Addiction Neuroscience & Volition

Below is a small part of a very, very rough draft of a chapter on the neuroscience of addiction that I am working on.   Feedback and comments are welcome as I am still very much thinking through the piece.
 

Addiction Neuroscience & Volition: Character Flaw or Bona Fide Brain Disease?

Perhaps one of the most interesting features of the neuroscientific literature on addiction is the explicit attempts to use the research for political purposes.  Rather than isolate themselves behind a wall of scientific objectivity and neutrality, a surprising number of prominent addiction researchers use the brain disease model to argue for changes in both public perception and policy. The use of neuroscience for projects of destigmatization is not unique to addiction.  Vidal (2009), in speaking more broadly about neuroscience, suggests that brain images have contributed to the destigmatization of illness.  Abi-R (2010) argues that we are in a third wave of brain research that brings together a diverse hybrid of perspectives and researchers that are held together by “some common institutional projects…a common reductionist approach to the explanation of complex phenomena pertaining to the brain, behavior and the nervous system (p.12).”  The common project of neuroscientific addiction researchers appears to be the reframing of addiction as a brain disease for the explicit purpose of destigmatizing and decriminalizing drug use and bringing it more fully into the purview of the medical, rather than the criminal justice, system.

Dackis (2005), for instance, claims that neuroimaging will “substantiate the biological basis of addiction and…ultimately erode entrenched societal attitudes that prevent addiction from being evaluated, treated, and insured as a medical disorder (p.1431).”  In his view, neuroscience will eventually end the discrimination and criminalization of addiction (2005, p.1431).  Others characterize the failure of the public to adopt the brain disease model as “a public relations problem (Nature, 2005, p.1413)” for science and medicine.  But by highlighting and disseminating “select advances in addiction research,” scientists can and should reverse the public’s “misconceptions” and “facilitate changes in policy (Dackis, 2005, p.1431).

These researchers believe that promoting a biological basis for addiction will undermine competing notions that addiction is “a character flaw rather than a bona fide brain disease (Chou, 2005, p.1427).”  At stake for the researchers is nothing less the definition and source of volition and free will.  Their argument hinges on the notion that addiction undermines volition because, if addicts’ behavior is involuntary, they cannot be culpable for their ‘disease.’  Volkow (2005), for instance says:

We have learned how some drugs and alcohol can disrupt volitional mechanisms by hijacking the brain mechanisms…  However, despite these advances in understanding the neuroplastic changes to drugs and alcohol, addicted individuals continue to be stigmatized by the pernicious but enduring belief that their affliction stems from voluntary behavior.  The loss of behavioral control in the addicted individual should spur a renewed discussion of what constitutes volition (p.1436).

This tension between medically- and character-based paradigms of pathology is not new and has existed for decades in conversations about addiction – as well as a host of other ‘diseases.’  What is new is the attempt to pinpoint a biological basis for the loss of volition and to locate it in the addict’s brain.  This is critical because as along as addiction is seen as having an element of choice, it remains difficult to characterize as a disease in which those afflicted are free from blame.  Historically, there has been confusion whether the pathology is the behavior or whether the pathology causes the behavior (Pickersgill 2009).  The neuroscience of addiction claims to have solved that dilemma by isolating the brain mechanisms that cause the undesirable behavior – compulsive use of drugs or alcohol. While the project of neuroscientists appears to be relieving drug users of the stigma and blame associated with addiction, such rhetoric can also be used to justify the “suspension of their personal autonomy, installing an imperative that they be governed by others (Brook, 2005, p.319.”  For if they cannot control their behavior – if they have a ‘defect of the will (Bull, 2008, p.154)”-- they must be controlled by someone else.  However, recently, neuroscientists have developed a number of interventions (most still experimental) that they claim can correct defects in the will of addicts.

 

Curing stigma

I’ve been buried deep in reading scientific articles about the neurobiology of addiction. Interesting stuff. Much of it is speculative, but it is definitely where addiction research has been and will keep heading. One of the things that strikes me most in reading these articles is the relatively overt and self-conscious acknowledgment of scientists that they are engaged in a rhetorical war to transform our understandings of addiction with the laudatory goal of decreasing the stigma surrounding addiction. There are certainly other motivations, but that’s for another blog post.

Perhaps the country’s most vociferous proponent of the brain disease paradigm of addiction is Nora Volkow, Director of NIDA, who wrote: “scientists are now able to portray addiction as a medical disease with physiological and molecular changes thanks to the scientific and technological advances that have occurred over the past decade.” She and others claim that these new understandings are critical to ending the stigmatization of addicts. The crux of this argument is that science has proven that addiction is not volitional. Again to quote Volkow:

[D]espite these advances in understanding the neuroplastic changes to drugs and alcohol, addicted individuals continue to be stigmatized by the pernicious but enduring belief that their affliction stems from a loss of voluntary behavior. The loss of behavioral control in the addicted individual should spur a renewed discussion of what constitutes volition, challenge us to identify the neurobiological substrates that go haywire, and influence evolving strategies...

Truly, one of the things that fascinates me most about the study of addiction is how it implicates notions of agency and volition, but I am not sure that ‘brain science’ is where I would root that discussion. Even if we were to accept that the brain has been hijacked, how is one to regain their volition under this model? I fear the answer lies in more changes to the neurobiology of the brain – strategies which we may want to embrace but only after careful scrutiny of the motives behind them and alternative understandings. Nor does it seem to me that the only way out of stigmatizing addictions (which I agree is pernicious and destructive) is to argue that addicts have a brain disease. What if, for instance, we focused instead on a paradigm that looked to economic and political causes of addiction? Wouldn’t individual stigma be diminished by understanding addiction is caused, in part, by the lack of meaningful opportunities and alternatives; personal and collective histories of abuse and oppression; or the emptiness and frustration generated by neoliberal consumer capitalism? I am not arguing that these are the causes of addiction; I am arguing that there are paradigms beyond a brain disease model that might decrease stigma without a message to people who use drugs that their brains have “been hijacked” and that they have lost their volition and agency.

Neurochemically normal

Today I read an interesting article by Simone Fullagar based on her interviews with Australian women taking antidepressants.  I've been looking for pieces that are grappling with what our new neuroscientific understandings of problems, like depression and addiction, mean for how people understand themselves and their possibilities for self-transformation.  Fullagar (2009) notes:

Relations of biopower have moved beyond the body as the focus of a clinical gaze towards a different somatic conception of subjectivity that visualizes life at the molecular level.

Locating illness at the molecular level seems to give a certain kind of biological certainty that extends beyond notions of individual choice.  The idea, for instance, that addiction is brain disease, seems to give it a biological basis that downplays the notion that drug use is an individual’s failure of will or a poor decision.   This transformation towards what has been called the neurochemical self is especially interesting to me in light of other scholarship that suggests we are increasingly held responsible for own health and illness.  Galvin (2002), for example, argues that, in our neoliberal society, matters once seen as the responsibility of the state are increasingly matters of individual responsibility.  According to Galvin:

The healthy person is, in effect, symbolic of the ideal neoliberal citizen, autonomous, active and responsible, and the person who deviates from this ideal state is at best lacking in value and worst morally culpable.

If we can choose to be healthy (think of the constant exhortations to exercise, eat right, take your medicine), then the corollary is that we are culpable when get sick.  How then do we reconcile these two trends --  to locate illnesses (particularly those previously understood to be based on personal choice, like addiction) in the brain and to hold people increasingly responsible for their own health?  Are we blaming the person or blaming their brain?

Fullagar helped put a few pieces together for me.  In my interviews with drug users, there is a constant refrain about how addiction treatment medications help them “feel normal.”   Fullagar heard the same from some of the women in her study taking antidepressants and notes that the promise of the medication is restore normality.  The normality being restored, however, is that consistent with very prescribed notions of a neoliberal self (in the case of Fullagar’s analysis these selves are also gendered in traditional ways).   She says:

These products [pharmaceuticals] products have emerged out of the broader transformation of knowledge within biocapitalism, science and the clinical encounter to profoundly change the way that we imagine and relate to our biological selves at the molecular level…  Within mental health and illness discourses, this flexible, somatic individual is rendered thinkable as neurochemically deficient via the authority of molecular science that locates disorder and dysfunction in the brain (p.392).

“Neurcohemically deficient selves” --  selves which, once they understand they are neurochmeically abnormal, are then responsible for becoming normal.   And normalcy is defined in ways consistent with neoliberal ideals of individualism, responsibility, and consumption.  Increasingly, biocapitalism is at the ready with a pill or a technology that can return you and your brain to normal – the normal that serves their interests.

Doctors and drugs

Clinton McCracken, a Canadian drug researcher, recently did a brave and unusual thing --  he published an article in JAMA [readers may have to view an ad] describing his own drug use.  His narrative troubles the DSM IV criteria for substance abuse and disrupts the silence of researchers and medical professionals surrounding their relationship to addiction.  He was able to use drugs consistently for years without meeting the criteria for abuse.  Indeed, in the end, the harm that came to him was less from his drug use than from the criminal justice response to it.  However, the story of his fiancee, who died following a bad reaction to injection drugs, unfortunately reminds us of the very real harm that drugs can do, especially drugs bought on the street or through overseas online pharmacies.   Given our current system of criminalizing some drugs, many people, like McCracken's partner, put themselves at risk trying obtain drugs and/or end up with drugs that contain hazardous adulterants or contaminants.  This may be one reason why many people are increasingly reliant upon prescription medications obtained from their own doctors.

What is striking about McCracken's account is how rarely we hear from researchers or medical professionals either about their own drug use or about their own role in supporting addiction.  I am not trying to demonize doctors.  In fact, some accounts suggest that doctors are prescribing opioids either to keep their patients away from heroin and the dangers associated with obtaining and using it on the street and/or to help them establish a steady source of income.  It seems to me that doctors need safer and better ways to talk about addiction -- how they deliberately or unwittingly support it, how they clandestinely treat it, how they want to treat it, and how addiction affect their own lives.   Unfortunately, doctors are silenced by the stigma and very real professional and legal consequences of talking openly about these issues.  I don't necessarily agree with everything McCracken had to say, bur I do applaud his willingness to raise these issues publicly among his peers.

Becoming Normal: The Social Construction of Buprenorphine & the Embodiment of New Drug Treatment Technologies

  Here's the intro to my dissertation proposal.  Feedback and comments welcome.

In a radical departure from almost a century of U.S. drug policy, in October 2002, the U.S. Food and Drug Administration approved the use of the pharmaceutical, buprenorphine, to treat opioid dependence in office-based settings. Unlike methadone, which remains mired in restrictive government oversight and requires daily attendance at a highly regulated clinic, buprenorphine is available through any certified physician in any office–based setting.  As such, buprenorphine marks a profound change in how, where and by whom drug treatment is delivered.  For the first time since the passage of the Harrison Act in 1914 and subsequent court decisions (through which doctors were expressly forbidden to treat addiction by prescribing narcotics), doctors can treat addiction to opioids (heroin and prescribed opioid medications) by prescribing a drug/medication.  Buprenorphine is the first, and to date, the only medication approved for the office-based treatment of opioid addiction, but an increasing number of medications are being developed to treat a wide array of addictions.  As the leading edge of this movement to treat addiction through prescription, buprenorphine has been heralded by addiction medicine experts as the technological breakthrough that will finally move the treatment of addiction into the medical mainstream. 

Conrad and Schneider (1992) have noted the escalating medicalization of deviance through which behaviors once viewed as moral failings are increasingly viewed as illnesses.  One hallmark of medicalization has been the widespread adoption of medications to treat problems previously understood as behavioral (Diller, 1999).  However, neither alcoholism (Valverde, 1998) nor drug dependence (Smart, 1984) fit easily into the medicalization model, even though the medical model of addiction dates back to the 1800’s and has gained in prominence in the U.S. over the past thirty years.  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 a crime.  Thus, the world of addiction and addiction treatment has been and remains one of contestation, confusion, and slippage.  Buprenorphine enters directly into this contest as the first real medical “solution” to opioid addiction since the introduction of methadone four decades ago.  It represents a clear attempt by medical professionals and the pharmaceutical manufacturer to further medicalize addiction and to resolve some of the discursive ambiguity surrounding addiction treatment.  As such, it offers a unique opportunity to study the processes and conditions of medicalization and to explore how and why criminal and medical models to explain addiction continue to coexist. 

In addition to exploring processes of medicalization, this project is concerned with the sociology of body and the relationship between the social construction of addiction and the formation of the 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; Pitts-Taylor, 2003; Shilling, 2003).  Doctors play a particularly important role in labeling and legitimizing bodies and in managing subjective experiences of our bodies (Shilling, 2003), and biomedical technologies (Persson, 2004), like buprenorphine, are intimately and importantly involved in the production of self.   However, the ways in which medical rhetoric about addiction and these new treatment technologies affect the interiorization and embodiment of medicalized identities is poorly understood.

Using interviews with doctors who prescribe buprenorphine and patients who take it as well as an analysis of documents about the introduction of buprenorphine in the U.S., I will examine how buprenorphine is being socially constructed and how new drug treatment technologies, like buprenorphine, are embodied and understood by the people who use them, how it shapes their subjectivity and identity, and what new possibilities for freedom or constraint these new identities offer. 

Paying Addicts for Sterilization

Sorry for the long silence on ye ole blog, but i've actually been focusing on my dissertation for a change.

But this just in for those of you who think there isn't an element of social control to drug treatment.  JoinTogether.org reported this frightening tidbit:

The highly controversial Project Prevention, a North Carolina charity that gives cash payments to drug addicts who undergo sterilization or start on long-term birth control, is receiving a similar mixed reception as it expands into the United Kingdom.

Time magazine reported April 17 that Project Prevention founder Barbara Harris decided to form a U.K. chapter after 400 e-mails of support followed her appearance on a BBC Radio 4 program in February. The organization, which relies largely on private donations to subsidize its $300 payments to addicts, received $20,000 from an anonymous supporter to launch its U.K. effort.

Sigh.  Her goal of reducing the number of drug-exposed infants is a good one, but, really...  sterilization?  And can we talk about the ethics of offering $300 incentives to addicts?  Gah.

biological determinism and free will

A whole lot of energy goes into proving or refuting the  biological basis of undesirable behavior.  In large part, these are political arguments.   If it is my genes/my brain/my disease that 'made me' use drugs/kill my neighbor/be homosexual, then I should not be held accountable.  I am sick, not bad.  Not so says one of my favorite social theorists, Nikolas Rose.   In great article in the History of Human Sciences (Vol. 13:1), called Screen & intervene: governing risky behavior, Rose  notes how resoundingly biological dermininism has failed in the US courts.  He goes on to say:

"Indeed, the trend of contemporary legal thought, especially in the USA, is to operate on the premise of the inescapability of moral responsibility and culpability. On this basis, no appeal to biology, biography or society should be allowed to weaken moral responsibility for the act, let alone to diminish the requirement that the offender be liable to control and/or punishment. In this context, the argument from biology is likely to have its most significant impact, not in diminishing the emphasis on free will necessary to a finding of guilt, but in the determination of the sentence. This is unlikely to be in the direction of mitigation. For if antisocial conduct is indelibly inscribed in the body of the offender, reform appears more difficult, and mitigation of punishment inappropriate. More likely are arguments for the long-term pacification of the biologically irredeemable individual in the name of public protection."

Yikes...  So much for the argument that medicalization beats criminalization.  If our medical arguments can be used to create 'biologically irredeemable' individuals (see the post on chronic, relapsing conditions below), we may be doing more harm than good.  Rose goes on to point out the ways in which new neuroscientific technologies are being used to identify people "at risk" or predisposed to criminal behavior.  Soon, you may not even have to commit a crime to become suspect.

Addiction = chronic, relapsing disease? Not for most...

 

So in my ever pokey quest to obtain the elusive PhD, I’ve been reading Addiction: A Disorder of Choice by Gene Heyman.  Super interesting and provocative so far.  I’m sure I’ll post more about the book later, but for now I want to mention his very helpful analysis of studies on the prevalence and natural history of addiction.  As I’ve written before on this blog, the two dominant models of addiction are (and have been for decades) a disease model and a criminal justice model.  Setting aside the criminal justice model, the disease model is generally characterized by two (not mutually exclusive) discourses: 1) addiction is a brain disease and 2) addiction is chronic, relapsing condition. 

Heyman takes a close look at the scientific literature to better understand where the ‘chronic, relapsing condition’ notion comes from and how accurate it is.  He notes that most of the studies upon which this paradigm relies are of based on samples of people in treatment.  Turns out, not surprisingly, that those in treatment are quite different from others who use drugs but do not enter treatment.  Heyman reviews several large studies based on samples of the general population, which reveal that, in sharp contrast to the rates of relapse among treatment-based samples, most folks who have been addicted to drugs quit on their own and do not relapse.  In fact, three of largest national studies suggest that almost 80% of people who were addicted at one time are able to quit drugs and stay off them.  Qualitative studies of former addicts support these data and indicate that many people quit as they mature and/or have increasing reasons to quit (e.g., job, family, health).   

Research looking at what distinguishes treatment- and non-treatment-based samples shows that the biggest difference is that those in treatment-based samples have much higher rates of psychiatric comorbidity, which could plausibly affect the natural history of addiction quite differently.  Heyman has taken a lot of heat for his primary thesis that addiction is a choice, but I think his analysis of these studies is really important.  So much of what we know about addiction is based on research samples of those in treatment (my own included), which we know to be biased.  A broader view suggests that, for a whole lot of people, addiction is not a chronic, relapsing disease.  I am not suggesting that there are no folks who experiences addiction as a disease.  I've known lot of people who do.  But, I've also met a lot of people who reject the disease model of addiction and do not feel it resonates with their own experiences of addiction or recovery.  What does seem to be true is that addiction is experienced very differently by different people.  Maybe that's why I'm so interested in how the sociology of the body might be able to help lend some insights into how and why embodied experiences of addiction and recovery are so varied.

McClellan Resigns from ONDCP

Here's some bad news in my opinion (as reported by JoinTogether.org):

Respected addiction researcher Tom McLellan has announced that he will resign as deputy director of the Office of National Drug Control Policy (ONDCP) this summer.
McLellan told Alcoholism and Drug Abuse Weekly in an interview that he was not unhappy with ONDCP's mission, its personnel, or the forthcoming National Drug Control Strategy. "There's no deep dark secret here -- I'm just ill-suited to government work," he said.
ONDCP issued a statement on April 16 confirming McLellan's plans to resign. "Tom has been a leader in helping the Obama administration fashion a comprehensive and balanced approach to drug policy that puts new emphasis on prevention, treatment, and recovery while acknowledging the important role of law enforcement," said ONDCP Director Gil Kerlikowske. "I will miss having Tom at my right hand, but we will continue to benefit from his wise counsel and knowledge."

McLellan said he would remain at ONDCP over the next several months to help implement the new drug strategy. "With the passage of health care reform and the crafting of the new drug control Strategy that will be released soon, I believe we have laid the foundation to make real progress in reducing drug use and its consequences," he said.

This is your brain on bacon

Have you noticed lately the increasing effort by public health advocates to start regulating food in ways that are similar to tobacco and alcohol?  Building on the huge success of tobacco policies that reduced smoking rates dramatically over the past several years, public health advocates are now turning their attention to fat, salt and sugar.  The skyrocketing rates of obesity and concomitant health care costs make their case pretty compelling in my view.  In fact, my work place, The New York Academy of Medicine, is involved in campaign to tax sugar-sweetened beverages.  You can get involved by clicking here.

So I am not universally adverse to drawing parallels between food and drugs, but this new study pushes my critical sociologist buttons.  Check your animal cruelty sensibilities here and listen to the methods.  Rats were implanted with electrodes and then fed this:

The cafeteria diet consisted of bacon, sausage, cheesecake, pound cake, frosting and chocolate... 

Long story short...  the rats that had the junk food diet available to them all day, not only grew obese, but become compulsive eaters and continued to eat even when they received an electric shock for doing so.   Here's the part I object to (rat mistreatment aside):

These data demonstrate that overconsumption of palatable food triggers addiction-like neuroadaptive responses in brain reward circuits and drives the development of compulsive eating. Common hedonic mechanisms may therefore underlie obesity and drug addiction.

So it's not the equation of compulsive eating to addiction that really bothers me...  it's the reduction of both to neurochemical processes.  I am sure there are biological components to addiction and maybe for addictions of all types.  But what does it mean when we tell someone with an addiction that they have a brain disease or tell someone who is obese that eating bacon down regulates your striatal dopamine D2 receptors?  And what does it mean for our social and political responses to the problem of addiction?  

Stanton Peele and others have done some interesting critiques of the disease model of addiction (of which the brain disease model is just one subset).  As Granfield and McCloud discuss in their book about people who quit drugs on their own, Coming Clean, it turns out that a lot of people don't like being told they have a chronic, relapsing disease.  Not only does that model and rhetoric belie the reality that the vast majority of people who use drugs stop on their own, it isn't an empowering message for people who are trying to quit.  The disease model is not without it's advantages, however.  Sending people to treatment sure beats locking them up, and one can argue that having a disease is less stigmatizing than the other popular construct -  addiction is a failure of will.  But surely we can come up with a more nuanced model for addiction than either of those.  While you all figure that out, I am going to have a bacon cheeseburger. 

Want to talk about the real drug problem?

So when are we going to start talking about the real drug problem in this country? A new issue brief from the CDC on “unintentional poisoning” (that’s what we’re calling drug overdose these days, especially when it involved prescription medication) reports that, in 2006, overdose was the second leading cause of unintentional injury deaths after motor vehicle accidents! 26,400 people died from overdose that year. Even more alarming are the rapid rates of increase --- overdose deaths have increased 5 fold since 1990. What drugs are killing people at such alarming rates? According to the CDC: “the increase in drug overdose death rates is largely because of prescription opioid painkillers.” There has been a ten-fold increase in the ‘medical use’ of painkillers in the past 15 years, and prescription opioids were responsible for more deaths in 2006 than heroin and cocaine combined.

There is no way to address the epidemic of prescription drug abuse with answering hard questions about who is using these drugs (largely middle-aged, white people), who is prescribing these drugs (doctors), and who is profiting from the sale of these drugs (Big Pharma). According to a market industry report, “the global market for pain management pharmaceuticals and devices amounted to $19.1 billion in 2008 and is expected to increase to $32.8 billion in 2013.” That’s a lot of incentive to prescribe opiates. Under the 1914 Harrison Narcotic Act, doctors cannot prescribe narcotics for the treatment of addiction, but they can and do prescribe it for pain. So, we have a set of policies where doctors can, for example, prescribe methadone (an opiate the causes physical dependence) for pain but cannot prescribe it (except in a few highly regulated clinics) to treat addictions. Just to reiterate, doctors can prescribe the medications that cause addiction, but once people are addicted, both addicts and doctors are trapped in a difficult dance over if and how medications will continue to be prescribed.

This confusion in our policies has created a cottage industry of pain management clinics, particularly in states like Florida with less regulation (try googling Florida + pain management). For sure, many people are seeking legitimate help for acute or chronic pain conditions. But clearly, a lot of folks are becoming addicted, and thousands of them are dying each year from overdose. Despite increasingly irrefutable evidence that the real drug problem in this country is prescription medication, the vast majority of our drug policies in this country are still aimed at punishing those involved with illicit drugs. I’ll leave you with questions: When does a medication become a drug, and what is the difference between the two anyway?

alcohol: the other drug

There is a really interesting new study out from the CDC on the health behaviors of adults that includes information about the Americans' use of alcohol.  According to this study, 61.2 % of us drink, while only 5% are heavy drinkers.  So here’s a mind-altering substance that is widely consumed and affects far more people than most illicit drugs but is regulated entirely differently. I’m not saying that there isn’t room for improvement in our policies surrounding alcohol, but they are far saner than many of our drug policies.  Alcoholism is a serious problem, but unless someone commits a crime while drunk, we generally don’t lock up alcoholics but refer them to treatment.   

One of things that I found most intriguing about the study was the finding about consumption, abstinence and education. Drinking levels increased as education level increased: people with masters, doctorate, or medical degrees are much more likely to drink than those without a high school diploma. 

 Not surprisingly given the correlation between income and education, richer Americans were more likely to drink than those living below the poverty level.  Moreover, poorer people who used to be regular drinkers were more likely to have quit drinking than richer ones.  Perhaps, then, it isn’t surprising that alcohol is regulated, while other drugs, which are perceived to affect communities of color, are criminalized.  When it comes to our drug policies, it’s hard not to see racial disparities in our approaches.

racial disparities in sentencing persist

A new study from the U.S. Sentencing Commission suggests that racial disparities in sentencing have actually increased since the loosening of federal sentencing guidelines.  According to the report, since the 2005 Booker ruling that gave federal judges more discretion, Black men have received sentences at least 10% longer than those imposed on white men.  The report cautions that these statistics can't explain why these disparities exist, but it seems to me that the U.S. history of racial oppression and mass incarceration of men of color is one place to start looking for answers.  This report comes at a time when the U.S congress is considering legislation that would reduce disparities in sentencing between powder and crack cocaine, which has long been recognized as leading to racial disparities in drug-related sentencing.  Drug law reform is desperately needed, and reformers are right to take aim at mandatory sentencing that leads to racial disparities.  However, this new report suggests that we need to play close attention to states like New York that have recently reformed the harsh and ineffective Rockefeller drug laws (requiring mandatory sentencing for drug-related offenses) with judicial discretion.  Judges, like the rest of us, are not free from racism, and dismantling the racist prison industrial complex cannot rest on judicial discretion alone.  This latest study is just more evidence that reforming our drug policy must go far beyond over turning mandatory sentencing.  It's time to think more deeply about how to reorient all of our public policies to reduce the harm associated both with drug use and the racism inherent in the "war on the drugs."

Looking for good resources on international drug policy?

International perspectives on drug policy are helpful for a few reasons.  First, some of the most interesting and progressive policies are happening outside the U.S.  Second, we need global strategies to meaningful address the worldwide problem of drug-related harm.  We certainly seem to have no problem conceiving of the 'war on drugs' as an effort that crosses international borders.  Why not start learning from our global neighbors about new approaches harm reduction, treatment and prevention?  The International Drug Policy Consortium isn't a bad place to start.  In addition to a library of more than 200 publications, they offer a great set of principles to guide best practices in national drug policy.  Imagine what U.S. drug policy would look like if we took these principles seriously:

Overarching principles:

1) Human Rights Principles
Articulating how the protection and promotion of human rights principles can be incorporated into national drug strategies and programmes, and issuing challenges under human rights legislation and procedures where these obligations are breached.

2) Harm Reduction Principles
Articulating how proven harm reduction concepts and programmes can be integrated into effective drug policy.

3) Social Inclusion Principles
Articulating how the most effective approaches to reducing the demand for drugs should focus on finding ways to counter the stigmatisation and marginalisation of drug users, and offer those who need it help to reintegrate into society.

4) Civil society engagement
Advocating to national governments the benefits of engaging with civil society. All too often, due to the political sensitivity in this field of policy, policy makers have viewed civil society as a problem to be avoided. If constructive mechanisms can be created for respectful engagement, however, NGOs (including user and family representatives) are an invaluable source of expertise, particularly in their understanding of what is happening in drug markets and drug using communities.

5)  Objective Setting and Data Gathering
To propose a structured approach to the assessment of priorities for national drug policies, focusing on the real health and social harms to individuals and communities.  To describe how a range of high level objectives can be articulated that are relevant to the particular situation, and examine the options open to policy makers for establishing systems to measure progress against those objectives.

Criminal justice:

1)  Better drug laws
Articulating the problems with the creation of harsh and unsophisticated drug laws, and the need for better legal frameworks, for example, for proportionate sentencing, diversion to treatment, and support for harm reduction. Building on the existing work of the Canadian HIV/AIDS Legal Network (who have developed and are piloting some of these materials), we hope eventually to be able to articulate and promote model legislation to governments around the world, who are developing or reviewing their domestic legislation.

2) A new role for law enforcement
Articulating a new role for drug law enforcement in the 21st century, moving away from a singular focus on arrest, seizure and punishment, and towards a contribution to tackling the consequences of drug markets in terms of crime and violence, community harms, public health and drug dependence treatment.

3)  Reducing incarceration
Articulating the evidence that widespread incarceration of drug users does not reduce prevalence, is expensive, and can increase health and crime problems. Producing ‘tool kits’ for national governments on the legal and criminal justice approaches that they can take to reduce incarceration.

4)  Effective policy for prisons
Looking at how prison administrations can implement best practices in supply reduction, prevention, treatment, and harm reduction in custodial institutions.

Health and social programmes

To promote systems of effective drug prevention and drug dependence treatment and care, based on the experience of humane and effective practice around the world.  Drug education and prevention will be based on models which have been shown to achieve meaningful outcomes. Drug dependence treatment should be delivered through an integrated system using evidence-based models. Harm reduction and other public health measures should be fully integrated into the treatment and care system.

Strengthening Communities / Community safety

To examine the ways that drug distribution at national and local level can cause crime and social problems for law abiding communities, and promote creative ways for policy makers, law enforcement agencies and communities to respond, focusing on the reduction of violence and intimidation experienced by citizens and communities. The exact nature of markets, and the related violence and disorder, varies in different parts of the world, but there is a common theme of ruthless protection of turf and profits, and some important lessons from experience of the authorities in attempting to tackle it.

The Neuroscientific Construction & Embodiment of Addiction

Because I can't get enough rejection, I submitted this abstract today in response to a call for papers about the sociology of neuroscience.  Whether or not I write something for this volume, I can't wait until it's published, since I really do think our love affair with neuroscience is under examined.  Actually, before we got to the abstract, here's one my favorite quotes illustrating the brave new world of the 'brain disease' model of addiction.

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).

Interesting, isn't it, that that notion of addiction co-exists with 'war on drugs' approach to addiction?  Can you say... holy incoherent drug policy?


Here's the abstract:

Addiction is unique among medicalized social problems in that responses to addiction that frame it as a disease continue to co-exist uneasily with behavioral and legal responses that frame it as a crime or as a failure of will.  Recently, however, neuroscientific representations and technologies have begun to change the ways in which we understand, respond to, and treat drug addiction.  Increasingly, addiction and addiction treatment are being embodied and 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 and promote neuroscientific “fixes” for the problem of addiction.  

The National Institute on Drug Abuse (NIDA) has been the most visible and active proponent of a neuroscientific model of addiction in the U.S.  Since its founding 1989, the Medications Development Program of NIDA has tested more than fifty medications to treat cocaine dependence, obtained FDA approval for two medications to treat opiate dependence, 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 (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 most of which target neurochemical processes in the brain.  In addition, for the first time in seven decades, medical doctors in the U.S. 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 and the triumph of a neuroscientific model of addiction. 


Relying on a review of the scientific literature as well as materials produce by NIDA and pharmaceutical companies selling addiction treatments, I argue that new neuroscientific 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 the medical industrial complex, and the movement away from carceral regimes of discipline towards new forms of self-governmentality.  I also argue that recently developed drug treatment technologies based on a neuroscientific understanding of addiction represent a renewed effort to move addiction fully into the realm of biomedicine and simultaneously shore up the tenuous boundaries between addict and patient, drug and medicine, drug dealer and doctor.  Finally, through an analysis of 37 interviews with patients being medically treated for opioid dependence, I explore how a new biochemical treatment technology (buprenorphine) and the neuroscientific representations that surround it are embodied and experienced in ways that are both constraining and offer new possibilities for autonomy. 

New approach or more of the same?

On Monday,  the Office of National Drug Control Policy announced its 20100 budget proposal.  I had hoped new leadership in the White House would mean a new approach to drug policy --  one that focused on reducing drug-related harm, rather than on failed interdiction, law enforcement, and criminal justice approaches. Indeed, the press release announcing the budget proposal says:

"Funding for prevention measures under the President's proposal would increase 13.4 percent over the level of funding for the current fiscal year, and expenditures for treatment programs would be increased by 3.7 percent."

This is a step in the right direction, but with a total increase of 3.5%, one wonders just how many dollars are being wasted on failed drug war policies --  policies that do little stop the flow of drugs but do have a deleterious effect on our neighbors to the south.   I had hope for bolder leadership from the new drug czar, Kerlikowske.  Let's hope he's just getting started.

Some fabulous libraries for research

A lot of really interesting stuff has been written about drugs.  In fact, one the things I like most about the study of drugs is how many disciplines it crosses.  It seem that everyone has an opinion about the subject. 

Fortunately for those of us who can't get enough scholarship about drugs, the Drug Policy Alliance has the Lindesmith Library.  This collection is search-able online by going here and is well maintained by talented staff.  Those of us lucky to in or near New York City can make arrangements to visit the hard copy collection.  I've had many meetings in their library, and there is lots of enticing stuff.

For those of you with a passion for the history of medicine, my work place, The New York Academy of Medicine has a really interesting historical collection in a beautiful space.  They are doing a lot of work on digitizing parts of the collection.  You can see some of their digital exhibits here.

Drugs, disparities, and million dollar blocks

One thing I've learned working in public health is that disease and risk -- like economic disadvantage--  are not evenly distributed among populations.  The series of maps below (tip of the hat to my colleague, Tracy Pugh for putting these NYC Dept. of Health and Mental Hygiene & NYC Justice Mapping Center maps together) show that public health problems tend to cluster in certain neighborhoods.  Not coincidentally, these are the same neighborhoods that have both low income and high rates of drug-related arrests.  These (also not coincidentally) happen to be neighborhoods where lots of  people of color live.  The Columbia Graduate School of Architecture, Planning and Preservation zoomed in on one these poor neighborhoods in Brooklyn in a project called "million dollar blocks" (which, parenthetically, made it into a MoMA design exhibit).  As they say on their website:

"Using rarely accessible data from the criminal justice system, the Spatial Information Design Lab and the Justice Mapping Center have created maps of these “million dollar blocks” and of the city-prison-city-prison migration flow for five of the nation’s cities. The maps suggest that the criminal justice system has become the predominant government institution in these communities and that public investment in this system has resulted in significant costs to other elements of our civic infrastructure — education, housing, health, and family. Prisons and jails form the distant exostructure of many American cities today."

Million dollar blocks are those where more then a million has been spent on incarcerating residents of that block.  This important work begs the question:  how could we improve the health of these neighborhoods if we invested a million dollars into community development, jobs, or education ... instead of incarceration?  How many public health problems could be solved?


NYC Community Health Survey 2008: Percentage of an onset of asthma in the last year by neighborhood

 NYC Community Health Survey 2008: Percentage of population ever been told having diabetes by neighborhood

 

NYC Community Health Survey 2008: Percentage of uninsured by neighborhood

 

 NYC Justice Mapping Strategies: Men Admitted to Prison 2006

NYC Justice Mapping Strategies: Prison Expenditures, 2006

Ibogaine documentary

So several weeks back, I saw I'm Dangerous with Love, a documentary about an experimental treatment for addiction called ibogaine.  Ibogaine is illegal in the U.S., but nonetheless, an underground movement to use ibogaine to help people kick drugs has emerged here.  The documentary raises compelling questions about drug treatment and why and how it is that we have increasingly ceded to the medical profession and science to 'cure' addicition.  I wish that Q&A with the 'star' and the director that followed the screening were also available.  It was one of the most intelligent discussions I've heard about what drives addiction and how our current treatments miss the mark.  If it comes to a theater near you, be sure to check it out!

Prescription Drugs

So maybe you know this but the most abused 'illicit drugs' in the U.S. (after marijuana) are prescription drugs.  The chart below from the most recent National Household Survey on Drug Use, includes mis-used prescription drugs as illicit drugs in the top line of all illicit drug use, but when you look at the drugs broken out, you can see that prescription drugs (and mj) are way out ahead of the others.

Makes you wonder why the War on Drugs is focused primarily on cocaine and to a lesser extent on heroin when these drugs are used far less often than those we get from our doctors.  I'm not suggesting we should start cracking down on psycho-pharmaceuticals, but I am questioning our irrational drug policy that makes arbitrary distinctions between drugs/medicines to serve political purposes.

Source: SAMHSA

Good Post from Everyday Sociology

When we talk about 'drug use' and drug users, most people think of illicit drugs like heroin and cocaine.  However, the most prevelant drugs of abuse (excluding marijuana, alcohol, and tobacco) are prescription drugs.  This post by Karen Sternheimer does a good job of explaining the issue.

Drugs in America: Not Just for Celebrities 

Highly recommend this book

If you are looking for a critical and inventive look at methadone that goes beyond condemning it as foucauldian form of restraint, check out fraser and valentine's book, substance and substitution: methadone subjects in liberal societies. these australian scholars have done a great job of combining a rich theoretical discussion with empirical research.

Addiction as a Brain Disease

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