Here's a piece I wrote a while back exploring the implications of some of the newest drug treatment technologies.
Border Wars: New Drug Treatment Technologies and the Addicted Body(C)
Julie Netherland
Abstract
Addiction and its treatment have been and remain an area of tremendous contestation. New drug treatment technologies represent an unprecedented effort to find biomedical “fixes” for the problem of addiction and increasingly localize, individualize, and interiorize addiction and addiction treatment. These technologies include vaccines to prevent cocaine addiction, subcutaneous implants of sustained released medications to block opiates, and new dispensing technologies to prevent diversion and abuse of medication. While these changes seem to reflect the growing acceptance of the brain disease model of addiction, they further confound the already porous boundary between medicines and drugs and between patients and addicts. I argue that recently developed drug treatment technologies represent a renewed effort to shore up the tenuous boundaries between addict and patient, drug and medicine, drug dealer and doctor by creating new experiences of embodiment meant to distance addiction treatment from illicit drug use. Moreover, the manner in which these new treatment technologies are embodied rearticulate and reproduce ‘the patient’ and ‘the addict’ in ways that are both constraining and offer new possibilities for autonomy.
Keywords: addiction, embodiment, drug treatment
Word count: 7,824
It’s all hypothesis at this point yet because we haven’t sliced open anyone’s brain yet, but it seems that normalizing the GABA receptor takes away the craving and anxiety that one would typically experience in the absence of the drug. And it doesn’t appear to be happening because of will power, love, God, discipline, family support, or anything else. It seems to be happening because the protocol resets a faulty mechanism in the brain.
-- Sanjay Sabani of Hythiam Corporation talking about a new pharmaceutical treatment for cocaine addiction (as quoted in The New York Times, 2006).
As the above quote suggests, biomedical technology is changing the ways in which we understand, respond to, and treat drug addiction. It also reveals the new ways in which addiction and addiction treatment are being embodied, located in the human brain, and materialized at the level of biochemical processes. Concomitant with the ascendancy of the “brain disease” model of addiction has been an increased effort to find biomedical “fixes” for the problem of addiction. These new drug treatment technologies are part of larger social, cultural, political and economic trends, including the increasing medicalization of social problems, the corresponding proliferation of pharmaceutical solutions, the rise of managed care and the medical industrial complex, and the movement away from carceral regimes of discipline towards forms of self-governmentality.
Addiction has a unique history among medicalized social problems in that it has always had a close and ambiguous relationship with the medicine. Many addictive drugs, for example, not only originated as medicines, but have been used as medicines to treat addiction. Morphine was once used to treat addiction to opium; heroin was first introduced for the treatment of morphine addiction; and methadone, used to treat heroin addiction, is also widely bought and sold on the street as an illicit drug. Articulating a coherent rationale for the line between illicit drugs and legal medicines has become increasingly difficult. Marijuana is now a prescription medicine in many states; addiction to prescription medications far outstrips the use of any illegal drug, except marijuana (Substance Abuse & Mental Health Services Administration, 2006); and opioids (like buprenorphine, methadone, and even heroin) have all been prescribed to treat opioid dependence.
Addiction is also unique among medicalized social problems in that neither alcoholism (Appleton, 1995; Keane, 2000; Valverde, 1998) nor drug dependence (Smart, 1984) fit easily into the medicalization model, even though the medical model of addiction has gained in prominence in the U.S. over the past thirty years. As the continuing War on Drugs and mass incarceration of (primarily African American) people for drug offenses would suggest, punitive constructions of addiction seem to have enduring appeal. Moreover, other non-medical approaches to addict, like Alcoholics Anonymous and Narcotic Anonymous, continue to proliferate both in community and medical settings. Medical responses to addiction that frame the problem as a failure of biochemistry or genetics continue to co-exist uneasily with behavioral and legal responses that frame the problem as failure of will or character.
Thus, the world of addiction and addiction treatment has been and remains one of contestation, confusion, and slippage. Nonetheless, with new developments in biomedical treatments, the brain disease model of addiction seems to be gaining hold, and treatments for drug addiction have become increasingly localized, individualized, and interiorized. Behavioral interventions, which attempt to address the psychosocial world of the addict, are being replaced by technologies that target the biochemical processes of the body and the brain as the site of intervention. Since its founding 1989, the Medications Development Program of the National Institute on Drug Abuse (NIDA) has tested more than fifty medications to treat cocaine dependence, obtained FDA approval for two medications to treat opiate dependence (buprenorphine and LAAM), and has most recently developed an “depot” form of naltrexone in which reservoirs of a medication that blocks the effects of alcohol and opiates are implanted subcutaneously and released over a period of several weeks or months. In 2004, the National Research Council and the Institute of Medicine (IOM) (at the request of NIDA) produced a report on the use of immunotherapies, vaccines, and a variety of depot and sustained release formulations of medications to prevent and/or treat addiction (National Research Council and IOM, 2004). In addition, for the first time in decades, medical doctors have been granted the right to treat addiction with certain pharmaceuticals in office-based settings, a legislative change that many hope heralds the movement of addiction treatment into the medical mainstream. While these changes seem to reflect the growing acceptance of the brain disease model of addiction, they further confound the already porous boundary between medicines and drugs and between patients and addicts.
I argue that recently developed drug treatment technologies represent a renewed effort to move addiction fully into the realm of medicine and simultaneously shore up the tenuous boundaries between addict and patient, drug and medicine, drug dealer and doctor by creating new experiences of embodiment meant to distance addiction treatment from illicit drug use. Moreover, the manner in which these new treatment technologies are embodied rearticulate and reproduce ‘the patient’ and ‘the addict’ in ways that are both constraining and offer new possibilities for autonomy.
Meaningful Substances
A number of scholars, beginning with Howard Becker and his classic work on marijuana users (1963), have noted that the meanings and experiences of substances are socially contingent. While the rhetoric of scientific empiricism and the randomized controlled trial (which specifically seeks to neutralize social and environmental variation) would have us believe that substances cause specific biological effects independent of any social or cultural influence, substantial evidence suggests that both the meaning of and a substance’s “drug effect” are mediated by the “psycho-socio-cultural matrix” (Cohen et al, 2001) in which the drug is ingested. Bergschmidt (2004), for example, cites reports that prescribed heroin is experienced as less pleasurable than expected by drug users, and Gomart (2002) notes that the differences between methadone and heroin are largely interpretative. This is not to say that substances have no biological effect on the body; but rather that those effects are socially embedded and responsive to history, culture, setting, and political context. The effects and meanings of substances are not static truths revealed in their chemical structures but are dynamic social phenomena that can be controlled, shaped, and imbued with meaning. Moreover, neither the drugged nor the addicted body is static in its meaning, but are dynamic in the same way.
The slippage between socially legitimate medicines and illicit drugs is evidence of this dynamism and stems precisely from the socially constructed nature of these distinctions. The need to continually articulate these differences and the difficulty of maintaining them are clear in the 2004 IOM report on new drug treatments. Ducking the obvious question of how to define addiction, the authors propose the following tautological solution to the drug/medicine conundrum: ‘For the purposes of this discussion, the chemical compounds that produce addiction will be called drugs, and the chemical compounds used to treat addictions will be called medications (National Research Council and Institute of Medicine, 2004, p.65).’ If, as a recent editorial in Addiction (Hall, 2006) suggests, no neurological justification for the legal status of different drugs exists, then the differences between medications and drugs must rest on rhetorical strategies like that in the IOM report. Furthermore, while the meaning of some substances (e.g., aspirin) is fairly unambiguous and seldom contested, those substances at the edge of the drug/medicine and addiction/treatment border are defined and controlled with particular vigilance. Gomart (2002) argues that, compared to psychiatric medications, ‘methadone is an under-determined object which can and must be controlled (p.122).’ Such control happens at multiple levels, including through rhetoric and discourse, regulation, cultural representation, and legislation. I suggest that the newest drug treatment strategies seek to control both the signification of substances and production of subjects by inscribing meaning materially onto and through the bodies of the patient/addict using novel biomedical technologies.
Biomedical Cyborgs
New drug treatment technologies are but one of a host of biomedical technologies that increasingly shape the body both materially and discursively. Donna Haraway and others have noted that the postmodern body is hybrid of human and machine. In her landmark Cyborg Manifesto, Haraway (1991) argues that the very dualisms and classifications that marked the 19th and 20th centuries have lost their purchase, calling forth a new kind of personhood: ‘By the late twentieth century, our time, a mythic time, we are chimeras, theorized and fabricated hybrids of machine and organism, we are all cyborgs (1991, p.2).’ Gray et al. (1995) have applied Haraway’s work specifically to the biomedical context and conclude that cyborgs are no longer the stuff of science fiction:
…the range of human-machine couplings almost defies definition: even existing human cyborgs range from the quadriplegic patients totally dependent on the vast array of high-tech equipment to a small child with one immunization (p.4).
Like other body-modifying technologies, biomedical technologies can be particularly powerful in shaping the subject because they work on the very material that has become so important to our sense of self in contemporary western culture -- our bodies and minds. Moreover, as Waldby (1997) points out: “Unlike other technical domains it is difficult to sustain the sense that ‘we’ are the masters of medical technology when ‘we’ are also its material objects (p.228).” The boundaries between biomedical object and self are blurred. Furthermore, the incorporation of medical technologies into the body is neither neutral nor random. All medical technologies, indeed all objects, have a cultural, social (Vitellone, 2003) and economic history that affects the contours and meanings of the disease and the patient. Considering the specific ways in which the medicalized body is materially and conceptually assimilated to the technology and what kinds of meanings are produced by this new hybrid is important (Waldby, 1997). In the case of new medical technologies to treat addiction, these meanings are embedded in and defined in relation to the cultural, social and economic history of illicit drugs as well as the larger medical, scientific and social context of 21st century life.
New Drug Treatment Technologies
Given the ambiguity at the border of drugs/medicines and addiction/treatment as well as the profound ability of technologies to reshape both the disease and the subject, new drug treatment technologies represent an important site for producing meaning. The question then, is what are the meanings of new drug treatment technologies; in other words, how do they mark the body and spatialize the disease of addiction, and what kinds of subjects do they produce? While there are a number of interesting developments in medical treatments for drug addiction, I am focusing specifically on the boundary where the technology meets the body in order to highlight how these technologies affect the embodiment of addiction and rearticulate the drug addict/patient/subject.
Vaccines for nicotine and cocaine have already been found effective in rats, and both of these vaccines are currently being tested in clinical trials with humans. The 2004 Institute of Medicine report lays great hope on such strategies, which work by introducing products into the body that stimulate the immune system. The immune system, in turn, counteracts the effects of the target drug by binding it to a carrier protein that makes the ‘drug of abuse’ too large to enter the brain (National Research Council and IOM, 2004, p.7). See Figure 1. Immunotherapies and vaccines are seen to be an improvement over substitution therapies (e.g., methadone, buprenorphine) because they block the illicit drug from entering the brain, are not addictive, and target the drug of abuse rather than biochemical processes in the brain (National Research Council and IOM, 2004, p.13). Because illicit drugs do not themselves stimulate an immune response, scientists estimate that a patient would require a series of 2-4 injections over 1-2 months and a booster shot every 2-6 months; these injections would be administered by a doctor or nurse in a medical setting.
Immunotherapeutic strategies do not affect symptoms of withdrawal or craving. Rather, as Figure 1 illustrates, their sole aim is to prevent the euphoric effect or “reward” of illicit drugs. The underlying assumption is that without the rewarding euphoric effects of the drug reaching the brain, the addict will no longer have motivation to use.
The authors of the IOM report concede that immunotherapeutic agents have some potentially negative consequences. Immunotherapies are likely to create a long lasting or even permanent biomarker in the body that could be used to identify a person as an addict even after they stop using drugs. In fact, ‘high risk’ individuals, who have never even used drugs may be vaccinated and, thus, permanently marked. Vaccines pose other problems as well. To use the words of IOM report authors, sometimes ‘drugs of abuse may also be used for therapeutic purposes (National Research Council and IOM, 2004, p.82),’ and vaccination could block or counteract drugs administered for therapeutic purposes. In addition, if a vaccinated individual tries to over-ride the blockading effect of the vaccine to get high, s/he could be at increased risk for overdose. Finally, they note potential ethical issues in determining who ought to be vaccinated against addiction. While they indicate that former users at risk of relapse are the most appropriate target population, they also acknowledge that, once the technology is developed it will likely be forced upon some people: ‘for some classes of individuals and in some situations, coerced immunization is likely to be legal (p.174).’ Populations likely to face coercion include prisoners, pregnant women, women involved with child protection agencies, and youth (National Research Council and IOM, 2004). One of the stated purposes of the report, in fact, is to articulate guidelines for a ‘fair coercion policy (p.17).’
Another class of recent drug treatment technologies involves new formulations of and methods for delivering medications to treat addiction to opiates and alcohol. Modifying the form of such medications is not new. Methadone has long been produced as a thick syrup to prevent it from being diverted and/or injected. The newest strategies of reformulating addiction treatment medicines involve sustained release or depot forms of naltrexone and buprenorphine (see Figure 2). In depot formulations, the medication is either injected under the skin as small particles or inserted in small plastic rods, which are ‘retrievable.’ Depot medications have also been used for contraception and the treatment of depression and schizophrenia (National Research Council and IOM, 2004, p.72). A depot form of buprenorphine, which provide 6-8 months of medication (administered by implanting a plastic rod in the upper arm), is currently in a Phase III clinical trial. A synthetic opioid, buprenorphine works by binding to the brain receptors to block the effects of other opioids. Buprenorphine is used to treat addiction to heroin and to prescribed opioids, like Oxycodone. Like methadone, it creates a physical dependence but is said to cause less euphoria and have a lower risk overdose than either methadone or heroin. In current formulations, buprenorphine is taken once or twice a day a sublingual tablet.
A recent press release by Titan, the pharmaceutical company developing a depot formulation of buprenorphine called Probuphine, encapsulates the medical rationale for these new strategies:
The Company believes that Probuphine has the potential to reduce the limitations currently associated with daily oral buprenorphine therapy, including poor compliance, variable drug levels, morning withdrawal symptoms… and misdirection of the drug (Titan, 2006).
Similarly, the IOM report (2004) cites low compliance as an important catalyst for many of these technologies. They note that methadone is preferred by patients over naltrexone because it is more pleasurable:
Compliance with naltrexone for the treatment of opiate dependence is lower than with methadone because naltrexone lacks the pleasant receptor-activating effects of methadone. Measures to improve long-term compliance are needed (p.90).
The underlying logic is that the pleasure must be minimized while compliance must be maximized. Low efficacy is a problem of compliance -- a problem that can be remedied by technologies that minimize the active role of the patient. Indeed, part of what these technologies do is to shape and produce a subject that is no longer just an addict but is also a patient. Though they are designed to improve compliance, like vaccines, depot and sustained release formulations may actually increase the risk of over-dose as people try to over-ride the blockade effects of the medications with other substances. In addition, both buprenorphine and naltrexone block the effects of all opioid-based pain medications, making the treatment of acute or chronic pain in these patients problematic.
Other new technologies rely on innovative ways of dispensing illicit or highly abused drugs as medications. By creating new ways of dispensing the substance and attempting to control its euphoric effects, substances that are illicit in most circumstances are reclaimed as medications, and drug addicts are reclaimed as patients. For example, prescribed heroin, which has been used to treat heroin addiction in Canada and several European nations, has been manufactured in pill and inhaled forms (Fricke et al, 2006). The same pharmaceutical company that produces Savitex, a spray form of medical marijuana, has developed the Advanced Dispensing System (ADS), a medication dispensing device which was planned for use in trials of self-administered heroin and methadone in Britain (BBC News, 2002). See figure 3. According to GW Pharmaceuticals, ADS offers:
… remote monitoring and control of the entire drug management process in real time. The technology provides a secure and tamper-proof means of dispensing drugs… This is of special interest for drugs with potential for abuse and misuse (emphasis added). (GW Pharmaceuticals, 2006)
Note the reference to “drugs” instead of “medications,” emblematic of the slippage between drugs/medicines and addicts/patients. Drugs require strict control, and ADS uses wireless technology that allows medical professionals to program in the amount and frequency of the dose. In addition, using ADS, doctors can monitor the dispensing of medication, change doses remotely, and obtain a complete record of medication dispensing.
Shoring Up Boundaries
Although the new drug treatment technologies described above differ in significant ways, they share important characteristics and important effects. All function to construct drug treatments in ways that create distance from “drugs of abuse.” New drug treatment technologies work to rewrite the addict’s body, which is generally characterized as irrational and impulsive, as the controlled and regulated body of a patient. At the same time they rewrite the addict as patient, they also construct the substances themselves to shore up the boundary between illicit drug and medicine.
Not coincidentally, manufacturers highlight that addiction vaccines, buprenorphine, and naltrexone are synthetic and manufactured medications. Some of these synthetic compounds (e.g., buprenorphine) are created to mimic in important ways the illicit and “natural” drugs they treat. However, the literature about them tends to emphasize how they are different from or act against illicit drugs. These treatments are produced and/or tested through pharmaceutical- or government-sponsored scientific trials and shrouded in the mystical language of pharmacokinetics and science. For the addict to become a patient, s/he must be prescribed a medical treatment manufactured in the context of science and delivered in a medical setting.
The “manufactured” nature of these medicines is further emphasized by packaging and by producing them in material forms that mirror as closely as possible other medications. Like drugs of abuse, pharmaceutical treatments for addiction are ingested in ways that maximize the absorption of the medication into the blood stream but that also distinguish them from illicit drugs. Many are made available primarily as sublingual tablets and implants -- forms of dispensing medication that are not yet routinely used with illicit drugs, which tend to be smoked, snorted, injected, and/or swallowed. In the case of vaccines, immunotherapies, and some sustained release formulations of naltrexone and buprenorphine, which are injected, medicalization is achieved by administering the injection in a medical setting by a medical professional. Whether the dose is administered through depot technology or at the hands of a medical professional, the patient is not allowed to dose him or herself in the way that the addict once did.
Another commonality among the new drug treatment technologies is their aim of blocking the euphoria or highs produced by drugs that are not socially sanctioned and/or by medicines that are being misused. Indeed, the euphoria associated with illicit drug use is seen as integral to the neurological chain of addiction -- it is the euphoria, along with physical dependence, that leads to compulsive use. These new technologies share both this underlying framework and a propensity to emphasize that medical treatments for addiction do not cause, but in fact block, euphoria. For instance, the IOM report repeatedly hails immunotherapies as an advance over other treatments because they block the illicit drug from ever reaching the brain and, therefore, disrupt the user’s rewarding experience of euphoria. Elsewhere, constructions of addiction focus on physical dependency or compulsive use (e.g., DSM IV), but these aspects are necessarily downplayed here, since many current medications used to treat addiction are addictive themselves. For example, even though they cause physical dependence, depot and sustained release forms of buprenorphine, are seen as advantageous because they cause less euphoria and because they block the euphoric effects of heroin and other prescribed opioids. The ADS, depot and sustained release technologies all protect, not only against the highs associated with the illicit drugs for which the user is being treated, but also against the euphoria associated with using high doses of the treatment medication itself. For prescribed substances, which can also be drugs of abuse, the only thing maintaining the boundary between medicine and drug is the dose -- that is, taking the substance “as prescribed.” Dosing technologies attempt to enforce the “take as prescribed” mandate in order to protect the medication from slipping back into the world of drugs. If the dose is regulated and controlled by technology, then the patient/addict cannot ‘abuse’ the medication/drug; pleasure is socially (Coveney and Bunton, 2003) and medically mediated. Similarly, the patient is kept from slipping back into the world of the addict, which (in this discourse) is marked both by euphoria and unregulated use.
By controlling the literal development and production of the substances, their packaging, their modes of delivery, and attempting to regulate their euphoric effect, the proponents of new drug treatment technologies seek to shore up the boundary between medicine and drug. In short, drug treatments cannot look, feel, sound like the drugs they are meant to treat. Their meaning must be determined and controlled, and new technologies provide important opportunities to do just that.
The Production of the Addict/Patient: Regulation, Constraint & Freedom
New treatment technologies work to embody medicines in ways that distinguish them from drugs; they also spatialize addiction and inscribe the addict’s body in important new ways. These technologies clearly reflect and reproduce a notion that addiction is a brain disease, located in the individual. Medical technologies are literally taken into or implanted in the individual body. The social location and social networks of the individual are obscured as dopamine receptors and immune response systems are highlighted. Rather than address addiction at the level of policy, neighborhoods, or families, the war on drugs is increasingly fought at the level of neurochemical processes. The addict’s body is physically marked by subcutaneous implants and vaccine biomarkers and discursively marked by the language of science -- addiction and its treatment are interiorized.
Despite the radical interiorization of addiction that these technologies represent, they strangely place control over addiction treatment outside of the body in the hands of medical professionals and multi-national pharmaceutical companies. Whether the dose is being controlled remotely through ADS, released through a depot, or injected in a series of booster shots by a doctor, the addict/patient is clearly bound ever closer to medical system and pharmaceutical industry. The rationalized, medicalized, external control of technology releasing medication in even, steady doses is meant to replace the impulse-driven, euphoria-seeking, irrational drug-taking practices of the individual. As it takes new biotechnology into itself, the treated body is marked by the discipline, control, and reason of science. The addicted body, a hybrid of the human and the technological, thus marked, gives rise to new senses of self.
The body has increasingly become a site where notions of self and identity are both produced and regulated (see for example, Budgeon, 2003; Butler, 2004; Entwistle, 2000; Shilling, 2003), and doctors play a particularly important role in labeling and legitimizing bodies and in managing our subjective experiences of our bodies (Shilling, 2003, p.126). So too, biomedical technologies are intimately and importantly involved in the production of self. As Persson argues, medicines are socially situated objects laden with meaning:
Embedded and embodied through this act [taking medicine] are cultural ideas about self and body, about illness and healing, efficacy and responsibility. … every pill is a potent fusion of ingredients, including scientific practices, political agendas and commercial interests. Medicines, therefore, are more than merely chemical compounds; they are cultural entities. As such they are products of human culture, but also producers of it (Perrson, 2004:46).
The subject produced by these new drug treatment technologies is certainly varied and dynamic and profoundly affected by other forces, such as personal history, race, class and gender. These technologies do not produce a single self or subject but rather overlapping and mutually constitutive subjects. New drug treatment technologies represent a shift away from punitive forms of control, like incarceration, or morality-based models, like AA and NA. Compared to other more castigatory responses to addiction, medicalized approaches appear fairly benign manifestations of a new era of self-governmentality. Nikolas Rose (1996) argues that individuals are increasingly subjected to therapeutic authority at the same time they are encouraged to live as responsible and autonomous beings. As Keane explains, ‘Therapeutic authorities work in the service of liberty and personal choice which ironically makes them more profoundly subjectifying than other more obviously oppressive forms of authority (Keane, 2000: 327).’
In her article about the German methadone system, Bergschmidt (2004) argues that methadone policies are an example of a system of Foucauldian biopower that encourages the subject to regulate him or herself. Indeed, the new drug treatment technologies described above encourage self-governmentality perhaps in even more subtle ways than methadone. Rather than being controlled by rituals of daily dosing and mandatory urine screenings at a methadone clinic, the new drug treatment patient is controlled and regulated by biomedical technology under the supervision of a doctor. Excluding coerced treatment for the moment, this is a subject who willingly submits to these constraints and to the process of being transformed from addict to patient.
However, in my view, these new medical technologies do not simply exchange pathologization for incarceration and rearticulate the addict as sick instead of bad. As Conrad and Schneider (1992) suggest, medicalization is not always a linear narrative. Rather, a deeper understanding of the path from badness to sickness must also account for the ways in which biomedical technology and its embodiment bring with them social, political, economic and cultural histories that reshape the subject in complex ways. The addict is indeed sick and must be pathologized, but like punitive models, these new drug treatment technologies suggest that the addict still needs strong control that originates outside him or herself. The addict is not merely being brought under the supervision of a doctor and governing him or herself by taking a pill every day.
These new technologies, even if entered into voluntarily, situate the biomedical agent literally inside the body, yet control over the technology does not reside in the treated individual. The individual has no way of escaping the effect of the vaccine (or the biomarker it leaves); s/he cannot remove the depot device easily or reverse the effects of sustained release injection of naltrexone. The addict remains controlled, because addicts are those in need of control, and on some level also always remain an addict. Similarly, the new drug treatment technologies increase the surveillance of the addict/patient. Whether it is through the frequent visits needed for the cocaine vaccine series or the remote monitoring through the ADS device, the new patient/addict is closely monitored and watched. The addict/patient is not merely sick. The addict is someone who must be protected against him or herself, someone who cannot be trusted to administer medication, someone who must be marked and monitored -- the addict remains and, in fact, is re-inscribed as the dangerous Other. Medicine and society’s mistrust and fear of the addict are literally embodied in the addict/patient through these new biomedical technologies.
Like all systems of constraint, new drug treatment technologies seek to produce a particular kind of subject. Although they engender a subject who remains a dangerous Other, their purported goal is a subject who is “drug-free,” who is governed by reason not impulse, and who is a law-abiding and “productive member of society.” Whatever one thinks of this normative view, the material and psychic rewards to successfully entering into it are enormous. Addiction, socially constructed or not, can cause real material and psychic harm. In addition to the threats to emotional and physical health and the damage to relationships, addicts face enormous social sanction precisely because they violate and disrupt normativity. Many are profoundly marked by stigma; others fall outside the limits of intelligibility all together (Butler, 2004) and have no access to the protection and benefits of economic, political and social institutions.
The desirability of being able to meet the requirements of a “productive member of society” is not something of which most addicts need to be convinced. Certainly, many people use drugs without great harm to themselves or others and may never seek treatment. Others may enter drug treatment only if coerced through drug courts and other government agencies. But many addicts willingly seek treatment on their own because they are troubled by the way their drug use (or society’s response to it) impacts their lives and relationships, and they want to regain a sense of normalcy, repair relationships, and rebuild their lives. In fact, the number of people seeking treatment far exceeds the capacity of our current treatment system. In writing about German heroin addicts, Bergschmidt captures some of what is at stake in meeting the demands of normativity:
A life that is worth saving has to be economically productive, governable, and willing to refrain from the dangerous and polluting practice of injecting ‘junk.’ The narration of a ‘desire for the norm’ is thus bound up with the hope to emerge from the field of objects ‘marked by death’ into social existence (Bergschmidt , 2004:69).
Moving into social existence by seeking treatment, whatever level of regulation that might bring, offers new possibilities for autonomy and self-narration. To be sure, these possibilities remain constrained, monitored and controlled. But as Butler (2004) suggests, all of us must be subject to the constraints of normativity to exercise autonomy. Gomart (2004) argues persuasively that, in the case of methadone clinics, constraint is productive and beneficial precisely because it moves the addict into the realm of the socially sanctioned and thereby opens up new possibilities. While acknowledging that much of the harm from addiction comes from the ways in which society constructs and responds to it, she concludes: ‘Methadone tentatively performed a user who would be less vulnerable in a society which penalized opiate use (p.97).’ Medications used to treat drug addiction are less harmful than the drugs they are meant to treat if only because society has defined them that way.
Furthermore, the paradigm of the unrestrained addict and the constrained patient tends to equate drug use with freedom and occlude the fact that few populations have less choice or are more harshly regulated and sanctioned than drug users. Many addicts are denied the resources needed for the exercise of most “freedoms” available in a modern consumer society. To the extent that addiction (whether conceived as biologically, psychologically, or socially produced) leads to compulsive or uncontrollable behavior, it limits real autonomy. The question is not one of freedom versus constraint but one of what kind of freedom is possible and what kind of restraint is tolerable.
Resistance, Relapse & the Failed Patient/Addict
New drug technologies, while constraining and regulatory, may indeed afford new productive possibilities and permit new freedoms as they move the addict/patient towards the socially sanctioned. S/he may regain the ability to sustain relationships and jobs or to escape the crushing weight of stigma or the compulsion to use. In this sense, these technologies are like other ‘body projects’ which allow new opportunities for self-narration and autonomy.
However, the regulatory capacities of these new drug treatment technologies may be limited in ways that are not yet be apparent. Drug treatment strategies to control drug use and drug-related euphoria, have always been accompanied by patients’ attempts to circumvent the effects of those treatments. These very technologies examined here were produced out of a dialectic between drug treatment and the re-appropriation of drug treatment medications by patients. The border between drug and medicine is continually crossed by those who will not or cannot recognize the discursive boundaries erected. Depot formulations, electronic dispensing systems, and sustained release formulations were developed primarily to address the problems of misuse and diversion by the patient/addict -- that is, their propensity to treat medications like drugs. In addition to misuse and diversion, the authors of the IOM report acknowledge that some patients will try to over-ride the blockade effects of vaccines and substitution therapies by simply using higher amounts of illicit (or prescribed) drugs. The ‘choice’ to use or misuse drugs/medicines remains, though the stakes become higher as the risk of overdose and death increase. Like with other drug treatments before these, patients will likely find ways to overcome the regulatory constraints of these newest technologies.
The refusal to submit fully to new drug treatment technologies is not simply or always an act of resistance or an exercise of autonomy. The continued use of drugs may well be driven by forces beyond individual choice, including the failure of drug treatment technologies to ameliorate the underlying causes of addiction and/or the incoherence of the distinctions being made between drug and medicine. Individuals move in and out of treatment; they continue to use drugs and/or misuse medications even while they are in treatment; they are often both simultaneously the addict and the patient. ‘Relapse,’ while widely acknowledged as part of the disease of addiction, is often seen as a failure of the patient rather than a failure of the treatment technology. The efficacy of these particular technologies is still being investigated, but in general the effectiveness of drug treatments (medical or behavioral) is extremely low. Estimates vary widely, but according to the Drug Addiction Treatment Outcome Study, which investigated both methadone and behavioral drug treatments, on average, treatment reduces major outcome indicators for drug use, illegal activities, and psychological distress by about 50% after one year (DATOS, 2006). Recognizing the high rates of relapse, proponents of the medical model increasingly frame addiction as a chronic medical condition, like diabetes or hypertension (see for example, Merrill, 2002). By locating treatment failure within the diseased patient/addict, doctors obfuscate their failure to treat addiction successfully as well as any role they might play in fostering addiction by prescribing addictive substances. The relapsed patient is seen as resistant or even “still sick,” but s/he is seldom seen as a victim of iatrogenic medicine. Wilkerson (1998) notes that such localization of pathologization ‘perpetuate[s] the perception that…suffering occurs on a random, individual basis (p.21).’ Treatment failure, like addiction itself, remains the problem of the individual addict/patient.
Social Location & the Dangerous Other
Finally, no discussion of constraint and autonomy can neglect issues of social location and the differential power operating in the production of selves. Neither technology nor bodies can be conceived of as outside power (Pitts, 2003), and ‘the language of biomedicine is never alone in the field of empowering meanings (Haraway, 1989: 203).’ While it is beyond the scope of this paper to fully explore the dynamics of race, class, gender and consumption in the embodiment of new drug treatment technologies, they clearly play a critical role. As Pitts (2003) points out: ‘…certain groups are more closely scrutinized under the medical gaze, and pathologized more readily than others… pathologization is never politically neutral (p.18).’ Both the brain disease model of addiction and these new drug treatment technologies enter into a context deeply marked by social, political, cultural and economic inequity. The ways in which these technologies are deployed, whose bodies they mark, and what kinds of subjects they produce are profoundly affected by existing fissures within society.
Despite the fact that the vast majority of substance users are white, the addict is generally constructed as a person of color, a dangerous Other, a threat to social order, and a force that must be controlled and contained. The disproportionate rates of incarceration for drug offenses provide some evidence of the ways in which addiction in the U.S. is racialized. Although African Americans represent only an estimated 15% of all users of illicit drugs, they represent 36.8% of those arrested, over 42% of those in federal prisons, and 57% of those in state prisons for drug offenses (Common Sense, 2006).
Given prevailing notions of race and addiction, the new drug treatment technologies may lead to an even more bifurcated system of responding to and constructing addiction wherein people of color remain under the criminal model and are incarcerated while white people are brought under the medical model and “treated.” While people of color are disproportionately incarcerated and unlikely to receive treatment even when they seek it out, white people are generally better positioned to choose, access and pay for medical treatments for addiction and to avoid incarceration. Nonetheless, an analysis of race and new drug treatment technologies cannot stop with imagining a treatment/punishment system bifurcated along the lines of race.
I have argued that the newest drug treatment technologies involve higher levels of control and surveillance than previous medical treatments for addiction. Perhaps new drug treatment technologies will be shaped to the contours of American racism and used in ways that satisfy the need to regulate and control the abject, racialized dangerous Other. For instance, it is not difficult to imagine that a vaccine for cocaine is more likely to deployed in Black communities than white communities. Similarly, one could imagine racism guiding the decision to give a Black patient the ADS system, while trusting the white patient to administer the medication him or herself. In addition, these are experimental treatments, and people of color have often borne the brunt of scientific experimentation. It is worth noting that the depot naltrexone shown in Figure 2 is being implanted into a Black person’s body by a white doctor. Finally, we must acknowledge that all of these forces are mutually constitutive. Who is the object of the new drug treatment technology will profoundly affect how the patient/addict and the technology itself are viewed and what meanings they produce. New treatment technologies will not only alter the way racism is articulated; new technologies will also be shaped by racism. No amount of naltrexone will disentangle race and addiction.
Conclusion
New drug treatment technologies seek to shore up the borders between drugs and medicines and between addicts and patients by obscuring the ambivalent nature of drugs/medicines and asserting a determinacy and a meaning that cannot be found in the substances themselves. Through their production, material form, packaging, mode of delivery, and attempt to control euphoria, new drug technologies function to create a distance between drugs and medicine and between addiction and addiction treatment. I have also argued that these technologies and their embodiment have profound implications for the production of the self in that they regulate the exercise of autonomy in important ways. Moreover, these processes are not ideologically neutral but bring with them social, cultural, political and economic histories that can serve a variety of interests.
The embodiment of addiction has taken a number of forms and interrogating who benefits from each new rendition of the addict is critical. Clearly, doctors and pharmaceutical companies stand to profit financially from new drug technologies and the vision of addiction they represent. In addition, both big pharma and medicine have histories of complicity in addiction that makes displacing the blame for addiction somewhere else (like within the addict’s brain) imperative. Addiction cannot be located in the addictive substances (many of which big pharma has produced and introduced) nor can it be placed in the hands of doctors (many of whom have not only made these substances available but insisted that their patients take them). The 6.4 million Americans who misuse prescription medications each month create problems for doctors who neither want to be seen as dealing drugs nor want to deal with the drug-seeking behavior of their patients. The doctor/patient dyad is mutually constitutive, and as new drug treatment technologies re-inscribe the patient/addict in particular ways, they also re-inscribe the doctor. They re-establish the doctor as one who treats, rather than fosters addiction. The addict is reclaimed as patient; the drug-peddling doctor is reclaimed as healer.
New drug treatment technologies and the contest over meaning they exemplify are just one part of a field of inchoate drug policy that is rife with confused and contradictory discourse. Treatment success rates for medical approaches remain low and yet millions of dollars continue to be allocated for investigating new medical technologies for treatment addiction. Doctors prescribe medications that can cause addiction and then prescribed more medications to treat the addiction to the medication they prescribed. Addictive substances are implanted under the skin of people addicted to drugs. The line between illicit drug and therapeutic medicine continues to blur and shift.
Though its form shifts and changes historically and contextually, the addicted body endures as a site of contest and conflict because, at some fundamental level, addicted bodies represent a risk to social order. As others have suggested (Balsamo, 1995; Pitts, 2003; Waldby, 1997), marginal bodies threaten the social order precisely because the body has become such an important site of control, production, and identity. Constructed as the dangerous Other driven only by a desire for euphoria, the addicted body challenges the fundamental responsibilities of the liberal subject in a capitalist consumer society – to behave productively, responsibly, and rationally (O’Malley, 2004). If it is not be contained with the walls of a prison, the addicted body and the threat it represents must be marked, isolated, controlled, regulated, monitored and inoculated by the latest biomedical technologies western science has to offer.
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Figures
Figure 1: Cocaine Vaccine Action
Source: http://www.cantab.co.uk/dc_ta_cd.html
Figure 2: Depot Naltrexone
Source: www.minddisorders.com
Figure 3: Advance Dispensing System
Source: GW Pharmaceuticals, www.gwpharm.co.uk
