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Binge Eating Disorder first appeared as a stand-alone disorder in the Diagnostic Statistical Manual of Mental Disorders-5 published in 2013. Fewer than two years later, The Food and Drug Administration (FDA) approved the use of Vyvanse to treat this disorder. The Shire drug company developed Vyvanse to treat Attention Deficit Hyperactivity Disorder (ADHD) and received FDA approval in 2008. Shire has a reputation for both marketing diseases and the treatments for those disease. The strategy is rather simple: first market the condition widely and then market the cure for the condition. It is marketing genius. When an already patented drug can be repurposed, even better.
Shire specializes in what physician/philosopher Carl Elliott calls “disease branding.” In his book, White Coat Black Hat: Adventures on the Dark Side of Medicine, Elliott describes “disease branding” as shaping “[the condition’s] public perception in order to make it more palatable to potential patients.” Disease branding is highly effective when a formerly shameful condition is destigmatized. Elliott uses the example of urge incontinence being rebranded as “overactive bladder.” What had been regarded as a constitutional weakness of some people (elderly men and older women or women who have given birth) is now marketed as a matter of having a bladder that is in overdrive. The message is that a person’s kidneys are just working too hard.
The success of “disease branding” is a consequence of the marketing being aimed directly at the general public. The point is that people begin to reframe and understand their behaviors in terms of the marketed medical condition. Armed now with knowledge of and a name for their condition, patients head to their doctors’ office and request specific medications they’ve seen in the advertisements. What’s even more worrisome is how people begin to understand their need for the medication. As Elliott expresses the concern, “your need for the medication becomes part of your identity.” This is especially insidious. Not only is the disease or condition identity-conferring but the drugs needed to treat the disease become identity-conferring. There’s a sense that a person won’t be who she really is without the particular drug. This need to be “who I really am” or “who I am really meant to be” will drive sales of those medications, which is exactly what pharmaceutical companies want.
Juxtaposing the fast-track disease branding of Binge Eating Disorder with Substance Use Disorders (SUDs) and the medications available to treat them raises some interesting questions and perhaps some useful insights.
1. If disease branding works well with previously stigmatized conditions, then why hasn’t disease branding worked for SUDs?
Several considerations come to mind immediately. The first is stigmatization comes in degrees. Oddly and perversely enough, I imagine there is a “sweet spot” of stigmatization that makes a condition potentially marketable. Having to go the bathroom a lot/too often or having a child who is overactive, distracting, and easily distracted are conditions hits that sweet spot in a way that heroin and meth use cannot. Even within the SUD categories, there are degrees are stigmatization. Some are tempted to believe an alcohol use disorder is at least more understandable and forgivable than a heroin, meth, or cocaine disorder.
To put it another way, SUDs already have been branded, not by pharmaceutical companies but by moral, religious, and to some degree medical authorities for years, decades, and centuries. This is a clear difference between SUDs on the one hand and binge eating disorders and ADHD on the other hand. The latter two are contemporary creations or constructions that don’t carry the same moral, religious, and medical disapprobation.
Potential profitability drives a pharmaceutical company to brand both the disease and its treatment. Where there are already drugs to treat a (branded) condition and furthermore those drugs have generic versions as is the case with methadone and buprenorphine, profitability is greatly reduced. The incentive is gone.
2. Why may it be a bad thing that conditions/diseases and the need for the medications to treat them confer identity in the ways described above?
Having these conditions and needing certain medications creates categories of people. Michel Foucault’s notion of bio-power is helpful here. Bio-power is operated through systems and structures. Some particular groups of experts shape and direct that power. Bio-power is productive; it creates types of people. Foucault’s discussion of madness is paradigmatic and offers an early example of disease branding. It was the psychiatrist’s power to diagnosis and to create categories through the assignment of individuals to these categories. Psychiatry as an expert discourse gained legitimacy with its exercise of power and thus was born a powerfully vicious cycle. The demand for diagnoses of madness was accompanied by a growing supply of new experts to make those diagnoses. I submit that the pharmaceutical companies through disease branding are exerting an enormous amount of bio-power.
Bio-power aims at manipulating bodies in order to make them docile. Power is in our bodies and is targeted at our bodies, and so it is certainly in the synapses of our brains. The brain is becoming a medical object par excellence. Foucault argues that schools and prisons exercise disciplinary power in order to make docile and ruly populations. My concern is that medical science, neuroscience, big pharma, and insurance companies will try to do the same with people who regularly and harmfully eat too much, or lack focus and are easily distracted or who use substances in increasingly worsening ways.
Elliot, Carl. 2010. White Coat Black Hat: Adventures on the Dark Side of Medicine. Boston, MA: Beacon Press.
Foucault, Michel. 1980. Power/Knowledge: Selected Interviews & Other Writings 1972-1977. New York: Pantheon.