‘Acute-on-chronic’: Emergency Affect and the One-way Staircase of Pharmaceutical Escalation

ABSTRACT

The opioid epidemic in the United States is often portrayed as leading to a “pendulum swing” from indiscriminate prescribing toward appropriate use. This portrayal imagines rational-ethical physicians trying to resist irrational-manipulative patients and pharmaceutical companies. Drawing on an ethnography of pain management in U.S. hospital and clinic settings, I suggest instead that chronic pain generates a constantly renewed “emergency affect,” a mutual experience for providers and patients that polarizes decisions toward either medication escalation or patient abandonment. Understanding this “emergency affect” can help provide a path forward through the opioid epidemic to embrace the discomfort of pain management.

KEYWORDS:

• United States
• affect
• opioids
• pain management
• social body

Acknowledgments

I would like to thank Mara Buchbinder, Diana Coffa, Helena Hansen, Ippy Kalofonos, Kelly Knight, Rachel Niehuus, and Na’amah Razon for comments on drafts of this article. I would also like to thank my anonymous reviewers, whose brilliant insights transformed this article. Finally, I owe a great debt to the characters who appear in this article (in pseudonym), both clinicians and people with painful bodies, who not only allowed me to learn from them during moments of practice, but also provided generous feedback on my analysis to ensure empirical accuracy and conceptual depth.

Notes

1. As a reference point, the initial daily dose for a patient who has just been through an abdominal surgery is usually about 20–40 mg.

2. When night residents take over from day teams, they receive a sheet of information about each patient that helps them take care of a large number of patients overnight without needing to investigate their history extensively in the medical record.

3. Many non-opioid options for pain treatment (topicals, nerve blocks) are not available for pancreatitis pain due to anatomic location. Mr. Robert, like Mr. Glass, had had many attempts to control his pain with long-acting pain modulators (tricyclics, GABA analogues), but like Mr. Glass, these had been ineffective at controlling his pain crises.

Additional information

Notes on contributors

Scott D. Stonington

Scott D. Stonington is Assistant Professor of Anthropology, International Studies, and Internal Medicine at the University of Michigan, Ann Arbor. He is author of The Spirit Ambulance: Choreographing the End of Life in Thailand (2020).