Social Science & Medicine 73 (2011) 833e842

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Social Science & Medicine

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Listening to Lyrica: contested illnesses and pharmaceutical determinism

Kristin K. Barker*
Oregon State University, Sociology, Fairbanks Hall, Corvallis, OR 97331, United States

a r t i c l e i n f o a b s t r a c t

Article history: Fibromyalgia syndrome is a debilitating pain disorder of unknown origins and a paradigmatic contested
Available online 28 July 2011 illness. As with other contested illnesses, the reality of fibromyalgia is disputed by many physicians. Thus,
millions of individuals who are diagnosed with fibromyalgia must cope with chronic symptoms as well
Keywords: as medical and public skepticism. In this context, the U.S. Federal Drug Administration’s approval of
Contested illnesses Lyrica, the first prescription medication specifically for the management of fibromyalgia, is of consid-
Fibromyalgia
erable interest. In this paper I examine the cultural logic whereby the existence (and marketing) of an
Direct-to-consumer-advertising
officially approved prescription medication for a condition lends support to the biomedical existence of
Medicalization
USA
the condition itself. I label this logic pharmaceutical determinism and argue that it represents an
Medications important new phase in the proliferation of contested illness diagnoses. Using the case of Lyrica, I
Gender describe the role that pharmaceutical companies and pharmaceuticals themselves play in promoting and
legitimating contested diagnoses and validating those who are so diagnosed. Through a narrative
analysis of the Lyrica direct-to-consumer advertising campaign and the responses of fibromyalgia
sufferers to the introduction and marketing of Lyrica, I demonstrate the symbiotic relationship between
the interests of the pharmaceutical industry, contested illness legitimization, and medicalization. I also
provide a gender analysis of this relationship, foregrounding how contested illnesses continue to be
shaped by their feminization in a cultural context that equates women with irrationality. Finally, I
address the consequences and limitations of relying on the pharmaceutical industry for illness validation.
Ó 2011 Elsevier Ltd. All rights reserved.

Fibromyalgia syndrome is a pain disorder of unknown origins. In
addition to chronic widespread pain, fibromyalgia is often charac-
terized by a host of associated symptoms, the most common of
which are fatigue, sleep irregularities, and cognitive and mood
disorders. The condition is said to affect between 2 and 5 percent of
the U.S. population, with a female to male ratio of approximately
9:1 (Neumann & Buskila, 2003). Fibromyalgia is not attributable to
any known organic abnormality (Wolfe, 2009). It is not detectable
using blood tests, x-rays, or other diagnostic tools. Instead, after
ruling out other possible causes for a patient’s symptoms, fibro-
myalgia is diagnosed using criteria established by the American
College of Rheumatology (ACR) in 1990. The formal criteria include
the patient’s report of widespread pain for at least 3 months and
tenderness in at least 11 of 18 locations on the body, called tender
points, to which pressure is applied during a physical examination
(Wolfe et al., 1990).
Parenthetically, tender points do not correspond to any
anatomical structure nor does tenderness in these locations
correspond to any observable pathology (Milton, 1999). It also bears
* Tel.: þ1 541 737 5375.
E-mail address: kristin.barker@oregonstate.edu.
noting that in clinical practice the tender point criterion is not
strictly observed. It has been suggested that patients who report
fewer than 11 tender points be diagnosed if they also report
a number of symptoms commonly associated with fibromyalgia
(e.g., fatigue, sleep and mood disorders, bowel irregularities) even
though the presence of these symptoms are not included in the
formal diagnostic criteria (Csillag, 1992). In response to acknowl-
edged irregularities associated with diagnosing fibromyalgia, new
ACR guidelines were recently proposed, which are intended to
compliment, not replace, the 1990 criteria (Wolfe et al., 2010). The
new guidelines emphasize symptom severity and pain level rather
than tender points.
Because fibromyalgia is determined by exclusion and inexactly,
many physicians remain skeptical of the diagnosis and the patients
so diagnosed. Not only are there concerns about the vagueness of
the diagnosis, but there is also the nagging question about whether
fibromyalgia is “real” (i.e., has organic biological origins) or not (i.e.,
is psychogenic). The feminization of the disorder intersects with
cultural stereotypes about women’s emotionality and irrationality,
leading some critics to claim that fibromyalgia is a form of modern
day hysteria (Hadler, 1997; Showalter, 1997). Consequently, for
millions of women, living with fibromyalgia requires managing

0277-9536/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2011.05.055
834 K.K. Barker / Social Science & Medicine 73 (2011) 833e842
a constellation of chronic symptoms while coping with medical and
public skepticism. It frequently takes a protracted time and
considerable tenacity to find a health care provider who believes in
fibromyalgia and is willing to diagnose and treat fibromyalgia
patients. Such providers are referred to as “fibro-friendly.”
Although being diagnosed generally affords sufferers considerable
peace of mind and some degree of validation (i.e., they are not
dying; there is a name for their condition; it’s not all in their head),
it rarely brings the experience of medical disparagement to an end
(Barker, 2005).
In all these regards, fibromyalgia is a paradigmatic contested
illness. In the last two decades there has been a dramatic rise in the
number of contested illness diagnoses and contested illness
sufferers (Barsky & Borus, 1999). Approximately ten million
Americans, most of them women, are diagnosed with one of several
syndromes characterized by a cluster of common and troubling
symptoms (e.g., pain, fatigue, mood irregularities) that are not
attributable to any organic abnormality (Manu, 2004; Wessley,
Nimnuan, & Sharpe, 1999). In addition to fibromyalgia, some of
these conditions include chronic fatigue syndrome, tension head-
ache, temporomandibular joint disorder, irritable bowel syndrome,
and multiple chemical sensitivity disorder. On the one hand, there
is a lack of conventional biomedical evidence for the existence
of these conditions. On the other hand, sufferers report significant
reductions in functional abilities, health status, and quality of
life, with little sustained improvement in well-being over time
(Manu, 2004; Wessley et al., 1999). In fact, these conditions are
called “contested illnesses” precisely because they represent
a clash between biomedical knowledge and patient experience
(Conrad & Stults, 2008; Moss & Teghtsoonian, 2008). Contested
illness sufferers, including those with fibromyalgia, must therefore
engage in an ongoing struggle to have medically unexplainable
symptoms recognized in orthodox biomedical terms despite
resistance from medical professionals and institutions.
In the case of fibromyalgia, the ongoing debate about whether
the condition is a “real” biomedical entity entered a new phase in
June 2007, when the Food and Drug Administration (FDA) approved
the first drug specifically for its management. Patient advocates and
a small handful of clinician-researchers with whom they are allied,
heralded the approval of Pfizer’s Lyrica for fibromyalgia as a thera-
peutic and symbolic victory. Two additional drugs have subse-
quently received FDA approval for fibromyalgia. Beyond the
potential therapeutic benefits, sufferers hope that the FDA approval
of drugs specifically for the management of fibromyalgia will finally
validate fibromyalgia in the eyes of the public and medical skeptics.
Their hopes are not without foundation. A number of scholars duly
note that the pharmaceutical industry (also known as Pharma) now
possesses significant cultural authority when it comes to defining
and legitimating diagnoses and disease entities (Conrad & Leiter,
2008; Greene, 2007; Loe, 2004; Williams, Gabe, & Davis, 2008). It
is increasingly the case that the mere existence of a prescription
medication for a condition is used to authenticate the biomedical
existence and character of the condition itself. I label this
phenomenon pharmaceutical determinism and suggest that it
represents an important new phase in the proliferation of con-
tested illness diagnoses.
Using the case of Lyrica, I describe the role pharmaceutical
companies and pharmaceuticals themselves play in promoting and
legitimating contested diagnoses. That is, I illustrate how the logic
of pharmaceutical determinism plays out in the case of fibro-
myalgia and suggest its applicability to other contested illnesses.
Through a narrative analysis of the Lyrica direct-to-consumer
advertising (DTCA) campaign and the responses of fibromyalgia
sufferers to the introduction and marketing of Lyrica, I demonstrate
the symbiotic relationship between the interests of the
pharmaceutical industry, contested illness legitimization, and
medicalization. In addition, I provide a gender analysis of this
relationship wherein I underscore how contested illnesses continue
to be shaped by their feminization and a cultural milieu that
equates women with irrationality. Finally, I address the limitations
of relying on the pharmaceutical industry for illness validation.
Medicalization: fibro and pharma
Medicalization is the process by which ever more aspects of the
human condition are defined and treated as medical in character.
Although there have been a few notable instances of demedicali-
zation (e.g., homosexuality and masturbation), medicalization has
been a dominant trend. Many different types of human experiences
and problems have been medicalized, including deviant behavior,
natural life processes, and everyday problems of living (Davis,
2009). Although the trend toward medicalization is long-
standing, the principal forces behind the process have changed.
Campaigns on the part of physicians to expand their jurisdictional
authority were a primary “engine” of medicalization during the
first three quarters of the twentieth century (Conrad, 2005). Par-
alleling a decrease in professional power more generally, however,
physicians’ role in medicalization has declined in relative impor-
tance while that of patient consumers and powerful corporate
entities have increased. For example, it is increasingly patients
rather than physicians who are eager to classify their “physical
distress” and “uncomfortable body states.as diseases” (Barsky &
Borus, 1995: 1913). Fibromyalgia and other contested illnesses fit
this description.
The pharmaceutical industry, one of the most profitable sectors
in the global economy, has also become one of the most influential
players in contemporary medicalization. The means by which
pharmaceuticals contribute to medicalization, or “pharmaceutic-
alisation” (Fox & Ward, 2008; Williams, Seale, Boden et al.,
2008), are complex and multi-dimensional, but one particularly
effective route is through direct-to-consumer advertising (DTCA)
(Moynihan, Heath, & Henry, 2002). Only two countries, the United
States and New Zealand, currently permit DTCA. In the United
States, televised DTCA took off in the wake of deregulations
associated with the passage the FDA Modernization Act (FDMA) of
1997. According to an oft-quoted (and likely conservative) esti-
mate, the pharmaceutical industry spent $4.2 billion on adver-
tising directly to American patient consumers in 2004 d twice
what it spent on research and development (Donohue, Cevasco, &
Rosenthal, 2007).
Using sophisticated marketing techniques, televised DTCA
campaigns encourage individuals to “ask their doctors” if a partic-
ular medication is a solution to their problems (Frosch, Krueger,
Hornik, Cronholm, & Barg, 2007). While there is the potential
that DTCA can educate some consumers about beneficial medica-
tions, many of the problems DTCA target are trivial (Conrad, 2007;
Moynihan & Cassels, 2005). Others are exceedingly common and
not life threatening (Mintzes, 2002). It would seem that all prob-
lems, however small, common, or benign, can be marketed as
a medical problem that can be mitigated with medication. The
Viagra DTCA campaign is legendary and its relationship to medi-
calizing healthy men’s sexual performance is widely recognized
(Loe, 2004). The moderate inconvenience of frequent calls of nature
associated with normal aging has morphed into overactive bladder
for women and benign prostatic hyperplasia for men. Add to this
list the DTCA campaigns for Paxil and Sarafem, which promoted the
new diagnoses of social anxiety disorder and premenstrual
dysphoric disorder respectively (Conrad & Leiter, 2008; Tiefer,
2006). The condition “Low T” (low testosterone), characterized by
declining energy and “fun” in men over 45, is a recent illustration of
 K.K. Barker / Social Science & Medicine 73 (2011) 833e842
how DTCA reframes common experiences as symptoms of specific
disorders in an effort to increase consumer demand for products
and, ultimately, corporate profits.
As these examples suggest, some DTCA campaigns focus on
selling the diagnosis as aggressively as the medication designed to
treat it. In some cases the campaign is selling a medication for
which the diagnosis has been designed. This situation has led some
critics to accuse the pharmaceutical industry of engaging in
outright disease mongering (Angell, 2004; Payer, 1992). Whether
these campaigns are educating and empowering consumers
(Bonaccorso & Sturchio, 2002) or selling sickness (Moynihan &
Cassels, 2005), the result is a dramatic increase in the market for
these prescription drugs. The evidence is clear: DTCA campaigns
increase prescription requests on the part of patients that result in
physicians prescribing requested medications, even when they do
not believe the drugs are clinically warranted (Mintzes et al., 2002).
But, when DTCA encourages consumers to self-diagnose as
a precursor to a prescription request, physicians may also comply
with the patient’s requests for a diagnosis about which they are
skeptical. In short, the pharmaceutical industry is increasingly an
active party in the diagnostic process. The pharmaceutical industry,
as noted by Jutel (2009: 291), is now an important “engine of
diagnosis.”
DTCA encourages the belief that there is “a pill for every ill” and,
increasingly, “an ill for every pill” (Mintzes, 2002). The latter
sentiment is an outcome of the pharmaceutical industry’s growing
cultural authority to define the object of medicine; that is, to define
disease. In Listening to Prozac (1993) Peter Kramer reflects on
“cosmetic pharmacology” (i.e., using anti-depressant medications
to feel “better than well”). Kramer’s book also draws attention to
the larger cultural tendency to emphasize pharmaceutical solutions
for various painful aspects of the human condition, as well as the
corresponding power we have bestowed upon prescription medi-
cations to define what is biomedically real. Similarly, Jeremy Greene
(2007: 227) chronicles how clinical trials for pharmaceuticals play
an increasingly influential role “in propping up the ‘diseaseness’ of
a putative pathological category.” The logic is as follows: if there is
a prescription medication to treat a problem, then the problem
must be a biomedical disease. Furthermore, as explained by
Andrew Lakoff (2006), the specific pharmacological approach
points to what type of thing the “disease” is. For example, if
a condition responds to a drug that impacts the central nervous
system, then the condition is a central nervous system disorder. As
previously noted, I refer to this logic as pharmaceutical determinism
and it is of considerable salience with respect to fibromyalgia.
Elsewhere I provide a detailed description of how the coming
together of women with a host of distressing symptoms and a small
group of rheumatologists (whom I refer to as “diagnostic entre-
preneurs”) led to the diagnostic making of fibromyalgia syndrome
(Barker, 2005). The result was the ACR diagnostic criteria for
fibromyalgia adopted in 1990. Fibromyalgia is a diagnostic label
given to medically unexplained symptoms that are widespread in
the general public and particularly common among women.
Compared to men, women report more chronic ailments, pain, and
dysfunction; they experience more physical discomfort and corre-
sponding limitations; they have higher rates of depression; they
use more prescription and over-the-counter medications; and, they
have higher rates of health care utilization (Bird & Rieker, 2008).
These patterns represent the complex interplay of biological, social,
and political realities (Doyal, 1995; Lorber, 1997). What is important
for our purposes is to recognize that, in recent decades, women’s
high rates of morbidity have increasingly become organized into
contested illness diagnoses like fibromyalgia. That is, contested
illnesses can be viewed as social constructions that transform
women’s common symptoms into medical diseases.
835
At the level of experience, the fibromyalgia diagnosis provides
sufferers with a framework for giving meaning to their distress.
Among other things it gives women a name to tie together
a dizzying array of otherwise disparate symptoms. However,
insofar as fibromyalgia remains medically contested, the medical-
ization of women’s distress under the rubric of the fibromyalgia
remains incomplete. Herein lies the importance of pharmaceutical
determinism to the story at hand.
Since the establishment of the ACR criteria, the treatment
protocol for fibromyalgia has been a symptomatic approach.
Patients are frequently given a prescription medication for each of
their numerous symptoms (e.g., pain, sleep irregularities, mood
disorders, bowel distress, etc.), and treatment outcomes are
generally poor (Goldenberg, Burckhardt, & Crofford, 2004). Lyrica is
approved as a systemic drug therapy for fibromyalgia. In clinical
trials it was found to improve functioning among those diagnosed
with fibromyalgia (Arnold et al., 2008; Crofford et al., 2008). In
other words, the drug’s approval gives creditability to the notion
that fibromyalgia is a discrete biological thing, rather than
a collection of disparate symptoms that are poorly managed with
a hodgepodge of existing medications. It is further suggested that
Lyrica confirms what type of biological thing fibromyalgia is. Lyrica
is an anticonvulsant medication, said to benefit fibromyalgia
patients by binding to neurotransmitters in the brain and spinal
cord, effectively reducing activity in the central nervous system
(Crofford et al., 2005). Fibro-friendly clinician-researchers,
including those working with and for Pfizer, maintain that Lyrica
corroborates the theory that fibromyalgia is a neurochemical
aberration wherein neurons become hyperresponsive to stimuli,
a state referred to as “central sensitization” (Crofford et al., 2005).
Since the approval of Lyrica, two anti-depressant medications
(Cymbalta and Savella) have also received FDA approval for fibro-
myalgia. Like Lyrica these medications are approved for the
systemic management of fibromyalgia. Although they are anti-
depressants, these drugs are said to improve functioning in fibro-
myalgia patients, independent of depression, via mechanisms that
shore up the theory of central sensitization (Recla, 2010).
The FDA approval of Lyrica for the management of fibromyalgia
and subsequent DTCA campaign must be understood in the context
of the disorder’s contested status, its feminization, and the cultural
authority conferred upon pharmaceuticals to define biomedical
reality. To that end, what follows is a close examination of the DTCA
campaign for Lyrica and the response of fibromyalgia sufferers to
the drug’s introduction and marketing.
Data and methods
The data I use in this analysis come from multiple sources. First, I
examine the central feature of the DTCA campaign for Lyrica. This
includes the six television commercials aired during network news
programming in the United States from the time the first
commercial appeared in November 2007, through May 2010 when
this article was written. I also include an informal feature of the
DTCA campaign, a television public service announcement created
jointly by Pfizer and a leading fibromyalgia advocacy group. I
accessed the commercials through the Vanderbilt Television News
Archive (http://tvnews.vanderbilt.edu/). To analyze the commer-
cials I used the schema developed by Frosch, Krueger, Hornik,
Cronholm, and Barg (2007) as a template. As specified in this
template, the basic story line of DTCA includes three elements: loss
of control due to illness/condition; regaining control through use of
medication; and concomitant social rewards. These elements
represent a plot, or a series of incidents that are sequentially
organized, and a plot is the hallmark of a narrative (Riessman,
2008). Accordingly, I analyze these commercials as narratives.
836 K.K. Barker / Social Science & Medicine 73 (2011) 833e842
Beyond identifying the basic story being told, narrative analysis
focuses on why a particular narrative is constructed (i.e., what is the
purpose of the narrative), emphasizing who is telling the story and
who is thought to be listening (Riessman, 2008; Spencer, Ritchie, &
O’Connor, 2003). The commercials were analyzed using NVivo,
a computer-assisted qualitative data analysis software program.
The analysis focused on how the commercials’ narrative elements
are presented in relationship to the promotion and legitimization of
the fibromyalgia diagnosis. As part of this undertaking I paid
particular attention to content that directly or indirectly addressed
the conflation of women’s cultural legitimacy and the legitimacy of
the fibromyalgia illness experience.
The main data used to capture the response of fibromyalgia
sufferers to Lyrica are electronic postings to a bulletin board run for
and by fibromyalgia sufferers, which is given the pseudonym Fibro
Spot. As part of an earlier research undertaking, I collected all the
postings to Fibro Spot from February 1, 2004 through February 28,
2005 and February 1, 2007 through February 28, 2008 (Barker,
2008). In early 2007, Fibro Spot’s homepage was one of the top
five online support groups listed in a Google search for “fibro-
myalgia.” The analysis I present here takes advantage of this
previously collected data, but I use only those posts that specifically
address Lyrica (pregabalin). The electronic posts were analyzed
using NVivo with an eye toward content that addressed the rela-
tionship between Lyrica and the legitimization of the fibromyalgia
diagnosis and illness experience. The study received a human
subjects exemption from Oregon State University Institutional
Review Board.
To supplement these data, and specifically to track the response
to the Lyrica DTCA campaign after 2008, I conducted a Google
search for “Lyrica commercial” on June 1, 2010. This search gener-
ated nearly a half a million hits. I evaluated the most visible
comments about the DTCA campaign (i.e., the highest ranked in this
Google search) contributed by fibromyalgia sufferers to a variety of
public forums, such as blogs and online newsgroups. This latter
technique is not intended to be comprehensive. Rather I have used
these comments to provide a snapshot of the most visible
responses to the Lyrica DTCA campaign as expressed online.
Analysis
Pharmaceutical Opportunism: DTCA & making fibromyalgia real
Fibromyalgia is only the most recent indication for which Lyrica
had been approved. The drug received FDA approval in 2004 for the
treatment of neuropathic pain associated with shingles and dia-
betes, and as a supplementary treatment for partial onset seizures
in patients with epilepsy in 2005. Pfizer introduced Lyrica as
a “follow-on” medication to its highly lucrative predecessor Neu-
rontin (gabapentin). That is, the drugs are very similar to one
another, but Neurontin was on the eve of losing patent protection.
In fact, Pfizer was found guilty of fraudulent marketing practices
and paid a criminal fine of $50 million for encouraging physicians to
switch patients from Neuorontin to Lyrica on an off-label basis,
which is the practice of prescribing a drug for a condition for which
it has not been approved (O’Reilly & Capaccio, 2009). In the
meantime, with Lyrica already approved for the management of
other pain states, Pfizer sought and received an expedited approval
for the management of fibromyalgia. The vast market potential for
fibromyalgia drugs is well recognized. According to a report by
Decision Resources, a leading research and advisory firm to the
pharmaceutical industry, the use of Lyrica, Cymbalta and Savella
will result in an eight percent annual growth in the fibromyalgia
market over the next eight years in the United States, Europe and
Japan (Hohenberg, Wilson, Daley, & Fam, 2007). As explained in the
report, “The arrival of drugs with regulatory labeling for fibro-
myalgia and the attendant marketing and increased awareness of
fibromyalgia will quadruple the size of this relatively new drug
market.” The report then asks: “How might drug developers capi-
talize on fibromyalgia patients’ need for drug therapy?” (http://
decisionresources.com/Products-and-Services/Report?
r¼pcorpn0108).
Increasing public awareness of fibromyalgia and declaring its
status as “real” have been major prongs in Pfizer’s plan to capitalize
on the fibromyalgia market. In August 2007 Pfizer joined forces
with the largest fibromyalgia advocacy organization in the United
States, the National Fibromyalgia Association (NFA), to create
a fibromyalgia awareness campaign. The Pfizer-NFA campaign
included a televised public service announcement and an interac-
tive website. The public service announcement featured a montage
of people, most of them in tears, explaining their intense pain, after
which the following voiceover is heard:
 Imagine feeling this kind of pain and no one knows what it is or
believes you even have it. This is fibromyalgia. Very real chronic
widespread pain and tenderness that affects millions. There
is hope. There is help. If you’re suffering talk to your doctor and
visit Fibrohope.org for more real stories (National Fibromyalgia
Association, 2007).
In addition to real stories about fibromyalgia, Fibrohope.org
provided visitors with the phone number to Pfizer’s call center
where they could receive “information about a prescription treat-
ment option.” In short, Pfizer’s sponsorship of the website and the
company’s alliance with NFA is paradigmatic of what others have
argued is in fact pharmaceutical marketing through apparent
awareness education initiatives (Angell, 2004: 135; Moynihan and
Cassels: 132) The FibroHope website is no longer active but it was
online from June 2007 to July 2008 and is accessible on the Internet
Archive (see http://web.archive.org/web/20080623213233/http://
www.fibrohope.org/).
The first television advertisement for Lyrica aired a few months
later in November 2007. The commercial opens with an exceedingly
thin middle-aged woman reading from her diary. She appears to be
very much in distress, her face clenched as she reads the following
diary entry: “Today I really struggled with my fibromyalgia. I had
pain all over. My muscles ached, so tender to the touch.” She sets
down her diary, sighs, looks directly at the camera, and proclaims:
“Fibromyalgia is a real, widespread pain condition which also makes
daily activities difficult.” She continues: “But until recently there
were no medicines approved by the FDA to manage fibromyalgia.
Prescription Lyrica is the first and only FDA approved treatment that
can help relieve fibromyalgia pain and improve function.” The
commercial ends with the visibly less distressed woman encour-
aging viewers to “ask their doctor” about Lyrica.
This advertisement ran for five months until it was replaced by
two new commercials that aired during 2008. The first of these
opens with a dark haired middle-aged woman sitting in her
shadowy kitchen telling the audience that fibromyalgia pain made
it hard to just do the little things she loved. “But then my doctor told
me about Lyrica.” Next we see the woman happily tending her
beautiful garden as she explains, “Lyrica helps me accomplish my
daily activities and helps me feel better. So now I can start to think
of something other than my pain.” The woman is warm and
familiarly appealing. The commercial ends with a close up of her
smiling and stating: “If you have fibromyalgia ask your doctor if
Lyrica is right for you.” The next commercial to air depicted a stylish
and slim, silver-haired woman strolling through a beautifully
restored section of New Orleans while apparently vacationing with
her attractive and attentive silver-haired male companion. The
 K.K. Barker / Social Science & Medicine 73 (2011) 833e842
commercial opens with the woman explaining, “My fibromyalgia
muscle pain wasn’t something you could see, but I felt it all over.
Some days I had to push myself to leave the house and do everyday
things. Then my doctor told me about Lyrica.” This commercial
introduces one of the cardinal features of the fibromyalgia illness
experience, namely the consequences of living with an illness that
is not visible to others. Fibromyalgia sufferers hate being told that
they don’t look sick, because such comments implicitly or explicitly
suggest they are mentally unstable or malingering (Barker, 2005).
This is especially noteworthy in the relationship to another
element of these commercials. The women characters in both of
these advertisements emphatically state, “Lyrica is not an anti-
depressant.” Pfizer must understand the importance of empha-
sizing this point as a way of affirming fibromyalgia sufferers and
validating the diagnosis (i.e., Lyrica is not an anti-depressant ergo
fibromyalgia is not a mental illness). Additionally, Pfizer is dis-
tinguishing itself from its new competition. By the time the second
of these ads aired, Cymbalta had received FDA approval for fibro-
myalgia and Savella’s approval was imminent. Perhaps to further
distance the disorder from depression, these two ads are far less
dark and distressing in mood than is the original commercial. In
contrast to the suffering woman sitting and reading from her diary,
these commercials are literally “sunny” and more strongly empha-
size the women’s improved function. By linking use of the drug to
pleasurable leisure activities, the positive emotional appeal (Frosch
et al., 2007) is more strongly conveyed in these ads than is the case
in the original commercial. The active woman with fibromyalgia
becomes even more central in the next wave of Lyrica commercials.
Two new commercials appeared in 2009. In both of these
advertisements the women who are portrayed with fibromyalgia
are at work. One commercial centers on a woman who looks as if
she either owns or manages a high-end bakery. It opens with the
women saying, “My muscles ached all over. I felt this deep,
lingering pain that was a complete mystery to me. My doctor
diagnosed it as fibromyalgia muscle pain and then he recom-
mended Lyrica.” She goes on to explain, “Fibromyalgia is thought to
be the result of overactive nerves that cause widespread pain.
Lyrica is FDA approved to help relieve the unique pain of fibro-
myalgia.” The woman is then shown warmly greeting her public
and working long hours in order to create elaborate and beautiful
confections. Now that she takes Lyrica, she explains, she has less
pain and can do more. Surrounded by pastries of her own creation,
she asks, “How sweet is that?”
The other 2009 commercial portrayed a university professor in
an empty lecture hall at the end of her class session. The professor
tells the television audience, “I had chronic muscle pain all over,
and I was so tender to the touch, but I didn’t know why. My doctor
diagnosed it as fibromyalgia and then he recommended Lyrica.”
Like the baker who found her pain “a complete mystery,” this
commercial addresses the lack of public awareness about fibro-
myalgia; even a university professor was bewildered by her pain
symptoms. Now, however, the professor educates the audience,
using the same lines as the baker regarding “overactive nerves” and
Lyrica’s ability to relieve the “unique pain” of fibromyalgia. Also like
the ad featuring the hard-working baker, this commercial empha-
sizes the transformative potential of the drug. With the professor’s
voiceover listing the drug’s side effects, she is shown walking across
campus with her briefcase in tow, smiling and greeting students,
and joining colleagues for espresso at an outdoor cafe. The
commercial ends with the professor asking the viewing audience:
“Could your pain be caused by Fibromyalgia? Ask your doctor about
Lyrica today.”
Like the previous commercials, these two follow the narrative
outlined by Frosch et al. (2007) (control lost, control regained, and
concomitant social rewards). But unlike the earlier versions, these
837
advertisements emphasize identifying one’s mysterious pain as
fibromyalgia as an intervening step toward regaining control over
one’s life. Whereas the narrative in the earlier commercials is
premised on the assumption that the viewers, like the women
portrayed, already have a fibromyalgia diagnosis, the women in
these two commercials describe how their doctors diagnosed their
inexplicable pain as fibromyalgia. The simple statement, “My
doctor diagnosed it as fibromyalgia” grants both the diagnosis and
the pain validity. Additionally, instead of telling the audience that
fibromyalgia is a “real” condition and that Lyrica is “not an anti-
depressant,” the women in these ads provide a brief medical
explanation for fibromyalgia and explain how Lyrica relives the
“unique pain” of fibromyalgia in medical terms. Both women are
shown in demanding jobs, rather than reading from a diary,
vacationing in New Orleans, or gardening, which lends additional
symbolic credibility to these women’s explanation and experience
of fibromyalgia. There are additional symbolic benefits of featuring
women at work. In the same fashion that the advertising campaign
counters the notion that women with fibromyalgia are imagining or
exaggerating the symptoms, it must also counter the related notion
that fibromyalgia sufferers are malingers. As portrayed, these
women are not using a diagnosis to skirt workplace responsibilities.
The career woman and the medical science of fibromyalgia are
also narrative elements in the final Lyrica commercial to air during
the period studied. This commercial, which first aired in the spring
of 2010, expands on the account of “overactive nerves” introduced
by the baker and the professor (Pfizer Inc., 2010a). The commercial
features a very chic and attractive woman fashion designer in her
fifties. She is shown sketching the design for a dress, selecting and
cutting the perfect fabric, and carefully fitting the garment on
a youthful model. Prior to this, the woman touches her shoulder
and the viewer sees a visual presentation of her muscles tissue;
then, traveling into the central nervous system, the viewer sees an
image meant to depict “overactive” neural firing upon which the
word “FIBROMYALGIA” is superimposed (Fig. 1). With these images
on the screen, the woman narrates:
 I had ongoing pain; a deep ache all over. I found out that
connected to our muscles are nerves that send messages
through the body. My doctor diagnosed it as fibromyalgia,
thought to be the result of overactive nerves that cause chronic
widespread pain. Lyrica is believed to calm these nerves. I
learned Lyrica can provide significant relief from fibromyalgia
pain. So now I can do more of what I love.
The commercial ends with the woman telling the viewing
audience, “I found answers about fibromyalgia. Then I found Lyrica.
Ask your doctor about Lyrica today.” Along with depicting the pre-
Lyrica limitations and the post-Lyrica freedoms, this commercial
Fig. 1. “Overactive Nerves” Lyrica Commercial (Pfizer Inc., 2010a)
838 K.K. Barker / Social Science & Medicine 73 (2011) 833e842
strongly emphasizes the importance of becoming aware of fibro-
myalgia as part of this transformation. Among other things, this
makes clear that, like the ads featuring the baker and professor, the
principal target audience are individuals who are not yet diagnosed
with fibromyalgia and may have never heard of the diagnosis before.
A particularly noteworthy aspect of this ad is its use of a visual
image to depict the bodily mechanisms said to underlie the
disorder. The image promotes the theory that fibromyalgia is
a neurochemical aberration referred to as central sensitization.
Using a visual image to represent a disease that in fact lacks any
visible biomedical properties is a potent symbolic strategy. After all,
scientific imagery and biomedical authority go hand in hand (Joyce,
2008). Although the image is merely a dramatization, it seems
intended to look real (i.e., a high-tech image of disordered neural
functioning) and viewers are likely to believe that they are actually
looking at the organic basis of fibromyalgia. The important cultural
association between biomedical visibility and reality is well
deployed by Pfizer with the result that this 60-second commercial
implicitly confirms the existence of fibromyalgia.
The DTCA campaign for Lyrica has evolved since the first
commercial appeared in 2007. Nevertheless, some of the
campaign’s elements have remained consistent. Without question,
the pharmaceutical resurrection that allows the individual to
become more active, is the dominant narrative thread in all six
commercials. Applicable here is the concern of many clinicians and
scholars that DTCA suggests that the ability to work and play hard
and live a happier life is just a prescription away (Fox & Ward,
2008). Extrapolating from clinical trials, Lyrica does provide some
symptom relief for some people. As observed in other DTCA
campaigns, however, the Lyrica ads portray the best-case scenario
rather than the average benefit to the average person (Frosch et al.,
2007). Accentuating positive outcomes is likely to result in unre-
alistic expectations on the part of some consumers and also to lead
them to deemphasize potential adverse reactions. The use of
slender women in all of the commercials, for instance, counters one
of the most common side effects of Lyrica, significant weight gain.
In the commercial featuring the professor, at the exact second that
“suicidal thoughts and tendencies” are listed as a possible side
effect, the screen fills with a burst of glorious sunshine coming
through the trees engulfing the professor in a warm glow. This
cannot be a coincidence and it seems troublingly manipulative
given the desperation for relief among chronic pain sufferers.
The status of fibromyalgia as a “real” illness (i.e., not a mental
illness) has also been a prominent feature of the DTCA campaign for
Lyrica from the onset. In the earlier commercials Pfizer disassoci-
ates Lyrica from anti-depressants in an effort to conceptually
distinguish fibromyalgia from a mental illness designation. The
later commercials promote the theory that fibromyalgia is
a disorder of central sensitization, eventually using imagery to
connote its organic nature. By having the women explain that their
heretofore mysterious pain was diagnosed as fibromyalgia by their
doctors, the later commercials add a new narrative element to
bolster fibromyalgia’s diagnostic legitimacy. By featuring women in
the workplace, the latter commercials also symbolically assert that
fibromyalgics are not malingers. At each step, the process of legit-
imating fibromyalgia in the DTCA campaign has been fundamen-
tally tied to the feminization of the disorder. On one hand the very
premise of the campaign, that fibromyalgia is a real disorder, vali-
dates women’s experience, even if used as a tactic for tapping into
a lucrative market. On the other hand, in an effort to portray the
women as credible and the drug as effective, the campaign’s
representation of fibromyalgia bears little resemblance to the
reality of fibromyalgia for most sufferers. The gulf between fibro-
myalgia as represented in DTCA and as a lived experience will be
addressed in more detail later in the paper.
These efforts on the part of Pfizer to legitimate fibromyalgia in
effect pick up where the ACR criteria left off with respect to
advancing fibromyalgia toward a more fully accepted medical
phenomenon. Whether or not Lyrica can complete what has thus
far been a partial medicalization of the fibromyalgia diagnosis, sales
of the drug shot up dramatically in the wake of the FDA approval.
The 2007 revenues for Lyrica were $1.8 billion, an increase of 58
percent from the previous year (i.e., prior to the drug’s approval for
fibromyalgia). Sales in 2008 and 2009 also increased dramatically
($2.6 and $2.8 billion respectively). In 2009, the only Pfizer drug
with higher revenues than Lyrica was Lipitor. Lyrica sales even
outpaced those of the company’s highly visible blockbuster Viagra
(Pfizer Inc., 2008, 2009, 2010b). Industry experts predict continued
robust increases through 2018, aided in no small part by Pfizer’s
DTCA campaign (Hohenberg et al., 2007). These numbers are
impressive but they only tell us part of the story. I now examine the
response of fibromyalgia sufferers to Lyrica.
Pharmaceutical optimism: a drug of one’s own
One of the most important observations about posts to Fibro
Spot concerning Lyrica (pregabalin) is that they began to appear
several years before the drug received FDA approval for any indi-
cation. There are posts, for example, summarizing a clinical trial of
pregabalin for fibromyalgia in 2004; posts announcing the FDA
approval of the drug for the treatment of neuropathic pain disor-
ders in 2005; and then a flurry of posts from individuals reporting
back to the group about their own experience taking the drug on an
off-label basis prior to its subsequent approval for fibromyalgia in
June 2007. This is an important observation because it makes clear
that participants at Fibro Spot did not learn about Lyrica from the
DTCA campaign. Instead, they had been eagerly following the
development of this new drug option for years. This fact requires an
appreciation of the overwhelming symptom experience of fibro-
myalgia, the condition’s exceedingly poor response to existing
medical treatments, and the desperation many sufferers feel for
some symptom abatement. In this regard their interest in pre-
gabalin was no different than their interest in any promising drug
treatment option on the horizon.
Even though Lyrica was already on the radar of many Fibro Spot
participants, they were nevertheless enthusiastic about the drug’s
approval for fibromyalgia. In the eyes of most sufferers and advo-
cates, the FDA approval represented a tremendous victory. Fibro-
myalgia advocacy groups, like the National Fibromyalgia
Association (NFA), marked the event as an important step toward
destigmatizing the condition and those it afflicts. Lynn Matallana,
the NFA President was quoted in the New York Times: “The day that
the F.D.A. approved a drug and we had a public service
announcement, my pain became real to people” (Berenson, 2008).
President Matallana also posted the following statement on the
NFA website announcing the FDA approval of Lyrica:
 The National Fibromyalgia Association has been working for
over ten years to raise awareness of fibromyalgia and its
debilitating chronic pain that affects the lives of 6 to 10 million
people in the United States. During that time, we have also
been hoping and waiting to have an effective drug treatment
approved by the FDA specifically for fibromyalgia so that we no
longer have to hear our health care providers tell us “there is
nothing I can do for you,” or worse, the pain is “all in your
head.” .[N]ow more than ever we are hopeful that public and
medical awareness will improve and patients will have an
effective treatment that could help reduce their suffering. The
future is bright indeed (Matallana, 2007).
 K.K. Barker / Social Science & Medicine 73 (2011) 833e842
Like Matallana’s NFA statement, posts on Fibro Spot similarly
capture the felt significance of having a drug of one’s own. The
following exchange is illustrative in this regard:
 A huge step for FM was made today. The NFA posted an article
that today a drug was approved by the FDA for the treatment of
FM, Lyrica. Progress is being made!
 [A]bout LYRICA, i tried it some time ago and it didn’t help me
but hopefully it helps others. at least there is a drug being used
to help some people with FIBROMYALGIA. may be people will
now understand that it is real and not just in our heads.
 Thanks so much for the news about Lyrica. May be now that
there is a drug for it, docs will take fibro more seriously.
These and other posts foreground the meaning of a fibromyalgia
drug in terms of potential therapeutic progress, diagnostic accep-
tance, illness recognition, and personal validation. Even individuals
who know the drug offers them no therapeutic hope recognize
Lyrica as a symbolic victory. As gleefully noted by one poster, the
general public is likely to conclude that, “[i]f there is a medication
for it then it MUST be real!”
When the first Lyrica television commercial aired it was an
instant topic on Fibro Spot. Participants were quick to realize that
the DTCA campaign could do more to spread the word about
fibromyalgia than all their previous efforts to explain their invisible
illness to doctors, family, and friends. The following post from Fibro
Spot captures the reaction of many participants, as well as the
general buzz at other online fibromyalgia communities.
 I just HAD to tell you all that in the last week I had 2, yes 2
people ask me about my fibro. They said they did not know it
was a real disease until they saw the commercial about Lyrica!
Its not enough for US to tell them. Noooooooo.they have to
see it on TV. [.] We have been telling the truth to family and
friends forever. [.] I think that Lyrica commercial is going to be
one of the best things that ever happened to us.whether the
med helps or not. It somehow validates us as human beings
that have a debilitating illness not just the hypochondriacs they
thought we were!
Lyrica commercials, it seems, are more capable of speaking
authoritatively about the reality of fibromyalgia than are sufferers.
Similarly hopeful, another participant applauded the advertise-
ment for its ability to “help us with those who do not recognize our
‘silent illness.’”
These comments concerning the FDA approval Lyrica for the
treatment of fibromyalgia and the ensuing DTCA campaign make
clear that Fibro Spot participants hope that the approval and
marketing of a prescription medication can do what has not yet
been accomplished. Namely, legitimize the fibromyalgia diagnosis
and corroborate their suffering. This route to diagnostic and
personal validation hinges on whether the medical community and
the general public will listen to Lyrica; that is, endow a prescription
medication with the cultural authority to define what is medically
real. In this regard, the actual force of pharmaceutical determinism
remains to be seen. It is, however, already clear that the portrayal of
fibromyalgia advanced by Pfizer is seen as problematic in the eyes
of many sufferers.
Pharmaceutical Realism: the limitations of Lyrica and its DTCA
representation
Shortly after these data were collected, Fibro Spot, which had
been in existence for more than a decade, disappeared. Ironically, in
a previous article I noted that Fibro Spot had remarkable staying
839
power among online illness support groups (Barker, 2008).
Although the group membership was still strong, the world of
online illness support has changed dramatically in the last several
years. It has become more concentrated and corporately backed
(e.g., Web M.D.) and has also moved onto social networking sites
(e.g., Facebook). One can assume that some Fibro Spot members
dispersed to better-financed forums and those hosted on newer
technological platforms. Unfortunately, this makes tracking their
responses to the evolving DTCA campaign for Lyrica impossible.
One can, however, readily gauge the reactions to the Lyrica
commercials as expressed by fibromyalgia sufferers in a number of
online venues. The early response shared the same optimism
expressed at Fibro Spot that the commercials are getting the word
out and increasing awareness about fibromyalgia. But this hope
quickly gave way to heated criticism. As is plainly evident in the
posts on Fibro Spot, sufferers want the commercials to do much
more than sell a new drug to treat fibromyalgia through the use of
glamorous images and exaggerated claims. Among other things
they want the commercials to accurately explain the experience of
fibromyalgia to the general public and silence medical skeptics. On
this score the DTCA campaign is judged to be an utter failure. There
is widespread anger that the women depicted with fibromyalgia in
the commercials are too beautiful, too fit, too active, and too
transformed by the medication. One fibromyalgia blogger captured
the opinion of many when she asked, “So, where does the middle-
aged frump (me) see herself in this ad?” (http://eclecticwoman.
wordpress.com).
But, by far the most intense criticism of the advertising
campaign emphasizes its perceived gross mischaracterization of
fibromyalgia. The commercials, many bemoan, give the troubling
impression that fibromyalgia is something akin to a headache;
a minor ailment that is easily and fully remedied by a single pill. It
takes only a few minutes of online searching to tap into the
widespread outrage at the implication that Lyrica will miraculously
restore their health and allow them to reclaim an active lifestyle.
The following comments mirror those of many others:
 I hate the TV commercials on Lyrica because it makes it seem
that ‘if you take Lyrica you can live a normal life’ What a bunch
of crap!” (http://www.healthcentral.com/chronic-pain/c/
365418/110033/comments/).
 It’s a horrible drug with a misleading commercial showing
women still working and enjoying life when there is no
enjoying life with Fibro (http://forums.commercialsihate.com/
forum_posts.asp?TID¼5825)
Posts and comments from a variety of forums suggest that the
commercials should depict real fibromyalgia sufferers sharing their
actual experiences with the drug. The following blog post uses
humor to make the point:
 Let’s all get together and make a real Fibro commercial, it
would take them months to videotape us getting out of bed,
trying to open soda cans or jars, trying to go to work, do our
hair or get dressed, trying to sleep. They would give up
filming us after about a week of it!! (http://eclecticwoman.
wordpress.com)
There were also a number of suggestions, some tongue-in-cheek,
for commercials that portrayed the potential side effects of the drug,
such as showing women made so fatigued they cannot get out of
bed, so dizzy they cannot walk in a straight line, and so bloated and
overweight they cannot move.
There is well-founded concern that when DTCA campaigns
accentuate positive outcomes, as they invariably do, some
840 K.K. Barker / Social Science & Medicine 73 (2011) 833e842
consumers develop inflated expectations about what the drug can
accomplish (Frosch et al., 2007). What stands out in this case is how
strongly fibromyalgia sufferers resent that the commercials create
an unrealistic public expectation about what both Lyrica and they
themselves can do. The following comments describe the situation
this way:
 “[H]ow many people believe those commercials. I hear that all
the time. ‘Why don’t you just take that Lyrica pill, you will feel
better in no time.’ Yeah, right!” (http://www.prohealth.com/
me-cfs/blog/boardDetail.cfm?id¼1257217).
 “I hate that commercial. It makes most of my friends/family
think I can swallow a pill and be healed. Very misleading”
(http://www.facebook.com/topic.php?
uid¼321530056520&topic¼12165).
Of course what is so troubling to sufferers about this disjuncture
is that it reconnects with their long-standing struggles to have their
illness taken seriously. If Lyrica does not restore them to health, as
seen on television, and in the vast majority of cases it will not, this
could be used to confirm that their problem is all in their head, that
they are hysterical, or that they do not want to get better. The
following comments are illustrative of what sufferers think:
 I was saddened by these commercials because they hawk
a “miracle” that just doesn’t exist, they give a false impression
of what the pills actually do, they give the uninformed/
uncaring people in my life yet more misguided ideas about how
I am “not really trying”.I agree that these ads are a complete
and utter joke and do more harm than good (http://www.
wearefibro.org/michellehamilton/discussions/837).
 These commercials are completely unrealistic and unfortu-
nately people believe what they see on TV. My family sees
a commercial like this and they believe this one little pill will
fix me. And if it doesn’t then I either must be exaggerating or
it’s somehow my fault that I’m not getting better (http://www.
dailystrength.org/c/Fibromyalgia/forum/9639628-another-
new-commercial-lyrica).
These angry comments reveal a critical stance toward pharma-
ceutical advertising. Very few of the women, even among those
who had not tried the medication, were passively or uncritically
“buying” the advertised message.
Juxtaposed to these comments concerning the DTCA campaign,
are the experiences of those who were taking or had taken Lyrica.
As noted there were posts on Fibro Spot reporting individual results
of pregabalin (Lyrica) use years before the drug’s approval for
fibromyalgia. Motivated in no small part by the near total ineffec-
tiveness of existing treatment options, a number of Fibro Spot
participants started taking Lyrica on an off-label basis shortly after
it was approved for neuropathic pain disorders in 2004. As is the
custom at Fibro Spot, members reported back to the group about
their new drug ventures. From the beginning the accounts of their
use of Lyrica were fairly tempered.
Their stories can be summarized thusly: a very small number of
success stories, some of which turned out to be short lived, a few
reports modest lackluster benefits, more accounts of insignificant
benefits, and numerous chronicles of side effects, most often
resulting in discontinued use. One woman who had been taking the
drug for a year said it worked better than anything she tried: “It
isn’t a cure all” but, without it she continued, “I wouldn’t be able to
get out of bed in the a.m.” The most positive testimonial came from
a woman who described Lyrica as “a miracle drug.” Prior to taking
the drug her pain was so severe she was unable to function even on
high doses of narcotic pain medications. After being on Lyrica for
just over a month, she was able to bake bread with her grand-
children and join a gym. Unfortunately two months later she
reported that her miracle drug was no longer providing her with
any relief. Others described the all-too-common experience of the
drug working for a while, only to wear off:
 I’ve tried the Lyrica, it was like a miracle drug the first three
weeks. Then the dragon symptoms slowly crept back in to the
point where they were before. [.] That’s not saying it won’t
help someone else. I pray that it does. At least the word is
getting out there that FM is a real disorder, and not “all in our
heads.”
A number of women reported significant pain reduction, but at
the expense of side effects that they found simply too much to
endure.
 I was just on Lyrica. Love it. No pain for weeks. So good I made
all kinds of excuses as to why I was turning red and itching
everywhere. Had bumps start showing up and becoming sores.
Told everyone (including me) it must be the cats. Never allergic
to them before but what the hell. Finally feet and hands swelled
up and doc took me off med.
The views expressed on Fibro Spot concerning the drugs efficacy
parallels that seen on other online venues. There are a small
number of individuals who report benefits with Lyrica, most often
in combination with several other drugs; and, even then, the gains
sometimes come with significant side effects. There are a few
reports of a modest reduction in pain, many reports of no
improvement at all, and a catalog of complaints including fatigue,
weight gain, vertigo, hallucinations, mental confusion, painful
swelling of hands and feet, itching and rashes, and suicidal
thoughts. Even taking into consideration the few individuals who
describe Lyrica as “a miracle drug” or “life saver,” there is no
evidence found online of lives transformed as radically as seen in
the best-case scenarios portrayed in the televisions commercials.
Obviously the posts on Fibro Spot and a perusal of online chat is
no substitute for randomized, double-blind, placebo-controlled
clinical studies. In general, these online comments are not incom-
mensurate with the findings from the two clinical trials used to
support the FDA approval of Lyrica. These studies, which were
subsequently published in 2008, found non-dramatic but statisti-
cally significant improvements in pain and other fibromyalgia
symptoms between patients on pregabalin compared to those
taking a placebo. In one study, the difference in self-reported pain
ratings between these groups was 4.66 vs. 5.64 on a scale of 0 (no
pain) to 10 (worst possible pain) (Arnold et al., 2008). This study also
found that those on pregabalin had improved scores on a widely
used patient scale or questionnaire designed to evaluate the impact
of symptoms on overall level of functioning, but found no such
improvements in scores on another commonly used patient ques-
tionnaire. The other study’s primary outcome measure was the
length of time patients reported some therapeutic response. The
main finding: “[P]regabalin was associated with a significantly
longer time to worsening than was placebo” in terms of reported
pain level and some other fibromyalgia symptoms including fatigue
and sleep disturbances (Crofford et al., 2008: 429). In other words, it
took longer for any meaningful benefits of the drug to wear off than
it took for any meaningful benefits of the placebo to wear off. Even
these nominal differences between treatment and placebo groups
in these studies, however, may be partly a methodological artifact.
The first study excluded individuals who did not respond favorably
to the drug in a short trial phase of the study prior to randomizing
subjects into the treatment and placebo groups. The second study
 K.K. Barker / Social Science & Medicine 73 (2011) 833e842
excluded individuals who were “placebo responders” during a one-
week phase of the study prior to randomizing individuals into the
treatment and placebo groups. By removing the individuals not
likely to respond to the drug in one case, and those most likely to
respond to the placebo in the other case, researchers maximized the
probability of demonstrating the drug’s efficacy compared to
a placebo. Both studies were funded by Pfizer.
Discussion
Although the pharmaceutical industry did not play a central role
in creating the fibromyalgia diagnosis, it has become instrumental
in its promotion and promises to become even more so in the
immediate future. After the establishment of the ACR criteria,
pharmaceutical companies seeded peer-reviewed clinical research
that resulted in the criteria’s propagation (Hadler & Greenhalgh,
2005). In addition, the pharmaceutical industry has supported
fibro-friendly physicians and sponsored physician education about
fibromyalgia. All of these efforts have been aimed at convincing
physicians that fibromyalgia is a discrete disease entity. This
strategy has met with only limited success; many physicians are not
yet persuaded (Wolfe, 2009).
The DTCA campaign for Lyrica and the campaigns for other
fibromyalgia drugs that will soon follow, represent the next phase
in the promotion of the fibromyalgia diagnosis. There is much
riding on Lyrica. Not just because fibromyalgia sufferers long for
some symptom relief, but also because the very existence of
approved drugs shores up a biomedical account of the disorder.
Rather than a collection of pills for a collection of ill-defined
symptoms, Lyrica contributes to the reification of fibromyalgia. As
new drugs receive FDA approval for fibromyalgia and other con-
tested diagnoses, the logic of pharmaceutical determinism will
similarly reveal itself. That is, a central rhetorical feature in the
DTCA campaign for these drugs is bound to use the existence of an
approved medication to corroborate the existence of the contested
condition itself. Pharmaceutical companies are likely to market
medications targeted at conceptually peeling off many contested
illnesses currently lumped together as functional somatic disorders
in the medical literature.
Even though Pfizer’s promotion of the fibromyalgia diagnosis
endorses its drug and increasing its profits, in the process it
threatens to discredit the suffering of individuals with fibromyalgia.
In this way, the DTCA campaign is both a blessing and a curse in the
eyes of those already diagnosed. Getting the word out about
fibromyalgia has long been seen as a necessary step toward legiti-
mization, but getting the wrong word out is not what most would
have hoped for. Although sufferers might have been able to over-
look the fact that the women featured in the Lyrica ads are beautiful
and bourgeois, it is more difficult to overlook the fact that the
commercials portray fibromyalgia as a condition that is readily
overcome. While it’s easy to understand why sufferers hoped that
Lyrica could vindicate them, depicting their disease as an unre-
lenting and encumbering condition, even when tempered by the
medication, would not be a lucrative marketing strategy. So it is
that the result of the DTCA for Lyrica is that it simultaneously
medicalizes and trivializes women’s suffering. The gap between the
DTCA portrayal of fibromyalgia and the reality of fibromyalgia can
be discrediting. The commercials threaten to cast any individual
sufferer who continues to be mired in her illness, given the avail-
ability of this proven medication, as hysterical. Pharmaceutical
determinism, therefore, may bolster the cultural creditability of
a diagnostic category and still fail to validate an individual’s illness
experience.
The Lyrica campaign is apt to contribute to medicalization
by producing a new cohort of fibromyalgics. The more recent
841
commercials target those not yet diagnosed by encouraging
primarily middle-aged women to indentify their common symp-
toms as fibromyalgia. Symptoms do not a disease make; and, yet,
when it comes to medically unexplained symptoms “society does
not readily grant permission to be ill in the absence of disease”
(Nettleton, 2006: 1167). The DTCA commercials for Lyrica d and
those for future drugs targeting contested illnesses d will simply
provide a new venue for access to diagnoses for which there is
already considerable hunger. Because they have more health
complaints then their male counterparts, women are more likely to
identify with DTCA narratives that suggest that their pain, fatigue,
and other common symptoms are signs of particular disease entities.
If asking your doctor for a specific diagnosis is akin to asking him or
her for a specific prescription medication, physicians are likely to
comply. Their compliance is even more likely given that the diag-
nostic criteria are so accommodating that it is essentially impossible
not to diagnose every patient who reports widespread pain of
unknown origins with fibromyalgia (Cohen, 1999). Furthermore, the
fact of the matter is that these drugs are a boon to health care
providers and institutions. Contested illness patients are notoriously
time and resource intensive in institutional settings where time is
a premium and resources are managed (Barsky & Borus, 1995). New
medications targeting this difficult population give clinicians
something to offer their beleaguered patients that is relatively cost
and time effective, even if it may not be particularly therapeutically
effective. The approval of drugs for contested illnesses will thus
encourage skeptical physicians and cynical managed care organi-
zations to contribute to the propagation of these diagnoses. The
analysis presented here strongly suggests such outcomes but
research assessing the empirical relationship between DTCA and
increases in contested illness diagnoses is necessary.
The above observations draw our attention to the complex
character of pharmaceutical determinism as played out in this case.
The logic of pharmaceutical determinism encourages sufferers to
experience the FDA approval of Lyrica for the treatment of fibro-
myalgia as an unambiguous victory; this, despite their anger at or
critical stance toward the DTCA campaign, or their personal expe-
rience of the drug’s limited effectiveness or concomitant side
effects. Clinician’s interpretations and actions are likewise shaped
by the mere existence of Lyrica as an approved drug for fibro-
myalgia. In other words, the deterministic capacities of pharma-
ceuticals (i.e., subsequent beliefs and actions are determined by the
existence of a drug) are at work even when the key players e
patient consumers and clinicians e have a host of misgivings about
the pharmaceuticals and diagnoses in question.
The medicalization of women’s distress under the rubric of
fibromyalgia has been woefully ineffective. Fibromyalgia has not
responded well to medical management (Goldenberg et al., 2004;
Wolfe & Michaud, 2009). It seems unlikely that any medical inter-
vention, including pharmaceuticals, will offer significant relief to
a considerable number of individuals diagnosed with fibromyalgia.
This is not because those with fibromyalgia are hysterics or
malingers, but because fibromyalgia is a conceptual label applied to
so many common symptoms whose origins are varied and complex.
I am not suggesting that women’s common symptoms are incon-
sequently or insufficiently worthy of redress. The important point is
to recognize the consequences and limitations of framing women’s
common distress as a discrete disease entity. Fibromyalgia sufferers
and advocates promote the theory that fibromyalgia is a neuro-
chemical aberration and now point to the FDA approval of Lyrica to
support this conclusion. However, this theory of fibromyalgia
cannot account for the disorder’s overwhelming feminization
(Barker, 2005). Here the insights of feminist scholars vis-à-vis
medicalization are indispensable. When we define women’s
problems as medical in nature, we disregard the fact that gender
842 K.K. Barker / Social Science & Medicine 73 (2011) 833e842

practices and gender inequality negatively impact women’s health Greene, J. (2007). Prescribing by the numbers: drugs and the definition of disease.
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Acknowledgments Cambridge: Cambridge University Press.
Loe, M. (2004). The rise of viagra: how the little blue pill changed sex in America. New
York: New York University Press.
The author thanks Tasha Galardi, Val Burris, four anonymous Lorber, J. (1997). Gender and the social construction of illness. Thousand Oaks, CA:
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Manu, P. (2004). The psychopathology of functional somatic syndromes: neurobiology
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