Medical theories of opiate addiction's aetiology and their relationship to addicts’ perceived social position in the United States: an historical analysis

Abstract

This paper uses qualitative methods to explore the relationship between US health professionals’ theories of opiate addiction's aetiology in the US during two time periods, 1880–1920 and 1955–1975 and contemporaneous perceptions of opiate addicts’ race/ethnicity, social class and gender. The author coded 297 medical articles on opiate addiction, published during the years of interest and randomly sampled from indices of medical articles, for descriptions of opiate-addicted individuals’ social position and theories used to explain addiction. Critical race theory and a social construction of knowledge framework guided the grounded theory analysis. This analysis indicates that during both periods health professionals typically attributed opiate addiction's causes to individual pathology when they believed that addicts were working class, poor and/or non-white women and men and to factors largely external to the individual when they believed that addicts were affluent, white women and men. This social patterning was consistent with contemporary efforts to reinforce inequitable social relations during these eras. Given the relevance of health research to public policy, this paper suggests that present-day health researchers critically reflect on the ways that their research is complicit in the creation of contemporary inequitable social relations.

Introduction

Drug-related laws and policies in the US have frequently contributed to the establishment and perpetuation of inequitable social relations. Historians and social scientists have repeatedly found that these laws and policies become more punitive when addicted populations become increasingly comprised of impoverished or non-native individuals or people of colour, a pattern that is particularly prominent during times of social conflict when drug-related laws and policies provide a means of justifying and enacting oppression (Acker, 2002, Brown, 1981, Courtwright, 2001, Hoffman, 1990, Jenkins, 1999, Jonnes, 1995, Musto, 1999, Petersen, 1977). Considerably less attention has been paid, however, to the ways in which the sociodemographics of addiction are related to its medical framing, despite the substantial role that health professionals have historically played in shaping drug-related laws and policies (Acker, 2002, Musto, 1999, Pauly, 1994), both as advocates and as producers of knowledge about addiction's nature, aetiology and prognosis. Courtwright (2001) has observed that shifts in the sociodemographic profile of the population of opiate addicts in the US have often been followed by changes in medical theories of addiction's aetiology, noting for example that when addicted individuals in the US were principally lower class whites, African-Americans or Chinese-Americans, health professionals tended to attribute their predicament to vice and personal pathology, attributions that were not made when affluent whites were addicted. Building on this research, this qualitative paper explores the relationships between US health professionals’ perceptions of the race/ethnicity, class and gender of US opiate addicts and their theories about opiate addiction's aetiology by analysing articles published in medical journals during two time periods, 1880–1920 and 1955–1975. Of particular interest are the ways in which these theories reflected, reinforced or challenged contemporary inequitable social relations.

This analysis was guided by the social construction of knowledge and critical race theory. The social construction of knowledge is a framework that maintains that all knowledge, including scientific knowledge, is socially produced and thus reflects the contexts, concerns, limitations and enlightenments of its producers (Haraway, 1991, Hubbard, 1990, Levins, 1996). This framework does not view science's roots in society as pernicious; these roots are, in fact, where it derives much of its richness and relevance. Instances in which science reproduces and justifies the inequalities of the society that produced it are, however, insidious (Haraway, 1991, Hubbard, 1990, Levins, 1996), as was glaringly evident in the case of eugenics. This framework also recognizes science's contributions, including its capacity to challenge inequitable social relations and deepen our understanding of our relationship with the world (Haraway, 1991, Hubbard, 1990, Levins, 1996). In this paper, the social construction of knowledge framework supports the analysis of the relationships between contemporary concerns about social relations and medical theories devised to explain addiction's origins in different social groups.

Critical race theory concerns the processes through which inequitable racial/ethnic relations are produced, maintained and contested (Calmore, 1995, Crenshaw et al., 1995; Delgado & Stefancic, 2001; Lipsitz, 1998). This theory posits that dominating groups establish and perpetuate these relations for material and social gain (Calmore, 1995; Delgado & Stefancic, 2001; Lipsitz, 1998, Wander et al., 1999). Relationality and intersectionality are two fundamental concepts of critical race theory. Relationality refers to the mutually constituted nature of racial/ethnic categories; that is, the definition of whiteness (or any race) depends upon the definitions of other races (Wander et al., 1999). For example, in the 18th and 19th centuries, the construction of whiteness as civilized and civilizing rested on the framing of Africans, Native Americans, Mexicans and other non-whites as barbaric (Wander et al., 1999). Critical race theory's explicit emphasis on relationality extends analyses beyond the traditional focus on the processes through which racial/ethnic minority groups are constructed to include inquiries into the creation of whiteness (Delgado & Stefancic, 2001; Duster, 2001). Intersectionality refers to the ways that racial/ethnic, gender, class and other inequitable social relations work in concert to shape social life; implicit in this concept is the idea that one form of inequality cannot be understood in isolation from others (Delgado & Stefancic, 2001). The present analysis draws on critical race theory, particularly intersectionality and relationality, to interpret the ways in which medical theories of addiction have been complicit in or challenged the processes of establishing contemporary inequitable social relations.

The two time periods studied, 1880–1920 and 1955–1975, were selected because both witnessed major changes in the prevalence and sociodemographics of opiate addiction as well as significant social conflict. Historians have concluded that the late 1890s were the pinnacle of a decades-long rise in opiate addiction, followed by a gradual decline in prevalence (Brown, 1981, Courtwright, 2001, Jonnes, 1995, Musto, 1999); simultaneously, the demographics of addiction slowly shifted during this period from primarily affluent whites to include impoverished and working class whites (Acker, 2002, Courtwright, 2001, Jonnes, 1995, Musto, 1999). Because of the gradual nature of these changes, this study period spans 40 years (1880–1920). The late 1960s saw a swift and sizeable increase in opiate addiction and also the rapid addition of affluent, suburban whites to the population of addicts that had previously been believed to be principally comprised of urban, impoverished African-Americans (Acker, 2002, Brown, 1981, Courtwright, 2001, Musto, 1999).

US society also underwent substantial change during these two periods. Between 1880 and 1920, US whites established new, contested forms of racial/ethnic subordination in the aftermath of slavery and expansion into territories that had once belonged to Mexicans and Native Americans (Zinn, 1995). During these years, millions of workers participated in tens of thousands of strikes to attain livable wages and working conditions in the wake of the industrial revolution and women of all classes and races agitated for recognition of their human rights, including their right to vote (Bederman, 1995, Von Drehle, 2003, Zinn, 1995). Similarly between 1955 and 1964, the US remained deeply fearful of communist threats both at home and abroad in McCarthyism's aftermath and African-Americans intensified the fight for equality, organizing for the right to vote and access educational and other public institutions (Garrow, 1986, Zinn, 1995). The years 1965–1975, however, witnessed a brief shift toward equality after persistent and escalating mass protests (Zinn, 1995). These substantial social changes, coupled with shifts in opiate addiction's prevalence and sociodemographics, suggested that medical articles on opiate addiction published during these two periods would provide a rich trove of data with which to explore the research topic.