Abstract
Addiction, a cultural construct long framed in moral, psychological, and social terms, is increasingly understood as biological and treated with medications. In the United States, methadone, buprenorphine, and a variety of psychopharmaceuticals are now commonly used to treat addiction alongside long-standing approaches such as 12-Step mutual aid. These biomedical interventions reshape the very condition they intervene on, influencing the ways treatment clients understand and experience addiction. Clients often experience medication treatment in tension with embodied and social practices of addiction: bodily routines, sensory experiences, temporalities, and social contexts of use. This article examines these tensions through theories of the social flesh and embodied citizenship. This analysis is based on a 20-month ethnography in and around “Sunrise” residential center in Northeast Ohio. Sunrise merges biomedical interventions with 12-Step, psychological and juridical approaches. These data show how biomedical practices alter client bodies and subjectivities, promoting body alienation at stark odds with the intense bodily connection clients established through drug use. This alienation results from rapid weight gain and heavy sedation clients attribute to medication effects, as well as mandated medication and adherence practices that strip clients of a sense of control of medication use. Many clients describe feeling “medicated out” of life: estranged from treatment peers and kin who oppose medications, counselors and other powerful authorities who demand their undivided attention, and friends with whom they are unable to relate when heavily medicated. Clients, however, do not passively accept this estrangement. They alter their bodily experiences by leveraging embodied practices developed during drug use. Through practices such as selectively taking medications based on historical bodily experience and illegal drug “testing” in the underground economy, clients reassert bodily connection and control, deriving a modicum of power—albeit constrained and risky—in a treatment system that strictly limits it.
The body and medicine do not exist in the abstract—as primary qualities to which secondary qualities are attached. There is no abstracted body that is ill or beautiful or in remission: there is this ill body, that beautiful body, this body in remission. “There’s something going on with this medicine,” Lola, an African American woman in her mid-30s and a client at Sunrise residential addiction treatment center, tells me with a drawl as we sit in a cold, empty group therapy room infused with the blank grey of the late winter Ohio afternoon. That morning I observed a 2-hour group therapy session in which she struggled to stay awake, slipping in and out of consciousness, arms heavy and head bobbing back, several times nearly slipping out of her chair only to be saved by the client next to her nervously catching her fall. Despite her sedation, Lola was eager to tell me about her growing frustrations with the medication treatment—methadone and a variety of psychiatric medications—she was receiving at the program as we sat down for our seventh interview since she entered Sunrise. She struggles to stay awake even as we sit for the interview but comes to with a start when I ask about the medications. “It ain’t right, put it like that,” the words spit out with a startling quickness. She jerks her head upright, catching herself before continuing more slowly. “It’s making me forgetful. It’s making me extra tired. It’s making me sleepless. I don’t get no rest at night, but in the day time I’m tired as I don’t know what. I can spend a day just laying there. I can’t fall asleep. And I’ve gained weight. It’s not worth it for me to be this heavy. I’m feeling like I’d be myself if I wasn’t so big. I hate this body. I wish I could take my skin off and hang it up and put on somebody else’s. I do…I really do.” Fieldnote (February 2, 2015)
Introduction
Addiction and its treatment have become central concerns in the U.S. due to the recent stark rise in opioid use and overdose death. Since 2000, the opioid-related overdose death rate has increased by 200% (Rudd, Aleshire, Zibbell, & Gladden, 2016). Ohio has been hit particularly hard. Unintentional drug overdoses, largely opioid-related, have been the top cause of injury-related death in the state beginning in 2007, and 3,050 Ohioans died of unintentional drug overdoses in 2015 (Ohio Department of Health [ODH], 2015). Meanwhile, clients entering treatment with a primary diagnosis of opioid dependence have increased dramatically (Massatti, Beeghly, Hall, Kariisa, & Potts, 2014).
As opioid-related problems intensify, policy makers and advocates have promoted medication-assisted treatment (MAT) with greater urgency (Volkow, Frieden, Hyde, & Cha, 2014). Ohio policy makers have made efforts to increase access to MAT, including the expansion of Medicaid publicly funded health care to increase coverage of these medications (ODH, 2017). Biomedical interventions, however, remain controversial in a treatment system largely rooted in psychological, criminological, and moral models that frame “addicts” as persons in need of psychological and social transformation to become “clean” through long-standing abstinence-based models of recovery such as 12-Step mutual aid that often exclude medication use from definitions of “sobriety” (Valverde, 1998). This model is rooted in cultural beliefs regarding what Saris (2010) calls the “fantastic quality of the nonaltered self…a fundamental understanding of a brain unsullied by chemicals deliberately ingested to effect a response” (p. 210). MAT is particularly challenging in residential programs because of their history of abstinence-based treatment and the logistical complications such institutions encounter when delivering these highly controlled pharmaceuticals. Little is known, however, about how clients experience MAT in these complex clinical settings.
Biomedical interventions reshape the very condition they target, influencing the ways clients understand and experience addiction and recovery. Further, client bodies are changed through drug use—illegal and biomedical—altering their materialities and embodied subjectivities and potentializing certain forms of agency. In this article, I examine bodily materialities, embodied subjectivities, and social belonging among clients at Sunrise, a long-term residential treatment center in a postindustrial city in northeast Ohio where I conducted ethnographic research from March 2014 to December 2015. This study focuses on how client subjectivities and social belonging are shaped in and through treatment where diverse beliefs about addiction among clinicians, kin, and peers and parallel health care, social services, and criminal justice systems coexist in tension.
Client subjectivities and efforts to access social belonging in this context bring to the fore fundamental questions often obscured in dominant discussions of addiction and appropriate treatment: How do bodily experiences of habitual drug use and biomedical treatments relate to one another? How do these experiences intersect with social belonging? How are bodies and social belonging reimagined, negotiated, and constrained in the context of biomedical addiction treatments and the social and political contexts of everyday life in and outside of treatment through which they take shape? How do these processes effect health, subjective well-being, and basic survival?
Background
Opioid-related death rose sharply in the period immediately prior to and during this study (2014–2015), intensifying the stakes of treatment. Death became a specter haunting daily life of Sunrise clients, most of whom survived at least one overdose and lost multiple members of their social networks, including kin, in this way. Each day, treatment staff and peers eagerly checked the obituary section in the local newspaper for death notices of friends, family, and former clients. Within the relatively safe confines of Sunrise, the outside world came to be viewed as a “battlefield” where people who use opioids are “dropping like flies.” Some clients, like Dave (Euro-American man, early 30s), whose mother died of an opioid-related overdose shortly before he entered treatment, came to believe they need MAT to prevent relapse and inevitable death. “I won’t make it without methadone,” he told me with a mix of resignation and urgency.
These social, political, and emotional dimensions significantly shape client experiences of MAT. The experiences of Lola and Dave illuminate the nuances and stakes of MAT from the vantage point of the clients themselves. Like many Sunrise residents, Lola struggled to manage medication treatment and its physical effects in the highly controlled, socially demanding, and politically fraught environment of treatment. While Lola’s experience may seem extreme, many clients experienced similar frustrations. They described feeling “medicated out” of life: estranged not only from their own consciousness but also from peers and kin who oppose medications, powerful authorities who demand their undivided attention, and friends with whom they are unable to relate when sedated by medications. Clients, however, did not passively accept this estrangement. Instead, they leveraged embodied knowledge and practices cultivated during drug use to reassert bodily connection and control in a treatment system that strictly limits it. In this article, I draw on theories of the materiality of bodies, always entangled in social and political contexts, and gendered understandings of agency to examine these experiences and practices ever more critical to appreciate, yet poorly understood.
Literature Review
Addiction, a cultural construct long framed in moral, psychological, and social terms, is increasingly understood as biological. Treatment now often emphasizes a biomedical model of the patient as an autonomous, independent agent and deploys biomedical technologies such as the “chronic brain disease” model, psychiatric diagnoses, and pharmaceutical treatments (Buchman, Illes, & Reiner, 2011; Saris, 2010; Vrecko, 2010). At the same time, treatments are ever more grounded in neoliberal discourses of personhood and citizenship rooted in ideologies of efficiency, individualism, and self-responsibility (Bourgois, 2000; Carr, 2011; Garcia, 2010). These shifts have not occurred in isolation from long-standing intervention approaches such as 12-Step mutual aid, various psychotherapies, and court-mandated treatment. The result is an uneasy amalgam of biomedicine, neoliberalism, and therapeutic practices that problematize not only cultural constructions of addiction and recovery but fundamental beliefs regarding socially acceptable personhood (Zigon, 2011).
Moreover, clients enter treatment with individual histories as well as psychological, social, and bodily practices developed during drug use. Ethnographic studies of illegal drug use have long emphasized “the Life”: the distinct, viable, and purposeful lifestyle of drug use that provides users a meaningful self-identity and social connection through drug consumption practices (Agar, 1973). Users rely on others to access drugs, basic survival resources, and community. They also often rely on these social networks to meet bodily needs such as avoiding withdrawal. These dynamics cultivate cooperative subjectivity (Hoffer, 2016). Within these networks, distrust, care, and economic support coexist. These relationships provide material survival as well as emotional sustenance and a rare sense of belonging in a society from which most “addicts” are alienated (Bourgois, 1998).
When they enter treatment, clients must negotiate these ways of being alongside contrasting expectations of interventions. Clients are required to be at once autonomous patients and members of therapeutic communities that emphasize mentorship, mutuality, and interdependence, all while eschewing drug-using networks that often include kin and were once central to daily life and survival. This shift complicates clients’ experiences of their bodies and medication use, shaping their sense of self and social belonging. As they manage medication effects, they must negotiate multiple, often contradictory, social worlds of service providers, treatment peers, and kin in which beliefs about biomedicine are often at odds. This clinical landscape creates new practices of belonging and exclusion, well-being and suffering.
Biopolitical theory has generated important insights into the ways biomedical knowledge and power is deployed to manage populations, producing particular subjectivities (Foucault, 1994). Scholars have advanced biological citizenship theory to examine how biopower intersects with sociopolitical inclusion, reconceptualizing citizenship as not solely a political relationship between an individual and state conferring rights and responsibilities, but a broader process in which rights and responsibilities are enacted through state and nonstate institutions and political cultures (Good, Fischer, Willen, & DelVecchio-Good, 2010; Nguyen, 2010; Ong, 2006). Rose and Novas (2005) describe “biological citizenship” as a form of citizenship in which, “specific biological presuppositions, explicitly or implicitly, have underlain many citizenship projects, shaped conceptions of what it means to be a citizen, and underpinned distinctions between actual, potential, troublesome and impossible citizens” (p. 439). Early applications of biological citizenship theory, however, have been critiqued as decontextualized and abstracted from lived experience (Whyte, 2009).
Scholars have specifically critiqued the application of biological citizenship theory to addiction (Fraser, 2010; Fraser & Seear, 2011; Fraser & valentine, 2008; Lovell, 2013). Lovell (2013), for example, examines the limits of biological citizenship in the case of Ukrainians migrating to Marseilles, France, to access MAT unavailable to them in their homeland. Despite hopes for social inclusion associated with this treatment, these individuals remain highly marginalized in a local context where addiction is not considered a biological condition. Lovell calls this “the biopolitical exception of the addicted body” (p. 148).
Fraser and valentine (2008) provide a similarly grounded and nuanced analysis of biological citizenship vis-à-vis addiction in their study of methadone treatment in Western liberal societies, arguing that methadone treatment and associated identities and ways of being do not fit neatly into simplistic dichotomies of good/bad, successful/failed, and stable/chaotic. Instead, they emphasize that the agency of “addicts” is often obscured by structural explanations and narratives of drug user “disobedience” in which gendered assumptions about “the malign agency of (some) men is foregrounded, and that of women is backgrounded” (Fraser & valentine, 2008, p. 162). Anderson (2008) similarly calls for attention to gender and agency, underscoring the importance of relational forms of agency particularly salient for women who use drugs (e.g., agency based in care for self and other, leisure/recreational activities, or expressions of revenge) that have been neglected, as structural definitions of power have dominated scholarship on drug use.
Recent social science research has focused on the materiality of bodies and embodiment in drug use and interventions (F. Dennis, 2016; S. Dennis, 2016; Vrecko, 2016; Walmsley, 2016). F. Dennis (2016), for example, draws attention to “drug–body–world” entanglements. Analyzing “triggers” through this lens, she stresses the “materialities involved in actualizing this potential for being moved toward drugs, including the role of material things, space, feelings, moods, body parts, other people, words (especially in text messages), vital memories, and thoughts” (p. 131). Walmsley (2016) draws attention to the drug–body relation and how people leverage it to manage opioid withdrawal in ways that highlight “the creativity and resourcefulness of drug users in the use of localized techniques for coping with coming off heroin” (p. 391). This research further underscores the materiality of bodies, drugs, and uses of the body–drug–world relationship in expressions of agency.
This literature draws attention to the ways local understandings of biology, the materiality of bodies, bodily entanglements in social and material worlds, and new or neglected forms of agency shape experiences of drug use, addiction, and treatment.
Theoretical Approach
In this article, I build on the literature by drawing on theoretical work that stresses the need to take the materiality of bodies seriously (Bacchi & Beasley, 2007; F. Dennis, 2016; Fraser & valentine, 2008). Michael and Rosengarten (2012), for example, critique social theory that “tends to produce the body as a non-contributor, as if an entirely passive entity” (p. 3). Drawing on the tradition of science and technology studies and the work of Karen Barad, they emphasize the ways bodies and their very meanings emerge through material and discursive intra-action marked by entanglement rather than interaction. Through this lens, medicine coproduces novel subjects and bodies. Building on this perspective, they call for explorations of how “emergent medicine and ‘its’ bodies might seek out both unexpected distributions of agency, or unforeseen topologies of affect, along with the way that abstractions are made to matter practically and affectively” (Michael & Rosengarten, 2012, p. 14).
Beasley and Bacchi (2000) draw attention to the disconnect between analyses of citizenship and analyses of bodies, critiquing disembodied models of universal, autonomous, and overly instrumental patient-citizens common in the citizenship literature that reinforce the mind–body split in Western thought. Yet “bodies give substance to citizenship, and…citizenship matters to bodies” (Bacchi & Beasley, 2000, p. 337). This critique has particular significance to feminist scholarship. While Beasley and Bacchi recognize the significant contributions this field has made to both theories of citizenship and theories of the body, they call for greater attention to bodies in feminist citizenship studies and to the political and social in feminist studies of the body. To do so, they propose the concept of “social flesh”: This use of ‘social’ captures a full range of intersubjective bodily experiences—based on movement and communication, the bodily requirements of sustenance and attention, the social relations around touch and non-touch. Our use of ‘flesh’ is meant to highlight our embodied existence. There is no suggestion of unchanging bodily essences; all bodies are necessarily social. (Bacchi & Beasley, 2007, p. 330)
I combine concepts of intra-action and social flesh with attention to gendered and relational forms of agency (Anderson, 2008; Fraser & valentine, 2008) to examine how the bodies of Lola and Bev, two women clients at Sunrise, are made through entanglement with “the Life,” biomedicine, and residential treatment. I aim for a thick description of embodiment and social belonging. These theoretical frames support a fuller understanding of addiction and its treatment at a historical moment when its very nature and beliefs about appropriate treatment are in flux.
Method
This research is based on person-centered ethnography (Levy & Hollan, 1998) conducted in and around Sunrise, a publicly funded long-term residential drug treatment center that delivers clinically hybrid treatment combining 12-Step mutual aid, biomedical, and various psychotherapeutic models of addiction and recovery. Treatment at Sunrise typically ranges from 3 to 4 months and the program treats 24 adults (12 men/12 women) at a time. The client population at the time of this research was approximately 75% Euro-American and 25% African American. At least 90% of the client population was taking some form of medication (methadone, buprenorphine, and/or psychiatric medications) while at Sunrise. Clients on MAT travel to an affiliated clinic to obtain doses of methadone or buprenorphine daily. Most participants in this study either entered the center on medications or began taking them while in residence. 1
Person-centered research was conducted from March 2014 to December 2015 and included treatment-based and post-treatment follow-up ethnographic fieldwork. Treatment-based research included participant observation in client groups, staff meeting observations, staff interviews, repeated in-depth interviews with 36 randomly selected clients, and additional in-depth interviews and participant observation with a subsample of 10 clients purposively selected to balance gender, race, and age. Fieldwork with clients in the subsample involved participant observation in everyday contexts of their lives in treatment: formal activities (e.g., educational, 12 Step, and therapy groups), informal settings (e.g., the dining hall, women’s lounge, waiting room, and smoking area), and (3) ancillary activities (e.g., off-site health, criminal justice, and social services appointments) (Spradley, 1980). Post-treatment ethnography included repeated in-depth interviews and participant observation with the subsample of 10 participants for 6 months post-treatment (i.e., fieldwork in family homes, transitional housing, 12-Step meetings, social gatherings, and medical, psychiatric, and legal appointments). I also conducted supplemental interviews with 16 additional clients to add depth and breadth to the data. This research was approved by the Case Western Reserve University Institutional Review Board (Ref: IRB-2013-514). The program and all participant names are pseudonyms to protect client confidentiality.
I ground this analysis in the experiences of two women clients—Lola and Bev—to illuminate central themes on how bodies as social flesh emerge in the complex social and institutional world of Sunrise. I selected these cases based on an intensity sampling rationale. These are “information-rich cases that manifest the phenomenon of interest intensely (but not extremely)” (Patton, 1990, p. 171). Lola and Bev were part of the subsample of clients who participated in the study during and after their treatment, generating rich data on their experiences across time and social settings. These experiences exemplify phenomena common in the broader sample. At times, these cases reflect broader themes with greater intensity, making these phenomena more visible.
I focus on the experiences of two women because of the gendered dynamics outlined in the literature on bodies and agency above. My aim is specifically to advance gendered analyses in critical drug studies because this area of research is particularly underdeveloped. As Campbell and Herzberg (2017) stress, this scholarship must simply ask, “Where are the women, and what are their lived experiences?” (p. 258). I also include women who are socially positioned in different ways to present a range of experiences and avoid homogenizing “women.” While both Lola and Bev came from economically marginalized backgrounds, like nearly all clients of this publicly funded treatment program, they represent different personal histories and racial identifications (Lola identifies as an African American woman, Bev a Euro-American woman).
Analysis
Sunrise clients’ bodies and subjectivities emerge as social flesh through drug–body–world entanglements (F. Dennis, 2016): materialities (medications and illegal substances), sensations (withdrawal and relaxation), feelings (frustration and love), memories (past drug experiences and traumas), people (peers and doctors), and thoughts (what is “normal”) in the socially and politically fraught institutional space of the center and in everyday life on the “outside.”
I analyze how the social flesh of clients emerges in these contexts by first providing an overview of the structures, temporalities, and expectations of the center. Then, I focus on the experiences of Lola and Bev to illuminate two overarching themes: (1) how clients’ bodily (dis)connection, cultivated through prior experiences of (il)legal drug use, conflicts with medication treatment and (2) how program expectations of intersubjectivity are challenged when clients experience sedation on medications. Finally, I explore embodied citizenship and its limits in this context, describing how clients attempt to reassert bodily connection and control, and seek social belonging and survival, within the highly constrained environments of Sunrise and everyday life after they leave the center.
Structures, Temporalities, and Expectations of Treatment
Each day at Sunrise, clients attend group therapy, 12-Step meetings, psychiatric appointments, and educational groups on the neurological, psychological, and social dynamics of addiction. While multiple models of addiction and recovery are presented, 12 Steps based on the Alcoholics Anonymous (AA) model is the foundation. Clients are taught that by working the 12 Steps, admitting they are powerless over alcohol and other drugs, and becoming active members of the recovery community, they can overcome deep-seated “character defects” and achieve long-term sobriety. This model is particularly significant at Sunrise because it is located near the birthplace of AA, but it has historically been central to addiction treatment in the U.S. generally (Valverde, 1998).
At Sunrise, sleeping, eating, group participation, and even free times are at once strictly scheduled and inconsistent. This institutional temporality is a mix of overscheduled and empty time that Cooper (2015) argues threatens clients’ sense of dignity and humanity. Clients are required to wake up and sign in for the day at 6:30 a.m. and must stay in their rooms after 10:30 p.m. Medication dosing times, 3 times a day, are strictly scheduled with significant consequences if missed, including loss of program privileges (e.g., weekend passes) and physical consequences (e.g., withdrawal symptoms). In between, clients have a busy schedule of group therapy, 12-Step meetings, and educational sessions, yet these often get canceled or delayed with little or no notice, leaving clients with unexpected free time and no certainty about where they will be required next. “Around here you never know what you’re gonna get!,” joked Dave with feigned enthusiasm as he sat listlessly flipping through the newspaper in the center’s dining room after a canceled group.
Client “out-dates”—the day when they are expected to complete and depart the program—are also uncertain, particularly when they do not have safe post-treatment housing arranged. This places clients (and counselors, who spend much of their time attempting to secure such housing) in a liminal temporality, anxiously waiting for news of housing approvals and out-dates. “I think my counselor is at a standstill with what to do with me,” Lola said as she approached her third month in treatment without secured post-treatment housing. These institutional spatio-temporalities are similar to those found by Fraser and valentine (2008) in queuing for methadone maintenance treatment, which they suggest may “reproduce rather than depart from the model of waiting and dependence widely seen as characteristic of lifestyles associated with regular heroin use” (p. 111).
These contexts leave clients with a sense of lost control of their time and estrange them from self-soothing bodily practices outside of treatment (e.g., seeking private space to decompress, taking a bath, spending time outdoors). Some clients specifically compared the institutional temporality of Sunrise to their experiences of time during drug use. Drew (Euro-American man, late 20s) explained that prior to entering treatment, “Every day I’d wake up early and and take my shot [of heroin]—just enough to get going.” Later he explained how the rest of his day was structured by both mundane tasks of housework and childcare and stable routines of heroin use structured to stave off withdrawal. This temporality is not one of “addict time” and “normal time” in isolation from one another but enmeshed. 2 Clients describe alienation from both, however, in Sunrise.
The social world of Sunrise intersects with that of the “outside.” Clients leave the facility for court dates and child protective services meetings. Often, they encounter former drug dealers or using partners in waiting rooms and on buses during weekend passes when they are allowed to leave the center under strict parameters. Some, considered by peers to be the lucky ones, see family members and friends during visitation nights at the facility. Their experiences of treatment, and of their bodies, are deeply embedded in these overlapping social and institutional worlds in which no consensus regarding what addiction is and how it should be treated exists.
To maintain positive status in the program, clients are required to abstain from illegal drug and alcohol use and they routinely take urinalysis drug screens to prove their abstinence. In addition to abstinence from alcohol and other drug use, to be considered successful in treatment, clients must share the most intimate and often traumatic aspects of their lives. In group therapy and 12-Step meetings, they share stories of abuse, estrangement from family, loss of children, and being shot and shooting others and are expected to support one another as engaged members of the therapeutic community.
These structures, temporality, and expectations foreground a number of tensions clients experience as their bodies and subjectivities are remade through treatment. In the following sections, I elaborate these tensions through an analysis of the experiences of Lola and Bev.
Embodied (Dis)connection
“I loved the way that I felt,” Lola told me, describing the first time she used cocaine with an abusive boyfriend as a teenager. “I felt like I couldn’t cry about anything,” she explains, “I remember being just in such a different time period, I would say. I just felt really good and the sensation was phenomenal. I mean I can’t even describe it. I was having an out of body experience. I didn’t even know who I was at the time.” Lola had a long history of emotional and physical trauma: molested by a cousin as a child, raped as a teenager, and mired in violent relationships as an adult. The “out-of-body” experience of her first cocaine use that blunted painful emotions was common in client narratives of drug use, particularly women with histories of sexual trauma.
Lola lived with the physical markers, such as scars, of her life’s traumas. These “war wounds,” as she calls them, contributed to her desire to escape her body. This longing was reinforced by her dealings with powerful institutions. Lola, for example, described her experience in a community-based correctional facility in which the staff “thought I brought drugs in and they made me strip all my clothes off. They was so in awe because I had a lot of scars all over my body from being beat[en] and from just a lot of different things that happened to me, and my skin is really bad as a result. I’m just going to have to live with those war wounds.”
While for some clients, like Lola, bodily disconnection through illegal drug use was a tool to ease trauma-related emotional and physical pain, other clients, like Bev, sought a sense of body grounded-ness through drug use. Bev, a Euro-American woman in her 40s, began using heroin at age 12 with her parents. I met her when she entered Sunrise for the second time after a return to drug use following 9 years of self-defined “sobriety” aided by 12 Step and medications (legally prescribed benzodiazepines to manage anxiety and opioids to manage chronic pain). “The only way I learned how to be by myself is with drugs,” she told me as she narrated her life history. “I enjoyed it, loved it. It’s almost like a relaxing thing for me. Like taking a hot bath, getting a massage.”
Bev’s “normal” state eventually became tethered to a precise combination of heroin and cocaine refined over years of drug experimentation:
3
When I shoot crack and do heroin, yeah, there’s times I’m high as fuck, but for the most part, I’m normal. [Interviewer: You feel normal. What’s normal for you?] I don’t feel shy, bashful, manic, a lot of pain. You know what I mean? I don’t feel like I can’t make it up the stairs. I can’t sit still. I can’t comb my hair ‘cuz I don’t have enough patience. All that. I love music and I can feel music. Yet music—I feel it so much that it can be such a bad trigger for me. I have to fight through that because I’m not gonna give up music ‘cuz I love it so much. Because I’m so attuned to it and I can feel it. Certain songs––after all the years, and doing certain drugs with this song and that song. You hear that song and you can smell, you can taste, you can feel exactly 20 years ago. Yeah, it’s crazy.
At Sunrise, past (dis)embodied experiences related to drug use existed in tension with biomedical treatment. Clients often came into conflict with medical staff—the psychiatrist and addiction physician—around medications prescribed and their doses. These conflicts centered on competing forms of validated knowledge: biomedical or experiential.
Bev’s body attunement complicated her MAT (Subutex, a form of buprenorphine) as her long history of illegal drug use shaped her beliefs about appropriate medication treatment for her unique body. The ensuing tensions with the addiction physician regarding dosage reflect common experiences of clients on MAT. Bev linked her buprenorphine treatment while at Sunrise to prior experiences of opioid use that had become imprinted on her body, shifting her tolerance upward. “That’s another thing that’s annoying about addiction,” she explains, with frustration: The longer you use and stop and use and stop and use and stop—I’ve probably stopped drugs maybe 10 or 15 times in my life, or I stopped a drug and was doing more of another drug, or I got pregnant or, all that shit—every time I picked back up my tolerance was so quick. When I was real young it took me a year to have that tolerance, then it took me six months, then it took me a month, now it’s down to weeks. My tolerance level is out of this world and nobody would believe it unless you sat and watched me. Or walked in my shoes. I think that’s his [the addiction doctor’s] problem. I think he thinks that I’m little. That I have plenty [of Subutex]. It’s like, ‘Dude, this is why I got on this program.’ If you’re gonna sit there and look at me like I’m stupid and I don’t know what I’m talking about and I’m drug seeking, then you’re fucking stupid.
Intersubjectivity and Estrangement
Bev’s case highlights some of the ways Sunrise clients experience medication in a “social grid”: an intersubjective matrix of formal and informal social networks—from counselors and physicians to peers and kin—that coproduce medication experience (Longhofer, Floersch, & Jenkins, 2003). The social grid is intensified in residential treatment, a setting where interpersonal exchange between clients is considered both the primary platform of recovery and its greatest threat. Clients must share their most intimate experiences and support one another in groups, yet their social relationships are often considered dangerous and framed as “codependent” or otherwise “dysfunctional” (see also Fomiatti, Moore, & Fraser, 2017). They are sternly warned by staff to maintain interpersonal distance from peers outside of group sessions. These strict interpersonal boundaries make meeting treatment expectations challenging. They also contradict the mutuality and interdependency central to alternative socialities that form through “the Life” (i.e., lifestyles, self-identities, and social connections associated with drug use) and in contexts of poverty (Stack, 1974; Venkatesh, 2006).
Adjusting to medications in this highly controlled setting was especially difficult for clients, many of whom reported personally troubling medication effects that alienated them from their bodies, psyches, and social worlds. Clients have limited choices regarding what they can eat and when and how they can move, and they often gain significant weight. They jokingly refer to Sunrise meals as “county food”: the same simple-carbohydrate heavy meals served in jails. There are also limited opportunities to be physically active. While the program attempted to introduce some opportunities for exercise—trips to the local recreation center and games of kickball in warm weather—this was logistically complicated and inconsistent. Common medication regimens such as polypharmacy and antipsychotics 4 with the known side effects of weight gain and sedation amplified these problems. 5 Most clients, particularly women, also firmly believe methadone causes rapid weight gain, even as MAT clinic staff argue against the validity of this belief.
Clients regularly made decisions about their psychiatric and MAT medication treatment based on considerations of their physical effects and related subjectivities. Many clients were reluctant to take methadone and antipsychotic medications due to their stigmatized association with weight gain, as well as their personal histories of struggling with this medication side effect. Bev avoided methadone because “It makes you blow up. Everybody I know that’s ever been on it has gotten really huge.” Lola refused Seroquel (antipsychotic) because she knew from her long history of psychiatric treatment that “That’s a weight gainer. I don’t take that.” The program psychiatrist was known among clients as “the candyman” because he prescribed multiple psychiatric medications—often his signature “cocktail”—after only a cursory assessment. When clients felt they were unable to communicate their concerns about the effects of medications such as weight gain, and/or they perceived the treating physician to be unresponsive to their concerns, they proactively altered the drug use themselves. As Bev, for example, explains: He [the psychiatrist] gave me a whole cocktail of shit. Trazodone, Seroquel, Neurontin, Vistaril, Depakote, oh, Wellbutrin, and I think that’s it. It was all high doses. Let me tell you what. I was fucked up when I took them…I’ve knocked them off on my own. The only thing I’m on now is Seroquel, ibuprofen, and Vistaril, if I need one.
Sedation was a concern for clients in addition to weight gain, as it posed significant barriers to clients’ abilities to meet treatment expectations. Clients spent most time in groups where they are expected to engage their counselors and peers in emotionally intense discussions. Staff determinations of treatment “success” are in part dependent on a client’s ability to interact with peers in groups (and having the energy to do so). If failure to engage in groups is communicated by staff to authorities such as parole officers, the consequences are potentially life-changing and include loss of child custody and incarceration.
Medication effects made meeting these expectations nearly impossible for Lola. She gained significant weight as she adjusted to new psychiatric medications in addition to the methadone dose of 100 mg she had been taking for the last 2 years at the strong encouragement of her probation officer. Her body was both a tangible, material barrier to her ability to negotiate treatment—she struggled to walk up and down the stairs just to get to groups—and a symbol of dehumanization and dependency to her treatment peers. This contradicted Lola’s account of her bodily experience when she was regularly using heroin and methamphetamine. In her social networks of “the Life,” she was known for her physical appearance and the care and energy she took to maintain it. Now, she felt alien to that self.
Although she believed methadone treatment has “its goods and its bads,” she was constantly frustrated by its physical and, by extension, its interpersonal effects. “I’m just tired of this weight,” she told me, explaining that: Methadone—it adds a lotta weight to women. It’s added about—I’d say I’ve gained 60 pounds bein’ on methadone. It’s not—I’m unhappy with the weight I’ve gained. It makes me miserable. It makes you hungry. It deteriorates the bones in your body and your teeth. My tooth is broke in the back. My teeth have been beautiful my whole life. Now I have a broke[n] tooth.
As I shadowed Lola through treatment, I sat with her in groups where she constantly drifted off to sleep, sometimes mid-sentence. Other clients would poke her shoulder to jolt her awake. This became an uncomfortable ritual for clients and staff alike, continually interrupting group discussion. “It’s horrible,” Lola told me, “because it’s like, wow, I just literally went to sleep, that quick. I know what’s happening to me. I just can’t control it. Then they want me to come to all these group meetings, and I feel like I need to be in a bed somewhere. My body shuts down on me. They medicated me out.” Lola’s impaired ability to meet treatment expectations—her experience of being “medicated out” of treatment—jeopardized her standing in the program and by extension her freedom from incarceration and future custody of her daughter, who was at the time in the care of a family member under the supervision of child protection services.
This embodied tension was also on clear display in treatment groups as Lola and other clients struggled to simply maintain wakefulness. In response, counselors advised clients to stand and, if needed, walk around the group room to stay awake.
6
At least one client would typically shuffle around the circle of clients in group therapy with eyes half-open, sometimes drooling, and generating the playful yet highly stigmatizing nicknames “sleepy,” “zombie,” and “[metha]’doner.” Lola felt this stigma keenly: I just truly want to feel normal. When I get off this methadone—I want to at least dose down a lot lower than I am. I want to feel like—when a conversation or topic [is] being brought up, I can be attentive and learn and know exactly what’s going on. I don’t wanna be here sleepin’ all the way through and missing the whole point of this. My tiredness stops me from calling [12 Step] sponsors, from calling people for rides to meetings. It causes me to just want to sleep, that’s all. I just want to sleep through every day. I don’t want to get up for nothin’. I’m just tired all the time. Just all the time. I can go take a nap, wake up and still be tired.
Lola felt this control intensely and was constantly troubled by her sedation. She often met with the program psychiatrist to address it, but attempts to work with the providers only further frustrated her: I don’t know what makes him think I need this much depression medicine. I don’t get it. It’s like, I couldn’t cry if I wanted to. [Interviewer: Do you feel that way, like you can’t have feelings?] Yeah. I can’t have real emotions right now because it’s really hard to push out what I need to feel. What if I go to a funeral or wedding or somethin’ and I fall asleep?…A lot people have caught me sleeping like this while I was home…I just don’t want that for my life. I want better. I want better for me and I want better for my daughter. I want my daughter to have the mother that she deserves. I want to be healthy.
In these ways, experiences of clients like Lola influenced other clients’ medication decision-making. These stigmas related to medication use, born of intersubjective experiences emerging in treatment, contradicted many clients’ motivation to go on MAT to prevent return to opioid use and the danger of overdose. Frequent news of the overdose deaths of friends and family increasingly intensified this motivation.
Embodied Citizenship and Its Limits
In this final section of my analysis, I explore embodied citizenship and its limits in and after treatment, asking: How do bodies and social citizenship intra-act in these contexts? How do clients draw on their bodies in efforts to enact agency, seek social belonging, and survive, within the highly constrained environments in which they live?
After months of attempting to proactively work with providers in treatment to manage medications and access housing, Lola resorted to strategic passivity. She began to participate minimally in groups—just enough to please clinical staff. This passive resistance was more common among African American clients: resistance born of long negative histories with health, social services, and juridical institutions. While at Sunrise, Lola coupled passive resistance with active efforts to reclaim bodily control through familiar practices cultivated during regular drug use outside of formal health care. Specifically, she quietly refused certain psychiatric medications based on her embodied knowledge of their effects. 7
Bev also attempted to proactively address her medication concerns. After leaving Sunrise, she met with the MAT clinic medical staff to discuss her buprenorphine dosage. This led to an extended assessment process involving three lengthy assessment appointments in an attempt to restart the benzodiazepine prescription she had received at the local public mental health clinic prior to her recent return to heroin use. Although she experienced some success with these institutions (she was eventually prescribed a benzodiazepine for anxiety), she grew frustrated as both her buprenorphine and benzodiazepine doses were held at levels she felt to be too low to treat her anxiety and withdrawal.
After a particularly contentious appointment at the mental health clinic—in which she felt she was treated as “less than human” and like “just another junkie addict” because of the history of heroin use in her records—Bev resolved she would “take care of myself.” She planned to draw on her embodied knowledge and social networks to access the benzodiazepine she had been seeking through the formal treatment system. “I already know where to get ‘em, but I was trying to do this the right way,” she stressed. The easier way, she explained, would be to act on her knowledge of her own bodily needs and buy the medications from a friend from her 12 Step and former drug use network. As we talked through her experiences with the addiction physician and providers at the mental health clinic, Bev considered why her bodily experiences of anxiety and withdrawal were being discounted despite her diligent efforts to work through the formal healthcare system to address them. “Maybe it’s because I’m a strong woman,” she wondered, “and maybe they don’t like that.”
In addition to these types of medication issues in which clients engaged with treatment systems through active and passive strategies, clients very often struggled to arrange access to safe housing after leaving Sunrise. While Bev was able to obtain a room in a transitional housing facility, other clients, like Lola, struggled to access such housing due, in part, to medication-related issues. Some social service organizations view MAT, particularly methadone but sometimes also buprenorphine, negatively because they see it as a continuation of drug use. Additionally, Lola’s heavy sedation made some programs question their capacity to accept her due to the lack of resources to manage possible medical complications.
After being rejected by several transitional housing agencies, 8 Lola found hope in a last-resort option: a religiously based program. There, her hopes were soon deflated after she was interviewed by the program manager:
He told me about the program. It’s a spiritual-based program. I would live in one of their houses from 9 to 12 months. I would be making purses, and I would be making wallets, bike chains, and jewelry. They’d be selling the jewelry, making money off of it. It’s supposed to teach me how to be a productive citizen and how to function successfully at a job in the real world, which I think that’s a bunch o’ B.S., ‘cuz they’re makin’ money offa the stuff that I’m makin’. They’re gonna teach me how to sew and then sell the stuff that I’m sewing…and they told me I had to get detoxed from methadone.
Why? Did you ask them why?
They will not accept me being on methadone. They consider that being on drugs. I told them that, okay, no problem. I guess I have to detox, because A) I don’t wanna be homeless when I leave here, and B) I’m not comfortable with the program, but will there ever be a program that I am comfortable with?
Limited access to housing led Lola to consider tapering and ceasing her use of methadone despite her belief that she need to be on it to prevent a return to heroin use. When Sunrise could no longer keep her in residence while she sought housing—she had completed the treatment requirements and the required length of stay—she ended up moving into her mother’s home and staying on methadone. Lola’s mother, however, strongly opposed methadone use, considering it to be a form of government control: a more common belief among African American clients with long negative histories with medical and criminal justice institutions.
This strained Lola’s post-treatment life, adding stress to an already difficult transition. Her mother provided only temporary housing and asked Lola to find an apartment of her own. Lola, however, had few financial resources. She began to intermittently use heroin again and, eventually, returned to making money through the illegal drug market in ways she had in the past. Specifically, Lola was an occasional “tester” of the heroin supply of her former dealer: paid by him to use the drug and provide feedback on its quality. This dealer was a close friend and former boyfriend who, Lola tells me with a sense of pride, “feels like I’m the only person who is not gonna lie to him” about the drug quality. He also sees her methadone treatment as an advantage in testing, she tells me, because the dealer believes if she can sense the effects of his drug supply “on top of the methadone, he[‘s] got [a] good product.”
While she was aware this was risky, she also felt she knew her body well enough to avoid negative consequences such as overdose. Alienated from her treatment peers and health and social services systems, she seemed to feel like a valued member of a community in this role, gaining a sense of social inclusion, albeit in an underground economy in which she takes on significant risk. This survival strategy may be viewed as an expression of embodied agency that draws on and reclaims the intense bodily connection Lola developed in illegal drug use, but from which she was so alienated in treatment, and draws on her methadone use as a resource.
What can Lola and Bev’s experiences tell us about bodies and citizenship? How do their experiences with (il)legal drugs intra-act to make their bodies and their social inclusion? How do these experiences relate to expectations of citizenship in addiction treatment as the autonomous model of patienthood gains prominence, but exists uneasily with long-standing models of addiction treatment based in mutuality and interdependence? Both women initially attempted to enact the proactive model of autonomous patienthood by working within the formal healthcare system to manage medications. Yet both eventually resorted to passive resistance when confronted with the limits of their proactivity within the health and social services systems, seeking medications in the illegal drug market and gaining financial resources via drug “testing.”
These responses underscore the significance of bodies in efforts to claim citizenship. Clients’ bodies are social flesh, their materialities emerging through intra-action in drug–body–worlds in and after treatment. Prior experiences with drug use and engagement with biomedicine potentialize forms of embodied agency. Bev drew on her embodied knowledge of medication effects and bodily experiences of anxiety and withdrawal to seek medications informally. Lola drew on embodied knowledge developed in her history of heroin use, as well as her current body on methadone, in drug testing.
Lola and Bev gained a modicum of power—albeit constrained and risky—by drawing on these strategies in the complex and highly restricted social and institutional worlds in which they struggled to survive. These forms of agency, however, came with significant drawbacks. They deepen preexisting oppositional subjectivities in relation to formal institutions and leave people dependent on underground economies for survival and social inclusion (Bourgois & Schonberg, 2009). They also expose individuals to health risks. Lola and Bev, for example, could not be certain of the purity of drugs they used in the contexts of psychiatric self-medication and drug “testing.” These risks lay bare a central paradox: when individuals resort to underground economies to access resources and social belonging, they challenge their marginalization and simultaneously reproduce it through exposure to health risks and continued alienation from formal healthcare and social services.
These forms of agency are coproduced with intersectional gender, race, and economic marginalization. Experiences of being “medicated out” or refused medications by healthcare providers emerge in intra-action with beliefs regarding the types of clients (in)capable of socially acceptable citizenship. Fraser (2003) argues that in a bifurcated post-Fordist model of regulation, certain individuals viewed as capable of socially acceptable citizenship are charged with responsibilized self-regulation, while others viewed as incapable of such citizenship experience “brute repression” (p. 169). As an impoverished African American woman, Lola’s case may reflect experiences of individuals who are marginalized in both illegal drug markets and health and social services systems by social categories of race, gender, and economic disadvantage that co-constitute social exclusion. Ettore (2004) argues that “[d]rug using bodies on the fringe of society learn to adapt their drug behaviour to their everyday lives. But, ‘stable’ systems of inequalities such as gender, race and class will shape the ways in which their already ‘marked’ bodies do this adaptation” (p. 331). Lola adapted to her exclusion from formal systems, expressing agency through bodily practices and social relationships as she resorted to a risky form of agency—drug “testing”—in the illegal drug market. These processes intra-acted with a body marked by social inequalities of gender, race, and class. Bev, a Euro-American woman who was also economically marginalized, may reflect the limits of race privilege for poor women with a history of illegal drug use. 9 Like Lola, Bev resorted to risky agency in the underground economy when alienated from formal health care. Both women’s bodies, inscribed by processually constituted social positions, emerged anew through these intra-actions.
Gunnarsson (2017) analyzes the relationship between intersectionality and intra-action from a dialectical critical realist perspective, asserting that phenomena can be both: [A] product of intra-actions and precede, be the point of departure of, new inter- and intra-actions. Even if something is a product of intra-active processes, it may have a relatively stable existence as product – or ‘thing’ if you like—from the point of view of which it then inter/intra-acts with other dimensions of reality…I suggest we think of the entities in the world as multifaceted in character, being simultaneously products, producer and process. (pp. 119–120)
Finally, these cases point to the need to attend to relational agency in illegal drug studies. To understand women’s agency in illegal drug markets, which has been largely neglected in the literature, Anderson (2008) calls for scholarship that returns relational forms of agency to the more common structural forms based on dominance models of power in which men emerge as more prominent. The forms of agency expressed by Lola and Bev are rooted in the social relations of their lives, in addition to the structures of power in which they are embedded. These expressions of agency involved invoking social connections in the illegal drug economy in which their bodies were marked by gender, race, and class positions and in which these women experienced little structural power. These forms of agency emerge through entanglement with marginalized social positions that are simultaneously stable systems of inequality and phenomena emergent through processes of intra-action. These articulations of agency provided Lola and Bev with a sense of social belonging in an underground world. In the process, they not only used their bodies but made them through the intra-action of individual bodily practices, personal histories with (il)legal drug use and healthcare, and intertwined categories of social inequality.
Conclusion
Lola and Bev’s experiences of biomedical treatment underscore the importance of framing bodies as “social flesh.” As Michael and Rosengarten (2012) stress in the opening epigraph, “[t]he body and medicine do not exist in the abstract—as primary qualities to which secondary qualities are attached. There is no abstracted body that is ill or beautiful or in remission” (p. 7). In this article, I have examined how Sunrise clients’ bodies, embodied subjectivities, and bodily forms of citizenship emerge through the drug–body–worlds of treatment that integrate biomedicine in tension with long-standing abstinence-based models. Client bodies and embodied experiences of self and social belonging emerge in and through the structures, temporalities, and expectations of the center. This socially and politically fraught clinical setting introduces a number of challenges for clients seeking bodily connection and social belonging.
The experiences of Lola and Bev starkly illuminate these conflicts. As their cases highlight, clients’ experiences of bodily (dis)connection developed through prior drug use in illegal markets and in prior experiences of formal healthcare conflict with the structures and expectations of the center. First, clients like Bev feel their knowledge of their bodies and drug effects is discounted or ignored by healthcare providers, as they attempted to access and manage medication treatment. Second, clients like Lola experience alienation from their own bodies, psyches, and socialities when sedated on medications in treatment. This experience of being “medicated out” conflicts with the high demands the program places on client intersubjectivity.
I argue clients’ histories with drug use and engagement with biomedical treatment potentializes certain forms of embodied agency. Bev’s case shows how clients draw on their embodied knowledge to access medications through informal social networks when they cannot do so through formal healthcare. Lola’s case shows how clients draw on embodied knowledge cultivated through drug use histories, and sometimes use their medicated bodies in drug testing, to generate access to resources and to feel a sense of social inclusion in the underground economy. These expressions of agency are relational; intra-act with gender, race, and economic positions; and occur within highly constrained life options.
This analysis has a number of implications for theory and future research. It highlights the importance of Beasley and Bacchi’s (2002) call for greater attention to bodies in the citizenship literature and to citizenship in the body literature. It underscores the need for research in illegal drug studies based in theories that take the materiality of bodies seriously when considering subjectivity and social belonging. It also draws attention to the need for theories that examine relational agency in addition to structural power. Greater attention to these forms of agency, particularly expressed among individuals struggling with socioeconomic marginalization, will deepen theories of citizenship in contexts of stigma and deprivation. As Anderson (2008) and Campbell and Herzberg (2017) stress, studies of power and agency among women are particularly necessary to fill gaps in critical drug studies.
There are also significant practice implications of this research. Fuller understandings of body–drug–world relations and forms of embodied agency among people engaged in drug use and treatment will support more effective interventions. This knowledge will help to more productively frame practices based in relational agency that occur under highly constrained circumstances, such as obtaining medications in the underground economy, as actions based in bodily connection and efforts toward bodily and social survival and not simply as “noncompliance.” This is possible, Bacchi and Beasley (2007) stress, without dismissing positive aspects of biomedicine. “Placing centre-stage bodies conventionally regarded as mired in biology, marginal or ‘lacking,’” they stress, will enable new modes of intervention (Beasley & Bacchi, 2000, p. 350).
Finally, the focus on biomedical interventions such as MAT, promoted with increasing urgency as a response to rising opioid-related overdose death in the U.S., tends to obscure the critical bodily, social, and survival needs of people struggling with drug use and treatment. The complex bodily experiences of clients like Lola and Bev must be more fully understood and taken seriously by providers and advocates of increased access to biomedical treatment. Their acute need for social inclusion and access to resources essential for survival, such as safe housing free of exploitative requirements, should remain central to interventions. In the context of the intense fear driven by the stark rise in opioid-related overdose in the U.S., experiences of biomedical treatment may be overly simplified, obscuring the often contradictory and sometimes painful ways individuals experience such treatment. Services, policy, and advocacy will benefit from greater attention to how clients’ very bodies are changed by these interventions and the ways their embodied knowledge shapes medication experiences, quality of life, and the ability to survive in contexts marked by significant socioeconomic marginalization.
Footnotes
Acknowledgments
I wish to thank staff and clients of Sunrise who participated in this study, generously sharing their lives to make this research possible. I also thank Dr. Lee Hoffer, my dissertation committee chair, for his ongoing encouragement of my work and constructive feedback. I am additionally grateful for the support of my dissertation committee members Drs. Atwood Gaines, Eileen Anderson-Fye, and Susan Hinze. Finally, I thank the anonymous reviewers of this article for their constructive feedback.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a National Science Foundation Doctoral Dissertation Research Improvement Grant (Behavioral and Cognitive Sciences Division) [#1324263]. This work was also supported by several Case Western Reserve University fellowships, including College of Liberal Arts and Sciences Writing Fellowship, Baker-Nord Center for the Humanities Graduate Research Grant, Richard A. Zdanis Graduate Research Fellowship Award, and Social Justice Institute Graduate Research Fellowship.