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Published in final edited form as: Soc Sci Med. 2015 Oct 19;146:147–154. doi: 10.1016/j.socscimed.2015.10.033

“Just Advil”: Harm reduction and identity construction in the consumption of Over-The-Counter medication for chronic pain Social Science & Medicine

Emery R Eaves 1,✉
PMCID: PMC4643358  NIHMSID: NIHMS734207  PMID: 26517291

Abstract

Direct-to-consumer marketing has sparked ongoing debate concerning whether ads empower consumers to be agents of their own care or shift greater control to the pharmaceutical industry. Ads for over-the-counter (OTC) medications in particular portend to offer simple, harmless solutions for meeting the demands of social life. Rather than join the longstanding debate between consumer agency and social control in pharmaceutical advertising, I approach self-medication with over-the-counter (OTC) analgesics using Harm Reduction as a framework. From this perspective, consumption of OTC analgesics by chronic pain sufferers is a means of seeking some level of relief while also avoiding the stigma associated with prescription pain medication. Qualitative methods are used to analyze data from two sources: (1) semi-structured qualitative interviews with 95 participants in a trial examining the effectiveness of Traditional Chinese Medicine for Temporomandibular Disorders (TMD) from 2006 to 2011 in Tucson, AZ and Portland, OR; and (2) print, online, and television advertisements for three major brands of OTC pain medication. Participants described their use of OTC medications as minimal, responsible, and justified by the severity of their pain. OTC medication advertising, while ostensibly ambiguous and targeting all forms of pain, effectively lends support to the consumption of these medication as part of the self-projects of chronic pain sufferers, allowing them to reconcile conflicting demands for pain relief while being stoic and maintaining a positive moral identity. Describing OTC medication as “just over-the-counter” or “not real pain medication,” sufferers engage in ideological harm reduction, distinguishing themselves from “those people who like taking pain medication” while still seeking relief. Justifying one’s use of OTC medication as minimal and “normal,” regardless of intake, avoids association with the addictive potential of prescription pain medications and aligns the identity of the chronic pain sufferer with a culturally sanctioned identity as stoic bearer of pain.

Keywords: USA, Chronic pain, Pharmaceutical Advertising, Over-the-Counter Medication, Harm Reduction, Stigma

INTRODUCTION

“Americans are constantly asking themselves if they are doing the right things in order to be the good people they want to be, and they answer those questions with reference to how they ‘choose’ to manage their drugs”

(Dumit and Greenslit 2006:130).

Decisions about which drugs to use and in which combinations, as well as positioning oneself “for” or “against” drugs in general are bound up with considerations of risk, moral identity, and control (Dumit and Greenslit 2006). Direct-to-consumer (DTC) marketing has sparked ongoing debate concerning whether ads empower consumers to be agents of their own care or shift control to the pharmaceutical industry (Applbaum 2009). Rather than join the longstanding debate between consumer agency and social control in pharmaceutical advertising, I consider how individuals with chronic pain describe their use of over-the-counter (OTC) pain medication as a harm reduction strategy for avoiding not only physical but also social and moral harms. I use ideological harm to encompass both forms of non-physical harm. Further, through analysis of over-the-counter (OTC) pain medication advertising I situate these harm reduction strategies into the context of marketing messages that support consumers’ desires to live up to cultural ideals through judicious use of OTC medication.

Consumption of goods, including medications, is a visual and tangible means of communicating social values, performing notions of self, and establishing social relationships (Douglas and Isherwood 1979; Bourdieu 1984; Miller 1995). Pharmaceutical consumption is part of constructing individual and social identity (Nichter and Thompson 2006; Baudrillard 1998; Rose 1998). Medications carry meanings not only about those who choose to use them, but also about those who choose not to (Cohen et al. 2001). Pills impact relationships with others and conceptions of oneself as an agent and as a moral individual (Vuckovic and Nichter 1997; Helman 1981; Barsky 1983).

Pharmaceutical advertising is implicated in promoting a “global monoculture of happiness” (Kirmayer 2002: 316) by offering pharmaceutical solutions to the cultural demands of being a pain-free and productive citizen (c.f. Ecks 2005). Advertisers tailor messages to support the self-projects of their target audiences (Greenslit 2005). Prescription drug advertisements encourage consumers to self-diagnose and advocate for their own care (Ebeling 2011; Applbaum 2009). OTC medications, however, are marketed directly to consumers who may buy them as they please. Ease of access signals relative harmlessness to consumers and easily justifies regular consumption (Nichter & Thompson 2006).

Illnesses such as depression (Lakoff 2004; Applbaum 2006), Erectile Dysfunction (Lexchin 2006; Moynihan et al. 2002), and Pre-Menstrual Dysphoric Disorder (Smirnova 2012) are defined, promoted, and effectively “sold” by pharmaceutical companies (Martin 2006a; Healy 2006; Kirmayer 2002; Fisher et al. 2014; Abraham 2010). Chronic pain, alternatively, is unique in that its experience as well as available treatments remains incompletely or ambiguously medicalized (Crowley-Matoka and True 2012). Despite availability of opiates and analgesics, their medical necessity and legitimacy (and the legitimacy of those requesting them) is questioned by many physicians (Crowley-Matoka and True 2012). Unlike medications that legitimate illness (Helman 1981; Barksy 1983), pain medication confers suspicion, particularly when mapped onto existing racial, ethnic, and gender stereotypes (Rouse 2009). Some studies, for example, find that African Americans, Latinos, and women (Calderone 1990; Bartley and Fillingim 2013; Pletcher et al. 2008) are less likely to be prescribed opioids in emergency department visits for all types of pain. The backdrop of a thriving street market for these drugs, recent outbreaks of HIV and Hepatitis in the U.S. attributed to injection pain medications (Ungar, 2015), and the broader context of the U.S. “War on Drugs” positions these medications between medication and illicit drug, even when used with a prescription (Quintero and Nichter 2011).

Biomedical literature describes the emergence of a so-called “opioid epidemic” since regulations were relaxed in the 1990s (Manchikanti et al. 2012:ES9). Research thus targets patients considered at-risk for developing behaviors such as drug abuse (Turk et al. 2008; Manchikanti et al. 2012, 2014; Sullivan et al. 2010; Nuckols et al. 2014). Physicians are concerned not only about addiction, but also about inadvertently contributing to the street drug market and facing legal retribution for over-prescribing (Islam and McRae 2014). Thus, the use of opioids for any purpose is questioned as a legitimate or even moral act (Crowley-Matoka and True 2012).

Patients who refuse pain medication, even for acute episodes, are often congratulated for fulfilling cultural ideals of stoicism and toughness (Crowley-Matoka and True 2012; Hay 2010). Consumers perceive pharmaceutical medications as potentially harmful, yet desires for simple solutions and “fast relief” justify continued use (Vuckovic and Nichter 1997:1289; Martin 2006b). Despite awareness that a prescription for opioid pain medication places them into the stigmatized category of potential drug abuser (Eaves et al. 2015a), the daily experience of pain makes avoidance of pain medications altogether an unlikely solution (Rouse 2009). OTC medications are appealing, therefore, for reconciling desires to live up to ideals of stoicism and self-sacrifice, while also obtaining relief from ongoing pain. Further, OTC medications are portrayed as less harmful, not addictive, safe alternatives to prescription medications. Despite the appearance of relative harmlessness, however, serious risks such as hearing loss (Curhan et al. 2010) or liver injury (Larson et al. 2005) are associated with their long-term use. In 2007, for example, the CDC estimated that acetaminophen was the leading cause of over 1600 cases of acute liver failure in the US (Larson et al. 2005).

In Public Health context, Harm Reduction has traditionally described an approach to practices such as injection drug use that targets harms caused through drug use, such as infectious disease transmission, rather than the drug use itself (Des Jarlais et al. 1993; Campbell and Shaw 2008; Marlatt 1996). Harm reduction programs such as needle exchanges have met considerable resistance in U.S. healthcare but harm reduction strategies have become part of the discursive—if not practical—repertoire of users (Campbell and Shaw 2008). Anthropologists, such as Nichter (2003), have extended the framework of harm reduction to include actions taken by individuals themselves to minimize the harm associated with risky behaviors. Harm reduction, in this view, involves expressing agency and manipulating one’s surroundings to achieve an enhanced sense of control. Here, using harm reduction as a framework, I consider how chronic pain sufferers creatively engage in harm reduction to mitigate not only physical, but also ideological harm. I consider self-medication in context of conflicting desires to obtain relief while avoiding being, in participants’ words, “one of those people with chronic pain”; a label that threatens to be more painful than the pain itself (Link and Phelan 2013; Goffman 1959).

To contextualize the strategies described by chronic pain sufferers, I explore the advertising of three popular brands of OTC pain medication. This is not an argument for consumer agency, as considerable research has shown the insidious gendered and racialized power involved in consumers’ adaptations of pharmaceutical advertisements in their definitions of self (Applebaum 2009; Rose 1998; Ebeling 2011). Rather, this is an exploration of how those living with a contested condition gain support from marketing messages in self-medicating to live up to cultural ideals.

RESEARCH STUDY PARTICIPANTS AND METHODS

Temporomandibular Disorder(s) (TMD), colloquially called “TMJ,” is the third most common chronic pain disorder in the United States, impacting 10 to 25% of the general population at some point in their lives, with higher rates reported for women than men (Dworkin 2011). Primary symptoms, including chronic pain affecting the face and temporomandibular joint (TMJ), negatively affect everyday activities, social relationships, and the emotional states of sufferers through interference with talking, smiling, eating, kissing, and other facial and jaw movements. Chronicity is characterized by variation in pain intensity, including less severe and more severe pain (“flares”). TMD is frequently associated with depression and sleep difficulty and is often co-morbid with other chronic pain conditions (Dworkin 2011). In US health care, TMD falls within dentistry rather than medicine, which limits insurance coverage.

I conducted semi-structured qualitative interviews between 2006 and 2011 with participants in a dual-site (Tucson AZ, Portland OR) randomized phase 2 trial that offered Traditional Chinese Medicine (TCM) to individuals with chronic TMD pain. Participants were between the ages of 18 and 70 years old (mean 43.25), 75% female, and 77% Caucasian. Most held steady jobs and lived with families or significant others. For a more detailed description of the overall study, TCM outcomes, and sample characteristics, see Ritenbaugh, et al. (2012). Participants were recruited through community outreach and newspaper advertisements that described a study evaluating TCM for jaw and facial pain. Entrance criteria required that participants report average pain levels of 5 or higher on a commonly used 0 to 10 Likert pain scale. Approximately every second participant who entered the trial was asked to participate in a qualitative interview component consisting of a series of up to five interviews planned to occur: 1) prior to beginning any study activities; 2) prior to beginning TCM treatment; 3) after two to three months of experience in treatment; 4) at the end of treatment; and 5) two to three months after treatment was completed. Because of the small number of men in the study we asked all men who entered to participate in qualitative interviews. Ninety-five people participated in baseline interviews. Of those, 44 participants completed at least three of the follow-up interviews in addition to the initial baseline interview (271 total interviews). All procedures were approved by the University of Arizona and Oregon College of Oriental Medicine institutional review boards and all participants provided informed consent. All names are pseudonyms to protect participant confidentiality.

Qualitative interviews were designed to elicit a broad range of experience related to living with pain. Whereas most anthropological research in TMD has been in the context of a chronic pain clinic (e.g. Good et al. 1992; Jackson 2005; Garro 1994), the TCM for TMD study offered an unusual context in which to broaden our understanding of the everyday experience of chronic pain. Questions therefore explored explanatory model (EM), illness history, treatment history, beliefs about illness and healing, family and social support, experience of stereotypes, expectations and hopes for treatment, and pain tolerance. Questions specific to medication use queried about how participants used medications, whether during or in anticipation of pain flares, as well as other aspects of how and why participants chose to use or not use particular medications. This article presents the results of secondary analysis of participants’ descriptions of their medication use independent of study activities. Participants’ reports of specific drug use and dosage were part of quantitative data collection and not considered here. For more information about specific medication use in the overall study, see Elder et al. (2012).

I conducted all interviews in Tucson and many follow-up interviews with participants in Portland (via telephone). Two interviewers conducted in-person interviews in Portland. Interviews were transcribed verbatim and coded using ATLASti qualitative data analysis software (Muhr 2011). In an initial round of coding I used a single broad code for all statements regarding medication use. After initial in-depth coding of all transcripts, I re-coded medication related quotations in greater detail. Notably, OTC medication use was not a specific focus of the interview guide or of the coding process. Participants’ emphasis on it emerged from this second level of analysis, particularly in descriptions of self in relation to medication use.

OTC MEDICATION ADVERTISING METHODS AND ANALYSIS

In addition to interviews, I collected advertisements used by three OTC pain medication brands from 2012–2014. Advil, Tylenol, and Aleve are marketed for general pain relief and were most commonly mentioned by brand name by participants. I searched online advertisements (ads); printed fliers; magazines; television commercials; and company web pages (Advil.com, Tylenol.com, and Aleve.com). Marketing search engines such as Moat.com, Google Images, and YouTube provided a wide range of advertising taglines. Advertising taglines and imagery were hand-coded to identify key themes and common marketing strategies as well as to ascertain what messages study participants might be receiving about the safety and acceptability of using OTC pain medication.

RESULTS

Results are presented in two sections. First, analysis of semi-structured qualitative interviews with individuals participating in a TCM trial for chronic TMD pain. Their views on pain medication in general, and OTC medication in particular, raise questions about the ideological context as well as the safety of consistent use of medications they describe as “harmless” and “not real medication.” Second, the emergence of OTC medications as a key aspect of participants’ performance of self is placed into broader context through analysis of advertising messages used to target consumers living with pain. Recognizing that descriptions of behavior are distinct from actual behavior, participants’ descriptions of medication use are explored not to determine actual intake, but to consider the role of these medications in the construction of an idealized self-concept (Ecks 2005).

Chronic pain sufferers’ descriptions of over-the-counter medication use

At study baseline, 1/3 of participants in the study ever used opioids but only 10% were using them regularly. While many used over-the-counter analgesics, most chose not to use prescription medications at all or to use them sparingly, regardless of pain severity, and in spite of having been prescribed them. In the overall study population, 89% of participants reported using ibuprofen (Advil), 53% acetaminophen (Tylenol), 35% naproxen (Aleve) and 20% aspirin (Elder et al. 2012).

Participants cited several reasons to avoid prescription pain medication, including: (a) maintaining awareness of pain to monitor symptoms and avoid further damage; (b) saving medication for when really needed; (c) perception of medication as less effective if taken often; (d) concern that pain medications impair ability to function normally; and (e) concern about addiction, one more problem to add to their list. Knowing pain would return as soon as medication wore off led participants to regard prescription pain medication as a poor coping strategy. The opportunity cost of temporary relief provided by prescription medications was simply too high. Participants chose instead to use OTC pain medications, still with reluctance, to mitigate opportunity costs while still gaining some level of relief.

When asked directly whether they were taking pain medication, the majority of participants said “no.” When probed, however, it was clear OTC medication had not been considered. Although participants expressed reluctance to take OTC pain medication regularly, they point to the incomplete medicalization of chronic pain in differentiating between OTC analgesics and “pain medication”. Henceforth, I use “pain medication” in the sense of participants, to refer to prescription pain medication.

“I’m not one of those people who likes taking pain medication”: constructing legitimate cultural identities

Participants described taking medication as something “other” people in pain chose. The “other”—the pain medication user—lacked the high pain tolerance and ability to “just handle it” that enable one to live up to cultural ideals of toughness and stoicism (Hay 2010; Eaves et al. 2015a). The phrases “not one of those people” and “not that kind of person” were common. For example, Dennis, a father of three who worked long hours in a traditionally male-dominated service profession, described his reluctance to take pain medication despite severe TMD pain in such terms.

I’m concerned about an entire culture being addicted to, you know, Pfizer. So I have political reasons that I’m concerned with medicine but, on a personal level I’m, I’m not the kind of person that’s going to, I know this is the classic answer, but I’m not the kind of person to be addicted to pain medicine.

(Dennis, 32)

Being “one of those people” who is addicted to pain medications carries multiple levels of stigma. Participants are well aware of the stigma and negative feelings directed toward people with chronic pain. They do not, however, categorize themselves as part of this group (Eaves et al. 2015a).

The construction of a stigmatized other through which to define oneself as a “normal” and “stoic” person living in spite of pain was a central theme in these participant narratives about pain medication. Key to this construction was the stance that OTC medication was not “real” pain medication and therefore not harmful. Deanne explained at first that she would not take medicine unless she was in a “life or death situation.” When questioned, she explained that she did not consider OTC medication to be pain medication.

Deanne: I don’t take medication. I never take any medicine unless, you know, I really, it’s like a kind of life or death kind of thing … I take a lot of herbs… I never take pain medication.

ERE: Never? Okay. Even with the, stuff like Excedrin?

Deanne: Codeine with Aspirin … yeah, but that’s not pain medication. I think it’s an aspirin, I don’t think of Excedrin for tension headache as being pain medication.

(Deanne, 56)

Pain medications, due to blurred boundaries between licit and illicit use (Quintero and Nichter 2011), were described in terms of harm not only to the body, but also to the identity of the individual. Sarah, for example, worked in a profession that demanded hard physical labor. Despite frustration at being limited by severe pain, she chose to avoid taking pain medications.

At this point, if I’m in pain, I’ll take like an Aspirin or two. But… if I start doing that I’m going to do it every day and I don’t want to do that. I’m not the kind of person who wants to take pain pills every freakin day … I’ve seen people that just get all stuck on painkillers and that’s just a horrible route. I just try to deal with it as best I can.

(Sarah, 42)

Dose decisions in the context of everyday pain

Chronic pain sufferers, particularly women, often report reluctance to talk about their pain for fear of being perceived as whiners or complainers (Werner, Isaksen, and Malterud 2004) or violating strong prohibitions in U.S. culture against dampening the mood in social situations (Hilbert 1984). Participants in this study similarly avoided talk about pain, not wanting to “burden” others or allow pain to interfere with social and family life (Eaves et al. 2015a; 2015b). Many chose not to talk about pain with significant others or even with their primary care physicians. Instead they managed their own medication intake in the form of OTC medications and tried to avoid being labeled a “chronic pain patient” just to be grudgingly offered prescription medications they didn’t want anyway.

I’m not sure what the recommended dose is anymore. I think it’s probably two or something, and just today I took four. I’ll take four of them at once. I’ll take what I can take without them making me feel funny or something. I may make it through the day with just those four. And then if it’s a normal day it’s going to be four in the afternoon.

(Lloyd, 54)

Dose decisions are often adapted from, or justified by, prior prescription recommendations as well as from practical experience (Dew et al. 2014). Sufferers’ knowledge about prescription doses of Ibuprofen and Acetaminophen was used to justify exceeding recommended OTC doses. Another common strategy voiced by participants, as Carol describes, was to alter intake in various ways to avoid the appearance of taking too much medication.

[On a bad day] I’ll take Advil Migraine, and I’ll. I’ll take, I take one at a time, hoping that’ll catch it but, usually I would take, you know, three by the end. [Later I will take more] If I haven’t taken what I think is too much. Cause the migraine Advil say two a day and I know that you can take a little more than that, but I try not to, ‘cause then I’m in a cycle that I have to take a pill every three hours or something, and I don’t want to do that.

(Carol, 61)

Despite fears about getting into a cycle or habit, present pain often overshadowed future concerns and participants reported taking OTC pain medications regularly. Byron Good (1994) asserts that everyday life goals are subverted by the presence of constant pain. The difficulty in mitigating future harm stemmed not from lack of knowledge about potential harms, but from the difficulty of dissociating oneself from the everyday experience of pain (Good 1994; Scarry 1985; Garro 1992; Jackson 1992, 1995). This difficulty led participants to report feeling at odds with themselves.

My predisposition is not to take medicine. So, I’m always at odds with myself in terms of, you know, just wanting it to go away and not wanting to take medicine.

(Fran, 46)

Unlike patients in recovery from surgery or other acute pain, chronic pain sufferers are faced with the decision of whether or not to take pain medication on a daily basis. In the context of chronic pain, every day presents the sufferer with the same decision: the pain or the potential harms of the medication?

A lot of times I just have to think about by what I want to do for that day (chuckles). How much I want to put up with, I mean the Aleve, the side effects of the Aleve or just the pain of the TMJ.

(Gloria, 49)

Although side effects were often mentioned, participants rarely explained what the side effects were. Because different brands of OTC medications contain different pharmaceutical components and we did not query specifically about brand usage, it is unclear how much participants were paying attention to brand or particular side effects. Often, side effects seemed to be used as a gloss for all potential harm, whether to the body or to the identity, of taking a medication regularly over an indefinite period of time.

Harm reduction in the presence of conflicting harms

While for many harmful behaviors there is a clear need to engage in harm reduction, pain sufferers are faced with a dilemma. Although the potential harm of taking OTC medications too often over long periods was referred to by most participants, the harm is unclear and ambiguous. At the same time, pain is experienced as a signal of continuous harm inflicted on the body (Jackson 2011). Although the harmfulness of OTC medications may be known, the pain itself often takes precedence over other issues. Often, participants like Brian, below, wanted to maintain awareness and monitor pain. Increased pain, he explained, signaled harm to be avoided and in this sense, not taking prescription pain medications was a form of harm reduction not because of the harmfulness of the medications themselves, but because of the potential harm of the disorder that pain medication precluded monitoring.

I don’t like to take pain killers unless I have to… basically it’s just numbing it and ignoring it as opposed to like oh there’s something wrong, I should do something about this.

(Brian, 28)

Despite awareness of harm, participants’ descriptions focused less on strategies for reducing harm than on justifying the medication use they engaged in. Participants described their medication use, regardless of actual intake, as “the minimum” necessary as they weighed their options on a daily basis. Many informants attempted to take the minimum amount of medication to ratchet pain down to a barely tolerable level. Josie, in tears when she described the severity of her pain and its impact on her life overall, exemplifies this pragmatic approach in her description of taking medication.

I’m okay with, taking the edge off, is what it feels like, and, I don’t like taking a lot of pills.

(Josie, 29)

Potential harms associated with OTC pain medications often seem ambiguous and open to interpretation. Although most sufferers referred to awareness of risks associated with use of these medications including liver damage or stomach problems, the risks were tied to words like “overuse” or “misuse” of the medications. Participants, as described above, were careful to justify their use, regardless of dosage or frequency, as not overuse or misuse. Due to ambiguity surrounding chronic pain itself, defining “overuse” or “misuse” is slippery and potential harm easily explained away.

Over-the-counter pain medication advertising messages

To contextualize participants’ daily decision-making, I considered OTC advertising messages targeting these consumers. I collected 63 different advertising taglines used in marketing OTC pain medication online, in magazines, and on television (29 Advil, 24 Tylenol, and 10 Aleve). Print ads with no taglines were also considered. These ads contained images of severe pain such as a mountain biker landing on his face, a boxer taking a punch, or a person with a wrecking ball impacting his forehead. While some ads portray injury and thus clearly target acute pain, most are ambiguous. Images often evoke the underlying cultural morality of stoic suffering that chronic pain sufferers worked to live up to at the same time the ads purport to offer the relief they desire. Major recurrent themes in taglines and images that I discuss in turn below include: taking action and responsibility for oneself; overcoming limitations; fulfilling social roles and obligations; being strong, tough, and stoic; professional legitimacy without professional oversight; the promise of technological innovation; and finding one’s true self or getting back to “normal” through medication.

Advertisements focus on taking action and taking responsibility for oneself through taglines such as, “Take Action. Take Advil” (Advil). Taking action and gaining control over one’s illness are part of self-governing and being a good citizen (Ecks 2005). Tylenol is sold with the tagline, “get relief responsibly.” In these ads, Tylenol draws attention to risks associated with combining drugs containing Tylenol’s active ingredient, acetaminophen. At the same time, this tagline could be interpreted as implying that consumers should use Tylenol rather than more dangerous painkillers such as opiates. Consumers like those with chronic pain are advised to take responsibility for their own safety and well-being while also seeking relief. Aleve claims that with their product, fewer pills are needed to obtain lasting pain relief. Consumers are asked, “If you could take fewer pills, why wouldn’t you?” Participants’ descriptions of taking one pill at a time to see if it helps, and then taking one every hour after, for example, are supported by such taglines, although often in seemingly problematic ways. Participants’ discourse surrounding taking the “minimum” in terms of OTC medication align with messages of self-responsibility for monitoring harm.

Using images of athletes and outdoor enthusiasts, OTC ads simultaneously portray images of happiness and stamina among those not limited by pain. Advil, for example, features a tennis player in the background of a court covered with hundreds of practice balls, coupled with the tagline “No pain. No limit” (Advil). OTC pain medication ads feature images of individuals who are happy, outdoorsy and participating in active lifestyles (cf. Singer et al. 2013). Pain is portrayed as the limiting factor in leading a happy, healthy lifestyle. According to Ecks (2005), pharmaceutical medications for contested conditions are only accepted insofar as they provide a path toward “true happiness” through social reintegration (Ecks 2005:246). Ads for OTC meds offer the happiness and fulfillment of social obligation sought by those with chronic pain

Messages of personal responsibility alongside messages of achieving true happiness through pain relief play on the feeling reported by many participants of being “at odds” with oneself. Sufferers are expected to take as little medication as possible while also overcoming the limitations imposed by pain. Both Advil and Tylenol feature messages of fulfilling social obligations with the help of their products. Participants in our study stoically described wanting to “just handle” pain. OTC ads urge people to use their products instead, inciting obligation to others, such as in one ad for Advil featuring a mother playing with her children alongside the words, “I take Advil because my kids deserve a mom without a headache.”

Family life is a crucial arena in the formation of moral identities (Finch 1989). OTC pain medications target such moral identities, featuring taglines such as “for everything we do, you do so much more” (Tylenol) or “we eased your back pain, you made it the best playdate ever” (Tylenol). Coupled with images of active parents enjoying time with their happy children, OTC marketing positions the deservingness of others as impetus to overcome bodily limitations and be pain-free.

In her study of young mothers’ use of OTC medications, Vuckovic (1999:51) reports that a culture of “time famine” leads young mothers to medicate themselves and their children to avoid missing work. Vuckovic found that OTC medications were a way to hide symptoms and discipline bodies to comply with lifestyle demands. OTC pain medication manufacturers target these audiences, knowing demands placed on parents—especially mothers—lead to regular use of their products.

Using taglines such as, “The brand hospitals use most” (Tylenol), advertisers call upon the authority of doctors, hospitals, or health care professionals in recommending their products. Taglines like “you can’t get a stronger pain reliever without a prescription” (Tylenol) and “advanced medicine for pain” (Tylenol) suggest that OTC pain relievers offer strength and legitimacy without the need for professional oversight. In their efforts to avoid being labeled “chronic pain sufferer” as mentioned above, the promise of prescription strength without the need to “ask your doctor” (as is commonly recommended in DTC advertising for prescription drugs) supports both the identity work and the desire for relief expressed by those living with chronic pain.

In the words, “Get back to normal, whatever your normal is” (Tylenol), the supremacy of being “normal” is communicated simultaneously with ideas of acceptance and individual expression. OTC marketers suggest that living in pain is not one’s “normal” state and consumers should therefore be involved in treating it. Using the tagline, “So I can be myself again, sooner,” Tylenol speaks to concerns that both the pain itself and its treatment—prescription pain medications—threaten the identity of the sufferer. OTC ad campaigns align with sufferers’ concerns by suggesting that these relatively harmless albeit powerful OTC medications are a way to be stoic while still regaining one’s true pain-free self.

DISCUSSION

From a medical anthropological perspective, “normal” is problematic (Lock and Nguyen 2010; Hacking 1990). Particularly in health care contexts, “normal” and “pathological” are defined in relation to available medical treatment (Kaufman et al. 2004). As Dumit and Greenslit (2006) point out, pharmaceutical advertisers are aware of the need to market their drugs in a way that aligns them with social ideals and consumer identities. Pharmaceutical marketing has considerable power to exploit the uncertainty surrounding contested conditions (Ebeling 2011). The ability of drug marketers to pathologize and render “ab-normal” any deviations from expected versions of masculinity (Åsberg and Lum 2009), eternal youth and beauty (Smirnova 2012), and responsibility for self-diagnosis (Ebeling 2011), for example, are well-documented.

Trade-offs between physical harm reduction and reducing potential harm to one’s identity involved narratives of harm justification as chronic pain sufferers described their use as minimal and responsible. Describing medications as “just over-the-counter” or “not real pain medication” is social harm reduction. These phrases are uttered with the intention of minimizing stigma and distancing the individual from the addictive potential of prescription pain medications. Harm justification is therefore harm reduction, but in an altered sense. Navigating discourses of authentic versus inauthentic suffering (Ecks 2005), participants reduce harm to their identities through description of medication use as “minimal” in light of their experience of intense and ongoing pain.

In advertising, OTC medications are often portrayed as simple solutions to problems (Tsao 1997). Consumers likewise equate OTC with “safe” and see widespread availability as an indicator of harmlessness (Nichter and Thompson 2006). Viewing OTC meds as harmless commodities is problematic, however, given that the Federal Trade Commission (FTC) does not require the same risk disclosures in OTC ads as for prescription medications (Ling, Berndt, and Kyle 2002). Applebaum (2009) argues that over-emphasis on consumer agency and simplicity masks the exercise of power in pharmaceutical advertising. In exercising agency, consumers are involved in the reproduction of pharmaceutical ideologies that have influenced the very definitions of normal and pathological they purport to remedy (Ebeling 2011; Healy 2006).

Drawing from de Certeau (1984) Dew et al. (2014) argue that consumers are not passively shaped by dominant discourses, but rather actively engage with them in their production of a hybridized self-medical practice. Future research should consider the extent to which OTC medication advertising supports notions of harmlessness and social acceptability of their products and the extent to which those living with chronic pain may be ingesting these medications without full awareness of potential risks (Brune and Patrignani 2015) or even of their own actual intake.

Limitations

There are several potential limitations to this data. First, TMD is a condition normally addressed by dentists rather than primary care physicians (PCPs). Reluctance to talk to PCPs about pain may therefore be related to the ambiguity of the condition itself. As Buchbinder et al (2015) point out, however, reluctance to ask for pain medication can be observed in other pain conditions as well and is therefore likely to be at least partially attributable to fear of stigma. Second, many participants refer to “Advil” by brand-name. Because interview guides did not specifically cover brand-loyalty as an issue, we cannot comment on whether Advil is a blanket term to refer to the product (like, for example “Kleenex”) or whether participants specifically seek the brand-name as opposed to generic Ibuprofen. Drug use as recorded by participants in the various study questionnaires was not specific enough to provide clarification on this point (Elder et al. 2012). Further, we did not observe actual intake of OTC medication and can therefore comment only on the self-constructions involved in participants’ descriptions of their use. Another potential limitation of this data is that chronic pain sufferers were recruited through a study offering TCM and patients would have to be marginally interested in alternative treatment to join. Note, however, Barnes et al.’s (2008) finding that in 2007, 43.1% of White Adults in the U.S. reported using some form of CAM, and that inadequate insurance was a key factor in use of CAM therapies. These data suggest, therefore, that more research is needed to determine how commonly people with chronic pain are self-medicating as well as seeking care in alternative settings.

CONCLUSION

In sum, participants worked to position themselves as “normal” and handling pain as any normal person would. Messages of normality, simplicity, and ease conveyed by OTC advertisements offer a sense of belonging in the everyday world that is often illusive to pain sufferers. OTC medications allowed sufferers to construct their pain as within the realm of what “normal” people experience in everyday life. Advertising messages play on cultural discourses to assist sufferers in reconciling inner conflicts between being stoic and suffering with dignity (Jackson 1994; Hilbert 1984) versus finding relief from constant pain. Drug marketing is thus implicated in perpetuating ideals of normality and deservingness but may also offer consumers with chronic pain the idioms of self-responsibility, self-care, and responsible citizenship they seek. Future research should explore chronic pain sufferers’ perceptions of OTC medications as harmless substitutes for prescription medication. Sufferers who choose not to discuss their use of these potentially harmful medications with physicians in their efforts to preserve stoic pain bearing identities face very real risks from OTC medications as they are not receiving clear disclosure of the risks from either physicians or advertisers.

RESEARCH HIGHLIGHTS.

  • Unique expansion of harm reduction to include patients’ management of social harm

  • Explores OTC medications as a way to avoid stigma associated with opioid epidemic

  • Suggests a need for future research on how people with chronic pain self-medicate

Acknowledgments

Funding for this research was provided by a grant (U01-AT002570) from the National Center for Complementary and Alternative Medicine, National Institutes of Health. Special thanks to Cheryl Ritenbaugh, PhD, MPH, the project Principal Investigator and my mentor, for guidance and support in writing this article, and to my advisor and mentor Mark Nichter, PhD, MPH, for comments and support throughout the writing process. I would also like to thank Mimi Nichter, PhD and Susan Shaw, PhD for helpful comments on drafts of the manuscript. Thanks also to project practitioners and to participants for their help and willingness to be interviewed about a difficult and personal topic.

Footnotes

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