Biehl's groundbreaking work on antiretroviral therapies in Brazil shows how poverty and marginalization are not simply contexts in which medical interventions are performed, but can give value to
and deprive value from
emergent therapies, as well as to the lives managed through medical intervention7
—a set of assertions that Vinh-Kim Nguyen extends by showing how policy decisions regarding AIDS therapies recast political and social relations in West Africa.8
Adriana Petryna's cautionary work on medical experimentation details the interdependency and variability of ethics and markets in the production of meaningful scientific knowledge derived from global clinical trials research.9
Andrew Lakoff's study of psychiatric practice and biotechnology in Argentina demonstrates how ideologies transform clinical reasoning, forms of knowledge, and even the objects of intervention themselves.10
More recently, Angela Garcia's bold and deeply intimate ethnography of heroin use and abuse in the American southwest examines
the unexpected ways that drug use and treatment become registers upon which expressions of relatedness (and “a sense of place”) are founded and through which dispossession is articulated.11
While my focus on pharmacotherapy with adolescents under treatment for drug dependency shares many of the concerns found in recent scholarship, I aim to demonstrate the ways the experience of therapy (however fractured) binds the individual to
the social and the clinical—and to show that the experience of therapy is not simply held apart from the therapeutic ideal defined by clinical medicine or research science, but instead blends clinical reasoning with the social worlds outside the clinic, reestablishing therapeutics from the inside outward.
A METHOD, OF SORTS
It is worth noting the methodological approach used in my study, and its limitations. I attempted to detail the lives of twelve adolescents during their time inside and outside a drug rehabilitation treatment center. The treatment center, an old converted monastery housing approximately sixty-five adolescents at any given time, was the primary site for recruiting adolescents into the study, through either physician or social worker referral. Strictly speaking, I did not use a cohort approach, namely, taking a single group of adolescents from a shared time zero, moving forward collectively over the three years. The clinical criteria for opiate dependency (heroin and/or prescription opioids), as well as treatment with buprenorphine (either in the clinical trial or simply active treatment), was far too specific in the particular clinic population to make it possible to recruit all twelve adolescents at once. Polysubstance abuse did not always mean opiate dependence, and if opiates were being abused, it did not always mean buprenorphine was used in treatment.12
Instead, I began with adolescents at different points in time over three years.
Once adolescents were discharged from treatment, I used the networks of relationships in which they were already enmeshed to continue following them. The network of friends, family members, custodians and guardians, social workers, parole officers, and so on, provided a kind of connective tissue between the treatment center and the worlds outside the clinic. But this did not resolve the episodic nature of my interactions. While the unpredictability of my engagement was a feature of individual predicaments and
collective circumstances, it deserves note. The residential treatment center seemed at first to provide a solid base from which to organize my research activities, but this base quickly became marred by the same insecurity as the world outside its walls. And the world outside the clinic was, to paraphrase Maurice Merleau-Ponty's formulation regarding bodily interiority, not elsewhere
, but rather the clinic was carried into other places—a kind of intra-corporality between body and place—even if these other places were, in a sense, nowhere.13
In reflecting on how (and why) this elsewhere
—could merit any attention at all, I am struck by Michael Taussig's recent writings on anthropological fieldwork. He writes,
They say science has two phases: the imaginative logic of discovery, followed by the harsh discipline of proof. Yet proof is elusive when it comes to human affairs; a social nexus is not a laboratory, laws of cause and effect are trivial when it comes to the soul, and the meaning of events and actions is to be found elsewhere, as in the mix of emotion and reasoning that took the anthropologist on her or his travels in the first place.14
This imprecise mix of emotion and reason drove my ethnographic pursuit of adolescents who would otherwise elude regard outside the clinic.
In order to gain access to adolescents under treatment, I became involved in a phase-III clinical trial for buprenorphine-naloxone (Suboxone) being conducted at the treatment center in Baltimore, a trial conducted through the National Institutes of Health / National Institute on Drug Abuse Clinical Trials Network. The trial compared two different treatment approaches to assess the efficacy of Suboxone in a large cohort of opiate-dependent adolescents. The residential treatment center in Baltimore was one of six sites nationally. When I began enrolling adolescents in my study at the Baltimore site, the clinical trial was well underway.
The clinical trial compared two treatment modalities. The researchers randomized adolescents into two treatment groups: a 14-day, direct-therapy group with no long-term psychosocial therapy, and a 12-week group with highly monitored treatment and psychosocial therapy.15
In the end, while the adolescents in the 12-week group showed better progress initially (fewer reported cravings and a decrease in other opiate use), the most striking
result of the study was that there was no difference between the treatment groups at the close of the 12-month follow-up period. There was also better retention in the group receiving more intensive and highly monitored treatment, but once that ended, the groups were indistinguishable no matter the earlier level of intervention. In addition, the researchers reported difficulty estimating the number of patients who achieved recovery, defined as a “voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.”16
The conclusions the researchers drew from the study were clear: retention in long-term treatment is a strong measure of the therapy's success or failure, but there is little known about what happens once adolescents leave monitored treatment environments.
During the weeks after the release of the study results, I talked at length with the researchers involved. I had grown to admire several of the clinicians involved in the study—clinicians who strongly supported and encouraged my efforts to follow adolescents beyond the walls of the treatment center and beyond the follow-up period of their study. In a meeting that took place in Baltimore a few weeks after the data were complied, several of the researchers shared their thoughts on the results with me:
[PHYSICIAN]: It's really hard to know what's working and not working. These data say the therapy works, but with a pretty big caveat: time.
[RESEARCH ASSISTANT]: But does it matter? I mean, while the kids were here they did great. When they leave, I mean, what are you going to do? I mean it's really the things we can't control, like mom and dad and friends, or society, right?
TODD: Are you saying these things you mention can't be factored into the reporting?
[PHYSICIAN]: No, that's not what she's saying. It's that it is virtually impossible to capture. You can say, “this kid went to group,” or “this kid kept his appointments,” or “this kid dropped out,” but the details that go into each of these…umm…mitigating factors are a different question entirely. It's not going to change how I treat kids when they come in addicted, or even leave addicted.
[NURSE PRACTITIONER]: I know what you're getting at, but the study design is just not able to incorporate your ideal situation of being a fly on the wall in the kids' lives, or tracking a thousand little variables that may or may not have anything to do with the pharmaceutical itself. We try to pay attention to that stuff when the kids come in for treatment, but as clinicians, not researchers.
TODD: I'm only saying that it seems like a lot of unaccounted things surely must influence whether or not a kid stays clean in the long haul, and it must be that sometime things break down…
[PHYSICIAN]: [Laughing] We're not picking on you, it's just that you need to know what a randomized controlled trial is all about. The drug works—but in the long term things begin to fall apart. That doesn't change standard of care. Of course you're right about trying to capture other factors, but that's a social science problem. Come on, it's your department.
The results of the trial do open up a large “social science” problem, namely, the problem of factors external to a pharmacotherapy that determine its success. There seems to be a serious difference between the clinical and research lens, but in the end, “it doesn't change the standard of care.” When the nurse practitioner who was associated with the study talked about paying attention to the things that surround the receipt of therapy, nondiscursive indications of the therapy's effectiveness (affect, comportment, mannerism) become discursive things that are discussed at length every day in the clinic. The fact that the details of a patient's lifeworld cannot find a register in the research is telling. But even more revealing is the way that these are somehow held apart from the research, making them “clinical” concerns in the most abstract sense.
Holding in suspension “the clinical” for the aims of “research” did not present a problem. It is clear that the results of the study, while frustrating, did not undermine the commitment to the pharmacotherapy or challenge the integrity of the clinical trial itself. The researchers staunchly defended the borders that delineate research and treatment. To quote one clinician,
“Research is research, treatment is treatment, and anything outside is outside—it's all about the kinds of questions you ask.” The results (and the reactions to the results) brought a key issue to light, namely, that the pharmacotherapy had a secure place within the logics of research and treatment, although long-term experiences by individuals with the therapy were much less secure.
In the end, I had several questions that could not be resolved by the idea that research, treatment, and the experience of therapy could remain neatly parsimonious. What happens to those adolescents who do not complete treatment? Or disappear once the time of research has expired? How should we regard them? And how do these results factor into the evolving narrative of buprenorphine?
NEW USES FOR OLD THINGS
On October 9, 2002, U.S. Senator Carl Levin issued a press release announcing the approval of buprenorphine for the treatment of opiate dependence.17
The document cited decades of research and a constellation of clinical trials demonstrating buprenorphine's efficacy as a pharmacotherapy for opiate withdrawal and replacement therapy, which had been entered into evidence during congressional hearings on the drug's approval.18
In the wake of this research, a new addiction treatment was made available—a treatment that renewed hope for thousands addicted to heroin and prescription opioids.19
The first of these clinical trials had begun over twenty-four years earlier.
In 1978, Donald Jasinski published a landmark paper from a small clinical trial using Buprenex, an analgesic licensed for the treatment of moderate to severe postoperative pain, in an attempt to treat opiate dependence in adults addicted to heroin.20
Jasinski and his colleagues conducted their work at the Bayview Hospital in Baltimore, one of the Johns Hopkins University medical centers. The participants in the study were by all accounts serious substance abusers. The inclusion criteria included having been addicted for at least four months and the use of heroin two or more times a day. The researchers had designed a randomized, double-masked, parallel group clinical trial in which, over a four-month period, sublingually administered buprenorphine was compared to two different dosages of orally administered methadone, followed by a period of gradual dose reduction and eventually placebo. The
two outcome measures of the study were retention in treatment and the presence of opioids in urine samples. At the time, the study was the largest randomized controlled trial demonstrating the...