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EDITORIAL

New Deviancy Theory and the Healthcare

System’s Role in Creating, Labeling, and

Facilitating Unauthorized Prescription

Drug “Abuse”

Although the “new” deviancy theories are now more

than 50 years old, they continue to inform our under-

standing of contemporary patterns of illicit drug use.1

The lines between licit and illicit forms of drug use have

become increasingly blurred as the “new” deviancy

theories were developed: the “misuse” of prescription

opiate analgesics and the expansion of marijuana

prescribing have pulled much of the discussion sur-

rounding these activities into the medical sphere. It is

our contention that the application of classic sociolog-

ical and criminological theory lends valuable insights

into contemporary patterns of unauthorized prescrip-

tion drug “abuse.”

Deviance is a sociological concept that refers to

behaviors and beliefs that deviate from the norms,

standards, and expectations of a given society.1 It is a

broader concept than crime and is distinct from the

notion of “difference” in that it contains the implicit

likelihood of authoritative intervention or sanction: that

is, it refers to behaviors and beliefs that are stigmatized.

“New” deviancy theories challenged established ways of

thinking about such phenomena by rejecting the idea

that there is a distinct, unambiguously deviant minority

whose behavior can be explained as a result of individ-

ual pathology or social dysfunction. In place of the

traditional “correctionalist” orientation, an “apprecia-

tive stance” was advocated that is committed to faithful

understanding of the world as seen by the subject.

Viewed from this perspective, it was argued that

deviance is meaningful behavior involving choice and

that there is an underlying continuity between normalcy

and deviance.2 Such continuity is evident in the use of

prescription medications, which is deemed legitimate

when it is authorized by a physician to treat a medical

ailment, but is likely to be deemed deviant if patients

continues to use when there is no longer a medical need

to do so—either for pleasure or because they have become dependent.

Howard Becker provided the most famous statement

of the “new” deviancy position when he noted that

“deviance” is not a quality of the act the person

commits, but rather a consequence of the application

by others of rules and sanctions to an “offender”:

deviant behavior, in other words, “is behavior that

people so label.”3 In his seminal work, Becoming a

Marihuana User, Becker describes a series of learned

steps that he deemed necessary for someone to become a

regular drug user:

. . . No one becomes a user without 1 - learning to

smoke the drug in a way which will produce real

effects; 2 - learning to recognize the effects and

connect them with the drug use (learning, in other

words, to get high); and 3 - learning to enjoy the

sensations he perceives.4

Due to the illegality of marijuana use throughout the

United States at the time, would-be users had to contend

with powerful forces of social control. It was, Becker

noted, by being a part of a user group that participants

could gain access to supply, keep their use a secret, and

gain access to justifications and rationalizations.

Use of prescription medications has many interesting

contrasts and similarities with the processes Becker

describes in relation to marijuana use. Marijuana and

opiates have the potential to create both euphoric and

dysphoric sensation. Physicians may spend considerable

effort educating patients about the risks and benefits of

DOI: 10.1111/papr.12458

© 2016 World Institute of Pain, 1530-7085/16/$15.00 Pain Practice, Volume 16, Issue 7, 2016 791–793

the drug—helping them to perceive the effects and to make sense of the experience. In this way, the informed

consent process replaces the role of the drug user group

described by Becker. As part of the process of guiding

patients and helping them to learn how to use prescrip-

tion drugs, we might infer that physicians might inad-

vertently facilitate the transition to “abuse.” From an

ethical perspective, two major principles of medical

practice seem at odds: the principals of primum non

nocere, or “do no harm,” and “patient autonomy.” In

respecting one of these principles, the physician violates

the other. How such principles are understood might

influence the way clinicians frame instructions for use,

side effects, and the risk profiles of prescription drugs.

The role that rationalizations and justifications play

in supporting deviant behavior was famously high-

lighted by David Matza and Gresham Sykes.5 Insisting

that “juvenile delinquents” do not subscribe to an

oppositional morality, these authors argued that delin-

quency is motivated by exaggerated adherence to widely

held subterranean values, emphasizing excitement and

hedonistic leisure over formal values and work. Matza

and Sykes also highlighted the role that neutralization

techniques play in sustaining deviant behavior by

warding off the guilt associated with such activities.5

These techniques include denial of responsibility, denial

of injury, denial of the victim, condemnation of the

condemners, and appeals to higher loyalties. It follows

that neutralization techniques only need to be applied

when behavior is deviant, and always when it is illegal.

During the initiation of prescription medications, these

techniques are unnecessary, but are likely to be activated

if use progresses beyond the point of medical need.

Based on this perspective, one can assert that prescrip-

tion use becomes deviant once the user needs to employ

neutralization techniques: the use of such techniques

signifies an implicit recognition that the behavior falls

outside of what is considered legitimate or acceptable

and is moving toward recreational use or dependency.

Drawing on these insights, clinicians might consider

assessing the use of neutralization techniques to diag-

nose “inappropriate” drug use. Addressing patients’

assumptions and beliefs is already a core part of

psychotherapy in the addictions. Further, understanding

the patient’s value system can help direct the informed

consent discussion to explicitly confront the sensation of

feeling high as part of the side effect profile of these

drugs, especially with regard to opioids.

Jock Young drew attention to the socially constructed

nature of deviance in his book The Drugtakers.6

Adopting a relativist position, Young argued that the

same activity might be labeled as simultaneously deviant

and normal depending on whose standards are being

applied. It is, in other words, the context surrounding

the action as well as the larger societal norms that

constructs the definition. This type of subjective assess-

ment of deviancy has direct parallels with the interplay

between physician and patient. It underscores some of

the largest practical difficulties when labeling/diagnos-

ing use, “misuse,” and “abuse” or, in the sociological

rhetoric, deviancy. There is a dynamic context for drug

use: at one moment, it can be to treat pain alone, and

another to enjoy the high or to meet a dependence, while

many times it achieves all three. As with deviancy, the

diagnoses of pain and/or dependency are subjective and

context specific.

Edwin Lemert’s7 distinction between primary and

secondary deviance is pertinent here. Highlighting the

importance of social reaction, Lemert notes that primary

deviance is commonplace and managed within a socially

acceptable identity, while secondary deviance is inter-

nalized and becomes part of the core definition of the

self. An example of secondary deviance would be when

somebody who uses drugs comes to define themselves as

an “addict.” Interaction with significant others is an

important influence and may lead to the normalization

or acceptance of the deviation as peripheral to identity

or may stimulate a symbolic reorganization of the self

around the deviant act. The distinction between primary

and secondary deviance parallels exactly the transition

from authorized use of medication to treat pain to

viewing the use of the drug or the addiction as the

pathology in and of itself. Furthermore, Lemert

describes secondary deviance as, “Adjustment to the

overt and covert problems created by the consequent

societal reaction to him,” which corresponds with the

way modern welfare systems give social support to

chronic patients due to their disability.8 The chicken and

egg debate about whether welfare support incentivizes/

creates long-term disability remains contentious.9

Harold Finestone showed how addiction is shaped by

the broader social context in his influential ethnographic

study of black heroin users in 1960s in Chicago. “With

little prospect of achieving or identifying with status

positions in larger society”, he argued, “the Cat [heroin

user] is the personal counterpart of an expressive social

movement.”10 According to Finestone, this form of

secondary deviance was an expressive, productive

adaptation to cope with systemic racism, segregation,

and exclusion from the formal economy. The heroin

792 � LEVIN AND SHINER

scene provided the basis of a countercultural identity

built around “cool” and “kicks” as well as the need to

“hustle” (to maintain the lifestyle). For the Cat, the

taboo and the desire to put himself beyond the compre-

hension of the “square” were motivating and unifying.10

The development of subcultures around prescription

medications requires an ethnographic study of its own.

“New” deviancy theories developed in opposition to

the prevailing dogma that there was a deviant minority

whose behavior could be explained as a result of intrinsic

pathology or social dysfunction. Modern medical

research tends to emphasize inherent pathology, neuro-

chemical pathways, and social determination in much the

same way as the very earliest deviancy theorist. Applying

“new” deviancy to this modern phenomenon can gener-

ate a novel understanding of the topic. The main

contribution of the “new” deviancy theories was to draw

attention to the counterproductive nature of stigmatizing

and exclusionary forms of social control: far from

eliminating “deviance,” such responses often serve to

entrench it. This does not mean that social control is

necessarily a bad thing, however, and we would do well

to heed the distinction Braithwaite draws between

shaming that is stigmatizing and counterproductive and

that which is reintegrative and crime reducing.11 Young

made a similar distinction when he claimed “the subcul-

ture of drugtaking” has “the only viable authority to

control the activity of its members” (p. 221). Rather than

harassing and undermining existing drug subcultures, he

advocated a policy of maintaining such cultures and

encouraging users to adapt their habits by providing

them with what he called “positive propaganda”— accurate, credible information about the effect of drugs.

Physicians treating patients whose use of prescription

medication is blurring into recreational or dependent use

are well placed to fulfill such a role. These lessons can

guide policy makers seeking to address the larger issues

contribution to this problem.

ACKNOWLEDGEMENTS

This article is based on a coursework submitted to the

London School of Economics and Political Science as part

ofthe MSc HealthPolicy,Planningand Financingin2015.

ROLE OF FUNDING SOURCES

The authors received no funding to support this work.

CONTRIBUTORS

David Levin worked under the guidance of Michael

Shiner to develop the major concepts for this work.

There was continued feedback and interaction between

the two authors. David Levin wrote the first draft of the

article, and all authors contributed to and have

approved the final article.

CONFLICTS OF INTEREST

The authors state that they have no conflict of interest.

David Levin, MD, MSc, BESc (Mech)*,†

*Department of Anesthesiology, University of Toronto, Toronto,

Ontario, Canada †Health Policy, Planning and Financing, London School of Hygiene

and Tropical Medicine, London School of Economics, London, U.K.

Michael Shiner, PhD‡

‡Department of Social Policy, London School of Economics, London,

U.K. E-mail: [email protected]

REFERENCES

1. Sumner C. Deviance. In: McLaughlin E, Muncie J, eds.

The Sage Dictionary of Criminology. London: Sage;

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Prentice-Hall; 1969.

3. Becker H. Outsiders: Studies in the Sociology of

Deviance. New York: The Free Press; 1963.

4. Becker HS. Becoming a marihuana user. Am J Sociol.

1953;59:235–242. 5. Matza D, Sykes GM. Juvenile delinquency and sub-

terranean values. Am Sociol Rev. 1961;26:712–719. 6. Young J. The Drugtakers: The Social Meaning of Drug

Use. London: MacGibbon and Kee; 1971.

7. Lemert EM. Social Pathology: A Systematic Approach

to the Theory of Sociopathic Behavior. 1st ed. New York:

McGraw-Hill; 1951.

8. Fitzcharles MA, Ste-Marie PA, Gamsa A, Ware MA,

Shir Y. Opioid use, misuse, and abuse in patients labeled as

fibromyalgia. Am J Med. 2011;124:955–960. 9. Clayton S, Bambra C, Gosling R, Povall S, Misso K,

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