The user has become central to the way technology is conceptualized, designed, and studied in sociotechnical research and human-computer interaction; recently, non-users have also become productive foci of scholarly analysis. This paper argues that a focus on individualized users and non-users is incomplete, and conflates multiple modes of complex relation among people, institutions, and technologies. Rather than the use/non-use conception, I argue for conceptualizing users as networks: as constellations of power relations and institutional entanglements, mediated through technologies. To illustrate, I offer a case study of Nexafed, a tamperproof formulation of pseudoephedrine. The market for Nexafed seems nonexistent in traditional use/non-use terms, but when we construe the user more broadly — as a network of interpersonal, legal, and institutional relationships, consisting of multiple modes of relation between people and technology — not only does the drug’s market make sense, but we also understand how new motivations (social shame, mistrust, robbery, gossip) can act as salient drivers of technology use. The Nexafed case illustrates the utility of a networked perspective to develop more nuanced theoretical understandings of use and non-use in sociotechnical relations, beyond the direct human-technology interface.
When consumer products are developed for the market, producers and investors typically think of users as the relevant audience. Designers are encouraged to think in terms of the user’s needs, habits, problems, capabilities, and goals when making decisions about the features of a product or interface of a Web site; user experience is a growing subfield of technology education and research; “user-centered” has become a watchword of conscientious design.
Sociotechnical research has largely followed suit. Human-computer interaction, mediated communications scholarship, social informatics research, and other related fields all emphasize the relation between a technology and its user. As Satchell and Dourish  put it succinctly: “the figure of the user lies at the heart of HCI.” Increasingly, non-users have also (productively) become part of the sphere of scholarly inquiry around technology and its interactions. In both cases, the individual user or non-user is most commonly constructed as the unit of analysis, and his or her relationship with the technology as the relevant sphere of inquiry.
In this paper, I argue for a broader conceptualization of use and non-use. I suggest that the current focus on (implicitly) individual use and non-use is incomplete, and conflates numerous interdependent, complex modes of relation among people, institutions, and technologies. An individualized use/non-use model simplifies and obscures many of the motivations and social dynamics that inhere in sociotechnical relations. As an alternative, I propose conceptualizing users as networks: as constellations of power relations and institutional entanglements, mediated through technologies.
To illustrate, I offer a case study of Nexafed, a new tamperproof pharmaceutical formulation of pseudoephedrine (a common remedy for nasal congestion — and, more controversially, a key precursor chemical for the manufacture of methamphetamine). When we consider Nexafed’s use cases in traditional use/non-use terms, its market appears nonexistent. But if we construe the user more broadly — as a network of interpersonal, legal, and institutional relationships, consisting of multiple modes of relation between people and technology — not only does the drug’s market snap into focus, but we also understand how new motivations (social shame, mistrust, robbery, gossip) can act as salient drivers of its use. Expanding the ecosystem of inquiry to the network, I argue, is a fruitful way forward for the conceptualization of the user and non-user — one that helps us to develop a more nuanced and complete analysis of sociotechnical systems, which accounts more fully for dynamics of social and political power.
2.1. Expanding conceptions of use
Canonical work on use and users has fundamentally considered the co-constructive relationships between users and technologies: how users shape, co-design, and interpret technologies, and how those technologies in turn impart various scripts of action onto the user (Pinch and Bijker, 1984; Akrich, 1992). More recently, a productive line of research has explicitly considered non-users, not simply as a pool of potential users or “not-yet” users, but as a heterogeneous set of actors — whose variable relationships with technologies, stemming from multiple motivations and assuming multiple practical forms, run the gamut from voluntary rejection to sociotechnical exclusion to active resistance (Wyatt, 2003; Satchell and Dourish, 2009; Oudshoorn and Pinch, 2003). The move from examination of (solely) use, to both use and non-use, has been a fruitful step in understanding how technologies can function as instruments of social exclusion. Other recent work, following on the theoretical development of the non-user, aims to reframe use and non-use as a continuum or spectrum. This perspective rejects a categorization of use and non-use as being overly simplistic, especially around issues of differentiated access (e.g., Internet connectivity) (Lenhart and Horrigan, 2003). This subsequent move to a spectrum model characterizes use and non-use states as fluid, multivalent, and unstable, rather than as immutable and distinct elements of identity (Harmon and Mazmanian, 2013; Baumer, et al., 2013).
The concept of non-use, and models that take non-use (and non-users) seriously, are productive in that they posit that there is more than one mode of engagement between people and technologies. Non-users and their reasons for not using can tell us as much about sociotechnical relations as can users’ reasons for using. Reasons for non-use, like use, are embedded in broader social structures (Satchell and Dourish, 2009), such as limitations on physical or economic access.
This said, the unit of analysis considered in accounts of use and non-use still tends to focus on individual behaviors. Though methodologies for studying use and non-use vary, methods most typically involve inquiring about an individual’s own pattern and level of engagement with a particular technology — often, by surveying or asking respondents directly (see, e.g., Brubaker, et al., 2014, interviewing individuals about their own reasons for leaving Grindr; Leavitt, 2014, asking Google Glass wearers about their own situational non-use of Glass; Baumer, et al., 2013, surveying Facebook users and non-users about their own behaviors and preferences regarding leaving Facebook; Schoenebeck, 2014, scraping Twitter data and interviewing subjects about their own temporary non-use of social media for Lent). This focus, while quite productive for developing a picture of individuals’ own engagements with technology through use or non-use, leaves little room for understanding how broader relations are mediated through use — or, to put it another way, how people and institutions can “peripherally experienc[e]”  technologies and be materially impacted by them, without being categorized vis-à-vis use.
Most contemporary models of use, then — even as they differentiate among degrees of use and acknowledge the fluidity of use states — still conceptualize the user (or non-user) as a fairly isolated unit with respect to her engagement with the technology in question. Though the spectrum model helps us to acknowledge political power in some ways (e.g., by highlighting that some people do not use a technology because they lack social or economic access to it, rather than because they have voluntarily opted out), I suggest that it obscures a number of other social dynamics, which emerge only when networks of institutional and interpersonal relation are accounted for. An individual use model fails to account for those who are affected by a technology beyond the ostensible user; moreover, as I will suggest, it fails to illuminate the full range of social and political entanglements that underlie and mediate technological engagement. Thus, I suggest a successive development: that we further expand our unit of analysis from spectra of use to networks of use.
A networked perspective on use and non-use relates to other theoretical perspectives in the study of technology. Most notable among these is the application of actor-network theory to sociotechnical systems (Latour 2005, 1996, 1992; Williams-Jones and Graham, 2003; Prout, 1996; Akrich, 1992). In its simplest form, actor-network theory posits that people and technologies are best understood as networks of mutually constitutive relations with one another, and that non-human objects, as well as humans and organizations, can be interpreted as actants with equivalent degrees of agency. Technologies “do” things as much as people “do,” and only by conceptualizing actants as connected through a dynamic network of interacting entities does a full picture of engagement emerge, in which sociotechnical systems are produced by these actants in concert. Actor-network theory has done much to broaden the scope of sociotechnical analysis by privileging the role of the material in social life. However, to date, very little scholarship has brought an actor-network perspective to bear in particular on models of use and non-use (Sassene, 2009, is a notable exception). My analysis here imports insights from actor-network theory by problematizing the concepts of use and non-use through a network lens.
My construction of use here also resonates with recent theoretical and methodological provocations about the primacy of networks in studies of technology. Marwick and boyd (2014), Levy (2013), and Levy and boyd (2015) posit that individuals’ engagements with surveillance and data-collection technologies can best be understood vis-à-vis their interpersonal relations, and that individually-oriented legal concepts like privacy, rights, and harms must be reframed in light of the networked nature of these engagements. Like those works, I explore here how we might reframe the individually oriented model of use/non-use in light of networked contexts.
Further, Cohen (2005) suggests that HCI researchers expand the concept of use beyond the “suturing” of person to product — an analytic process that, he asserts, “ignor[es] most of the parts of people that don’t come obviously into play when the person is using — literally handling — the product” . Cohen argues that this narrow definition of use fails to recognize the political and economic valences of use and non-use, and suggests that the critical question for design research is: “what relationships of filiation or force get established between the object under investigation, the people who use it, and the people who, in not using it or in peripherally experiencing it, are also affected by it?” . The expansion of inquiry to use networks, as I advocate here, can be understood as a response to this call.
A network model brings social and institutional power back in as central considerations in our conception of use. It does so by countering the underlying assumption of the individual as the unit of analysis in most dominant models of use and non-use, preferring instead to view individuals, institutions, and technologies as entangled in multiple modes of relation. As I suggest via the case study that follows, “use” and “non-use” are conceptually inadequate, and even more sophisticated dialectical models that rest upon them (e.g., the spectrum model) can lead to an incomplete and insufficiently nuanced understanding of sociotechnical reality. The networked model, by contrast, may offer a richer view.
2.2. Studying use as a network
To illustrate the importance of conceptualizing the user in this way, I offer a case study of a specific consumer technology: Nexafed, a new pharmaceutical. My discussion of Nexafed is intended as a sort of demonstration case regarding the analytic value of a network perspective.
The case study — an “in-depth, multifaceted investigation ... of a single social phenomenon”  — is a common analytic strategy across science and technology studies, legal studies, and sociology, among other disciplines (Beaulieu, et al., 2007; Ragin and Becker, 1992). The selection of a particular sphere of sociotechnical relation, centered on a specific technology, can serve as a strategic research site if it “exhibits the phenomena to be explained or interpreted to such advantage and in such accessible form that it enables the fruitful investigation of previously stubborn problems and the discovery of new problems for further inquiry” . I suggest that my investigation of Nexafed’s networks herein constitutes such a site for a “proof of concept” of the value of a networked view of use/non-use, in that analysis of this case offers a much more nuanced account of various motivations for, and types of, engagement among people, institutions, and technologies. In so doing, it aims to bridge between middle-range theoretical development and empirical method in science and technology studies (Gad and Ribes, 2014; Beaulieu, et al., 2007).
The selection of a pharmaceutical for this exploration is also strategic. Perhaps especially in the case of pharmaceuticals, the individual user is perceived as central, and the relationship between a consumer and a medical technology as intimate, bodily, and biological. Even the current iteration of the Wikipedia page for the term “end user” relies on a pharmaceutical example, noting for illustration that “the end user of a pharmaceutical product is the patient who takes it” (Wikipedia, 2015). Yet prior scholarship in sociology, STS, and related disciplines suggests that a complex network of actors, infrastructures, and social and professional norms shapes how decisions are made in this arena, particularly around socially controversial pharmaceutical choices (see, e.g., Williams-Jones and Graham, 2003, on networks surrounding the BRCA genetic test for breast cancer susceptibility; Prout, 1996, on networks surrounding the metered dose asthma inhaler; Dumit, 2012, on the role of pharmaceutical firms and their organizational logics on medicine; Chiarello, 2013, on pharmacists’ changing roles in ethical and medical gatekeeping, and Chiarello, 2011, on social movements’ role in same). Though these works make use of networked perspectives in their analysis, and often focus, in fact, on determinations about use or non-use of a particular medical technology, they do not specifically engage with theoretical models of use and non-use. My analysis draws upon that rich line of research in resituating a model of use and non-use around a pharmaceutical technology.
Methodologically, my analysis here is based primarily upon a review of documentary sources about Nexafed, Acura Pharmaceuticals and other drug companies, and methamphetamine. These included news stories about methamphetamine production, abuse, and associated social practices; state statutory schemes and public-facing documents from the U.S. Drug Enforcement Agency, state regulatory bodies, professional pharmacy boards, and drug companies; pamphlets and online materials provided by Acura to pharmacists and retailers; and media and interest group accounts about ways to combat methamphetamine’s negative effects on communities. Using these sources, I mapped a series of interrelated networks of sociotechnical relations underlying Nexafed’s use.
One could conduct more systematic empirical research about Nexafed’s use (perhaps, for example, conducting ethnographic fieldwork with consumers, pharmacists, the drug’s manufacturers, and/or experts on the methamphetamine epidemic). My analysis here is not intended to substitute for such data collection, nor does it purport to capture the entire range of relevant perspectives regarding Nexafed use. Rather, it is intended to demonstrate how a network-focused analysis of use — one that privileges institutional entanglements and multiplex peripheral engagements as well as direct interactions between human and technology — can unearth an entirely different set of motivations and explanations for use/non-use that typical models are unlikely to surface.
Throughout the analysis, I draw as much as possible from the emic framings used by real-world actors within the field (including institutional actors like retailers, regulatory agencies, and pharmaceutical companies) with respect to Nexafed use and non-use (Morris, et al., 1999). As described above, these frames include legal and regulatory structures and language (e.g., statutory schemes), which often explicitly articulate multiple modes of sociotechnical relation. In addition, I take seriously the persuasive messaging of various actors (via advertising, factsheets, white papers, etc.) as attempts to shape and motivate adoption and use of Nexafed (and, concomitantly, non-use or mis-use of other pseudoephedrine formulations). The emic perspective is useful in developing a middle-range theoretical model of use inductively, based on observation of real-world relationships and actions, rather than trying to apply an abstracted set of categories to such statements and behaviors.
Legal and regulatory frameworks provide particularly useful (and substantially overlooked) bases from which to draw in envisioning networks of use and non-use. In many ways, the law explicitly acknowledges the networked nature of sociotechnical relation to a degree not contemplated by theoretical models. Consider, for instance, Alabama’s statutory scheme aimed at combating methamphetamine abuse (Alabama, 2012). The law prohibits not only “possessing” meth, but also “obtaining” meth or a precursor chemical. It is also illegal to “possess, sell, transfer, or otherwise furnish” pseudoephedrine if a person knows or intends that it will be used in producing meth, as well as to “attempt to solicit another or conspire to possess, sell, transfer, or otherwise furnish” pseudoephedrine for said purposes (a practice known colloquially as “smurfing”). In addition a person cannot “use, deliver, or sell, possess with intent to deliver or sell, or manufacture with intent to deliver or sell, or ... possess with intent to use” drug paraphernalia to manufacture meth. Pharmacies are regulated as well: they are explicitly prohibited from selling pseudoephedrine unless licensed by the state pharmacy board, and are subject to several other requirements regarding drug placement, data tracking requirements, training, and more.
Though this legal scheme may not make for especially riveting reading, it is instructive: it contemplates a number of modes of relation among humans, institutions, and technologies — manufacturing, selling, furnishing, obtaining, possessing, soliciting another to possess, etc. — and inscribes those categories of engagement explicitly onto social life, via statutory language and accompanying regulatory infrastructures. Because legal schemes evidence multiple modes of sociotechnical entwinement, they offer a more nuanced understanding of engagement than is often present in more common use/non-use rhetoric. Review of legal and regulatory documents thus significantly informs my analysis by giving us a sense of multiplexity and institutional entanglement beyond “use.”
Nexafed is a new drug (commercially available since December 2012) marketed by Acura Pharmaceuticals. It is a formulation of pseudoephedrine hydrochloride (HCl), which is known to be a very effective nasal decongestant; pseudoephedrine HCl is the same active ingredient found in Sudafed, Nexafed’s better-known commercial counterpart. Nexafed and Sudafed are pharmacokinetic bioequivalents (see Figure 1): that is, they have the same therapeutic effects, over the same period of time. Sudafed and Nexafed are available at comparable prices, come in the same dosage, and alleviate decongestion in an equally effective way.
Figure 1: Graph demonstrating bioequivalence of Nexafed and Sudafed, from Nexafed Web site (https://www.nexafed.com/).
But Nexafed differs from Sudafed in one important respect: it is tamper-proof. Pseudoephedrine is well known as a key ingredient in many formulations of methamphetamine, or “crystal meth.” Illegal methamphetamine is commonly “cooked” in home-based meth labs using a combination of ingredients distilled from household chemicals, including pseudoephedrine, which is dissolved and mixed with various solvents in order to extract it from the medication. Meth is a highly addictive stimulant known for being a particular scourge in rural American communities, where its use often leads to severe mental and physical health problems, child abuse and neglect, and theft and violent crime (Egan, 2002).
The meth problem sparked Congress to pass the Combat Methamphetamine Act in 2006, which (among other measures) created purchasing restrictions for pseudoephedrine. Under the law, pharmacies must record and verify the identity of pseudoephedrine purchasers; public access to the product must be restricted, typically behind the pharmacy counter; daily and monthly per-customer sales limits apply. Most states also have their own pseudoephedrine regulations (which I discuss in more detail later in this paper). These more stringent regulations, however, are far from “solving” the meth problem. Meth cooks can fairly easily find ways to circumvent the rules — for instance, through practices like “smurfing,” in which a cook pays pharmacy customers to purchase Sudafed or other pseudoephedrine-containing products on their behalf (Randhawa, 2014).
Nexafed, however, aims to provide a technical, rather than regulatory, fix to the meth problem: Nexafed is “meth-proof.” Its manufacturer, Acura Pharmaceuticals, augments the medication with “Impede® Technology” — a series of ingredients that, when the pills are dissolved, “[cause] a thick gel to form, blocking the extraction [of chemicals needed to make methamphetamine] ... so that meth cooks will find it unsuitable to use” (Acura Pharmaceuticals, 2015) (see Figure 2). Nexafed’s unique formulation is an effort to ameliorate the meth problem through technological design. It aims to build control mechanisms about “correct” use of the product directly into the product — akin to well-known strategies like digital rights management (DRM) technology (Gillespie, 2009).
Figure 2: Graphic demonstrating Nexafed’s tamper-proof technology, from Nexafed Web site (https://www.nexafed.com/).
Nexafed’s marketing implies that its purchase is a socially conscious, morally motivated choice. Consumers are implored to “join the fight” and “protect your community” by choosing Nexafed over non-tamper-proof pseudoephedrine products. In a sense, the tone of Nexafed’s message recalls that of fair-trade coffee: the purchase of this product, instead of the more standard and better-known alternative, reflects on what kind of consumer one is and aligns with one’s social priorities (which are, the marketing presumes, against the ravaging effects of methamphetamine on local communities). But it is not precisely clear how the purchase of Nexafed enables one to “join the fight” against meth abuse. Nexafed is not exactly like fair-trade coffee: in the latter case, the purchase itself has economic implications that directly support a more equitable labor model; there are no such implications for Nexafed.
In fact, thinking in typical use/non-use terms, the market for Nexafed seems non-existent. If use is conceptualized as a binary and the user/technology relation as an individual one, there is no obvious market motivation for Nexafed’s purchase. In this model, the “user” stands in relation to the drug in one of two ways: as a person who intends to tamper with it, or a person who wants to relieve a stuffy nose and has no intention of cooking meth. If the user is a meth addict, the drug is useless, as the formulation makes it technically unfeasible for the tamperer to accomplish her goal. If, on the other hand, she is simply a person with a cold, it’s not clear why she would be motivated to buy Nexafed instead of a better-known standard pseudoephedrine formulation (like Sudafed). Thus, under this individualized model, the market for Nexafed consumption doesn’t exist; neither tamperers nor cold sufferers are likely to use the technology, so non-use dominates (and, clearly, the market for Nexafed cannot be built entirely on non-users).
A “spectrum” model does not take us much further. Accounting for differentiated degrees of access (e.g., whether Nexafed is more available in certain communities) or fluidity in use states over time is not particularly useful in illuminating the sociotechnical relations underlying Nexafed’s use.
Both of these models fail to offer a socially nuanced or complete account of technology adoption, then, because they both rest on a fundamental focus of the individual user as the primary unit of analysis. In so doing, they miss the most interesting social dynamics that underlie technological adoption and engagement.
The user or non-user of Nexafed is not an isolated individual; the relationship of interest is not merely the relationship between her and a pill. Rather the Nexafed consumer exists in a range of social contexts and networks; she is enmeshed in communities, relationships, and institutions that shape and define “use” of Nexafed. In the remainder of this section, I draw upon analysis of these institutional and interpersonal relationships to outline some of the networks that “use” Nexafed. What follows is not intended to be an exclusive or encompassing catalog of such networks. Rather, it demonstrates the utility of taking institutional relations seriously in considering the network as the unit of analysis in sociotechnical understandings of use.
3.1. Networks of household trust
The Nexafed purchaser very likely has at least some close family and household relationships. She may cohabit with a partner, or with children, who have easy access to the medications she purchases. Though she may seek to purchase a pseudoephedrine-containing medication simply because she has a cold — and no intention herself to tamper with it — she may be concerned about her purchase creating access for (say) a teenage child who is more likely to tamper with it. Sixty-four percent of parents in a 2011 study said that anyone in their homes could access the medicine cabinet (MetLife Foundation, 2012); in fact, the U.S. Drug Enforcement Agency specifically advises parents to lock up medications and to periodically count the number of pills in each container, and to “be aware that their family medicine cabinet ... [has] become today’s back alley drug dealer” (U.S. Drug Enforcement Administration, 2012). A parent taking these admonitions seriously, perhaps on the basis of a family member’s previous behavior, may take care to purchase tamper-proof medications as a way to mitigate the risk of familial access.
3.2. Networks of community reputation
Alternatively, a Nexafed purchaser may be socially sensitive about managing her relationships with retail pharmacists or pharmacy technicians. Recall that meth abuse is predominantly a rural problem. In a small town setting, our purchaser would be more likely to know, and possibly have a stronger social relationship with, the people working at a pharmacy. Recall that pseudoephedrine must still usually be purchased from behind the pharmacy counter, so the purchaser must specifically request it from a pharmacist or pharmacy technician. Even if she doesn’t intend to abuse the drug, she may purchase Nexafed rather than Sudafed as a communicative tool: to indicate to the pharmacist that she has no such intention and that she is not “part of the problem” that may be plaguing the community. Indeed, Nexafed’s marketing materials specifically suggest that by purchasing the product, consumers are “joining the fight” against meth abuse.
Research on pharmacists’ changing social roles, particularly around controlled substances and morally charged community debates, supports this conception of the sociotechnical relationship at work here. The Nexafed purchaser’s desire to communicate certain social signals to her community pharmacist might be a response to either informal relational norms, as described, or professional imperatives and formal control structures. In recent years, retail pharmacists have become much more likely to act as formalized legal and moral “gatekeepers” to pharmaceuticals (Chiarello, 2013). In addition to pharmacists’ traditional roles as medical gatekeepers — looking out for drug interactions, proper administration, and the like — they are increasingly called upon by regulators to police consumers’ interactions with drugs by “determining whether patients are using drugs or devices for illegal purposes and, if so, impeding access ... [including] purchasing drugs to make methamphetamine” . Pharmacists rely on intuition and behavioral cues to determine whether a drug request is legitimate. In addition, their gatekeeping practices interact with and rely upon statewide electronic databases that track information on what drugs are dispensed and to whom, for regulatory and law enforcement purposes, and may allow pharmacists to view patients’ activities across pharmacies. (Some states track only prescription drugs through these databases, while others track pseudoephedrine purchases as well.) A pseudoephedrine purchaser (whose knowledge about her state’s tracking systems is quite possibly imperfect) may be sensitive to being placed on a pharmacist’s “watch list,” formal or informal, motivating her to avoid this scrutiny by purchasing the tamper-proof form of the drug.
3.3. Networks of retail security
In addition to the pseudoephedrine consumer, the retail pharmacy can also be understood as a user of Nexafed. As a newly available drug, Nexafed’s marketing efforts are directed toward convincing pharmacies to stock the product as well as persuading individuals to purchase it, particularly as it is difficult to purchase pseudoephedrine online. (Federal regulations require consumers to provide photo identification in order to purchase pseudoephedrine-containing products. As a result, many retail Web sites, like Amazon and drugstore.com, only stock products containing phenylephrine rather than pseudoephedrine. Phenylephrine, the active ingredient in products like Sudafed PE, cannot be used to make methamphetamine — but it is also considered to be less effective at reducing nasal congestion than pseudoephedrine.)
Retail pharmacies may choose to stock Nexafed — either exclusively, or partially, in order to reduce stock of other pseudoephedrine-containing products — to mitigate their risk of being robbed by pseudoephedrine-seeking meth cooks. In recent years, the U.S. Drug Enforcement Agency has reported a rise in pharmacy thefts by robbers seeking prescription drugs and pseudoephedrine-containing medications (Aldax, 2013; Whitman, 2010). A video on the pharmacist-directed section of Nexafed’s Web site (also available on YouTube (“What is Nexafed?”, 2014)) informs pharmacists that “Thousands of pharmacies have adopted Nexafed as their modern decongestant of choice. Meth cooks will shop elsewhere for the older products they prefer — and that makes your community safer.” The voice-over is accompanied by an animation of a swerving, beat-up, exhaust-spewing car — presumably being driven by the foiled meth cook — bypassing the safe community of storefront pharmacies to look elsewhere for non-tamper-proof pseudoephedrine (see Figure 3).
Figure 3: Animation of foiled meth cook, from Nexafed Web site (https://www.nexafed.com/).
3.4. Networks of public relations
Earlier, we discussed a Nexafed purchaser’s concerns about interpersonal reputation, and her possible desire to communicate signals about her intentions to retail pharmacy employees. But reputational concerns may also motivate pharmacies’ decisions to stock Nexafed in their stores. The pharmacy-directed section of Nexafed’s Web site implores pharmacies to join the “[t]housands of pharmacies across the country ... leading the fight against methamphetamine abuse in their communities by selecting Nexafed,” and asks “[i]s your pharmacy doing all it can to deter meth abuse?” This messaging about making a difference and leading the fight suggests that pharmacies — in addition to the practical crime concerns detailed above — have a moral role to play in the fight against drug abuse, which they can fulfill by stocking and recommending Nexafed.
In recent years, retail pharmacies have been known to appeal to morality in determining which products to stock on their shelves — a move that is broadly perceived to be a public relations and goodwill-building strategy. In 2014, the U.S. pharmacy chain CVS announced it would stop selling tobacco products in all of its stores (over 7,600 locations) as an element of its “CVS Quits for Good” initiative. Making this decision, CVS stated, was “the right thing to do” (CVS Health, 2014), even though the company made about US$2 billion annually from tobacco sales (O’Donnell and Ungar, 2014). Though it is unclear to what extent positive goodwill resulting from the decision could offset this loss, CVS CEO Larry Merlo pointed out that the company had seen US$5.4 billion in new pharmacy business during the season following the announcement, and said: “I don’t want to imply that it’s because of the tobacco decision, but I think it becomes something more of an intangible that sends a powerful message to prospective clients that we are their best health-care partner” (Millman, 2014). Indeed, the company was widely praised for the decision, which generated over 100,000 (generally positive) tweets, and even a compliment from U.S. President Obama (Stengel, 2014).
When pharmacies do stock Nexafed, they publicize their efforts in ways that suggest the salience of the public-relations motivation. When Kmart began stocking Nexafed in all of its pharmacies in December 2014, Kmart Pharmacy’s vice president announced that doing so was “taking a step to protect the health of our communities[.] ... The average Kmart pharmacist has worked with the company for nearly 12 years, and they’ve seen first-hand the impact of meth use and production locally — and the important role pharmacies can play in addressing this important issue” (Kmart Pharmacy, 2014). Such an statement, made in a press release, suggests that pharmacies may be motivated to stock Nexafed based on public relations, moral imperative, and/or concern for community interest, akin to CVS’s anti-smoking initiative.
3.5. Networks of law and regulation
As described, federal law restricts the sale of pseudoephedrine-containing products in a number of ways — including purchase limits, the requirement that the drug be kept in a restricted area, and recordkeeping requirements. In addition, most states have their own requirements, including provisions about where the drug must be kept and what types of purchaser information must be tracked.
One proposed strategy for combatting meth production is making pseudoephedrine a prescription drug. Two states — Oregon and Mississippi — have made pseudoephedrine available by prescription only, as have certain municipalities in a handful of other states. Federal regulations have not implemented a prescription-only model, thought a recent agency report commissioned by members of Congress (U.S. Government Accountability Office, 2013) suggested that such a policy could contribute to reducing the number of meth labs — but with potentially negative impacts on consumer health, due in part to the comparative inconvenience and expenditure required for sick individuals to obtain the medication by prescription.
One could imagine, however, a regulatory strategy (on the local, state, or federal level) that retains the benefits of a prescription-only model while alleviating the burden on non-meth-cook consumers: by requiring individuals to obtain a prescription only for non-tamperproof pseudoephedrine formulations, but allowing tamperproof products like Nexafed to remain available without a prescription — either behind the pharmacy counter or even openly on store shelves. The CEO of Acura Pharmaceuticals, the company that makes Nexafed, has said that the company “certainly will be exploring what it may take to get an exemption” from federal requirements that pseudoephedrine be sold from behind pharmacy counters (Herman, 2012).
At least one proposal in West Virginia would require a prescription for most pseudoephedrine-containing products, but specifically exclude tamper-resistant formulations from the requirement (Eyre, 2014). Should policies like these be enacted, the market for Nexafed becomes quite clear; what sick person wouldn’t rather purchase Nexafed at the pharmacy than go through the hassle of getting a prescription for Sudafed? Moreover, the fact that Nexafed exists makes such a policy more realistic; without a tamperproof alternative already on the market, it’s difficult to imagine such a regulation being written. But in light of its existence, we can easily imagine a regulator or legislator proposing such a rule.
In exploring the market for Nexafed, we have considered the user in much broader terms than traditional models of users and non-users do. We have considered the user as a network of power relations that includes parents and children, pharmacies and pharmacists, neighbors and communities, regulators and legislators, police and thieves. Comparatively, conceptualizing the user or non-user in social and institutional isolation yields a thin and unnuanced understanding of Nexafed’s use.
When we consider use as a networked and inherently relational phenomenon — one that resides not in individuals, but across constellations of institutional and interpersonal relations — motivations for Nexafed’s use, and the types of sociotechnical engagement that may constitute “use” of a technology (coupled here, dialectically, with “non-use” of another technology, Sudafed) come into sharp focus. Parent/child networks may “use” Nexafed when parents purchase it to dissuade their untrusted teens from tampering with the drug to manufacture meth. In small communities, resident/pharmacist networks may “use” Nexafed as a social signal, treating it as a tool to communicate certain implied messages, in order to avoid arousing suspicions of illegal behavior. Pharmacy/criminal networks may “use” Nexafed as a hedge against robbery when pharmacies stock it instead of Sudafed — or, it may be used as a reputational tool in pharmacies’ public relations networks, as a statement of interest in the community’s health, perhaps especially salient in small communities that have been ravaged by methamphetamine abuse. Legal networks may even “use” Nexafed for political purposes, in that its existence may spur and enable lawmakers to rewrite regulations about access to pseudoephedrine, in order to alleviate the meth problem while preserving consumer health concerns. In each of these cases, use is a distinctly networked phenomenon; engagement with the technology of Nexafed itself can be quite indirect, and only makes sense in the context of the broader landscape of relationships.
None of these forms of sociotechnical engagement would likely be captured using a typical use/non-use framework; lawmakers, pharmacies, regulatory schemes, databases, and the like would not be accounted for, but as we see, they occupy primary (not peripheral) roles in the networks that constitute use. Considering use through a network lens, as we have explored here, expands our sphere of inquiry about use well beyond the direct human-technology interface.
This is not to say that the concepts of use and non-use are not essential to our analysis. In particular, in considering the emic understandings of participants in these networks and the ways they frame use and non-use, it is notable how frequently use and non-use are evoked — in persuasive messaging, advertising, and regulation — in attempts to influence the behaviors of other individuals and institutions within the network. The use/non-use dialectic here, then, explicitly operates to position Nexafed as a political and moral technology vis-à-vis a network of actors that is much broader than the person who swallows (or does not swallow) a pill.
Adopting a networked view of use and non-use is productive for three additional reasons. First, the networked view draws analytic focus to the fundamentally political nature of the technology at issue here — a crucial quality that traditional use/non-use models tend to obscure, but one that becomes key when use and non-use are politicized (e.g., by social movements; see, for instance, debates around controversial medical treatments (Chiarello, 2011) and other “product-oriented” social movements (Hess, 2005)). In actor-network terms, we can understand the injunction against a prohibited use — the production of methamphetamine from pseudoephedrine — as being delegated to the object of Nexafed, rather than (or in addition to) enforcement of this rule by human actors and institutional structures; some of the normative burden (and power) of doing so is “offloaded” onto a chemical structure contained in a pill (cf., Latour, 1992). Such institutional entanglements and power relations characterize all our engagements with technology, but can be difficult to locate without explicit attention to the constellation of networks mediated by technical systems, and what political technologies allow those actors to do (or do differently). Attention to mediated networks helps us in two regards: it makes sociotechnical research more effective and nuanced (for instance, by expanding the set of use motivations to be considered, as I explain in a moment) — and it helps us to develop a more sophisticated understanding of social power.
Second, a networked conceptualization of use helps sociotechnical researchers to make sense of different sets of use motivations than we might otherwise consider. It helps us to understand use as being motivated by interpersonal, social, and institutional concerns, and for those motivations to affect decision-making by consumers, purchasers, and intermediary suppliers alike. The technical affordances (Gibson, 1977) of the technology itself influence and interact with, but do not wholly determine, these use motivations. In the Nexafed case, we see that motivations like social shame, interpersonal mistrust, familial caretaking, robbery, gossip, public relations, regulatory interests, and moral duty may simultaneously act as salient drivers of technology use; these motivations would be very difficult to unearth using a traditional, non-networked conception of use/non-use. (Interestingly, the Nexafed case reveals that a number of use motivations can be understood as hedges against contingency: they are concerned with what other might do, from what regulators and lawmakers might require in the future, to what teenagers might take from a medicine cabinet, to whether thieves might rob a retail pharmacy. These use motivations can be read as efforts to reduce social risk on a variety of fronts.)
Finally, the networked model helps us to make sense of a particular set of technologies with intentionally limited technical affordances. Generally speaking, discourse around technological design emphasizes enabling a user to expand her horizon of action: to do more, more effectively or efficiently, than she could without the technology. But paradoxically, the discourse around certain technologies appears to feature their own limitations: they make a selling point out of what the user cannot do with the technology (what Pierce and Paulos (2014) term “counterfunctionalities”). Nexafed falls into this category, as does fertilizer that has been chemically altered so that it can no longer be used in explosives (Bullis, 2013); so do platforms (like Snapchat) that specifically advertise the fact that images can no longer be viewed after a few seconds have elapsed. Technologies like these are part of a long history of designers making efforts to restrict the interpretative flexibility of certain artifacts — by reducing their capabilities in order to encourage certain uses while restricting others (Kline and Pinch, 1996; Zittrain, 2006). A networked use model helps us to make sense of these design decisions by drawing direct attention to the social/institutional relations and power dynamics that underlie them as rationales for these explicit limitations, rather than merely as aspects of the human/technology interface.
The Nexafed case is instructive in illustrating the utility of a broad, networked formulation of use/non-use (and users/non-users) in sociotechnical research. This conception recognizes that complex social and institutional relationships are mediated through technological systems and design choices, and that ownership, control, operation, and choice aren’t necessarily integrated. In so doing, it helps us to develop a more nuanced and socially sensitive understanding of interactions among individuals, technologies, institutions, and society.
About the author
Karen Levy is a postdoctoral fellow at New York University School of Law’s Information Law Institute, New York University’s Department of Media, Culture, and Communication, and the Data and Society Research Institute. Her research focuses on how law and technology interact to regulate social life. She is particularly focused on social aspects of surveillance and data-gathering. Levy holds a J.D. from Indiana University Maurer School of Law, and a Ph.D. in sociology from Princeton University.
E-mail: karen [dot] levy [at] nyu [dot] edu
I thank participants in the 2013 Theorizing the Web conference for feedback on an earlier iteration of this project, as well as the special issue editors and two anonymous reviewers for their valuable suggestions. I gratefully acknowledge Intel’s Science and Technology Center for Social Computing (ISTC-Social) and the Data and Society Research Institute for financial support.
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Received 2 October 2015; accepted 22 October 2015.
“The user as network” by Karen E.C. Levy is licensed under a Creative Commons Attribution 4.0 International License.
The user as network
by Karen E.C. Levy.
First Monday, Volume 20, Number 11 - 2 November 2015
A Great Cities Initiative of the University of Illinois at Chicago University Library.
© First Monday, 1995-2017. ISSN 1396-0466.