Governing drug use otherwise: For an ethics of care

Drug policy, health and normalisation

Foucault’s (2000) seminal account of governmentality reveals how the knowledge claims generated in the human sciences are routinely deployed in the design of policies and practices by which everyday conduct is regulated within a given population. More recently, scholars have developed and refined this analysis in studies of drug policy and the various practices of governance and control it enacts (Alaszewski, 2011; Keane 2005; Nettleton et al., 2013; Race, 2008). Without overstating what are by now well-established arguments, Race (2008), Keane (2005), Duff (2004), Fraser and Moore (2011) have each argued that the governance of drug problems involves the instantiation of norms (and the legal, social and economic means of their enforcement) by which a normal, healthy and productive life may ostensibly be guaranteed.

Recent responses to illicit drug use in developed nations such as Australia, Canada and the United Kingdom provide further indications of the logic and practice of drug policy. The regulation and control of illicit drug use in each nation proceeds from the identification and elaboration of problems associated with the production, trafficking, sale and consumption of specific substances (Brownstein, 2013: 20–25; see also Miller and Rose, 2008: 15–16). A key feature of this process has been the attempt to ascertain the prevalence, scale and frequency of illicit drug use in varied populations (Fraser and Moore, 2011). This research indicates that rates of illicit drug use are growing in many groups in each nation, especially the young (UNODC, 2014), which serves itself as a powerful warrant for the ministrations of drug policy. While the basic prevalence of consumption is often cited as a problem in its own right in Australia, Canada and the United Kingdom, scholars and clinicians have also sought to determine the relationship between individual patterns of consumption and the distribution of health and social problems, such as accidents and injuries, hepatitis C, HIV/AIDS, unstable housing, unemployment, and mental health problems such as psychosis, cognitive impairment, anxiety and depression (Stockwell et al., 2005). These problems are typically articulated in relation to vulnerable individuals, although other studies describe structural, economic, social and political processes and the ways they mediate drug problems (Moore and Dietze, 2008). In either case, drug use is problematised by way of associations between the prevalence of consumption and the incidence of health, social and economic problems that invite formal remediation through the agencies of the state or its proxies. Consumption and its discontents shadow each other in this regard, as governments are called upon to act.

Having conflated consumption and the incidence of drug problems, the expert discourses that inform drug policy in countries like Australia, Canada and the United Kingdom can’t help but render drug use inimical to the aims and priorities of ‘normal’ life (Fitzgerald, 2005; Keane, 2003). As soon as drug use is posited as the cause of problems that inhibit the achievements of everyday life – such as maintaining stable housing, gainful employment, robust health and diverse social networks – drug use must be renounced in pragmatic and normative terms (Boland, 2008). The drug policies that accord with this logic transpire at a population and an individual level. At a population level, the governance of drug problems invariably entails select interventions designed to reduce the prevalence of consumption by limiting the supply and availability of illicit drugs. Complementary strategies target individuals, and the cultural groupings they comprise, in order to control private drug use practices. The focus on conduct provides the hinge between these two domains (Foucault, 2000). The instruments (or techniques) of drug policy assert their legitimacy by establishing conduct as an object of both administrative and normative concern (Keane, 2005). Drug policy is administrative insofar as it seeks to regulate private conduct according to the instrumentalities of the law, public health, education and so on. These efforts serve to inspire, uphold and/or promote individual norms, such as abstinence, risk aversion, rationality and self-interest, which provide drug policy with its requisite normative foundation.

Drug policy is premised, therefore, on the claim that drug use imperils the maintenance of ‘normal’ health and the enjoyment of ‘normal’ life (Fraser and Moore, 2011). Consistent with this logic, drug policy’s goal of maintaining the health of the ‘normal’ body is elevated to a potent normalising injunction that relies for its legitimacy on a series of taken-for-granted claims about how bodies function, how they ought to comport themselves, and how they should be maintained (Race, 2008; Sybylla, 2001). As a result, individual subjects lose their ‘natural right’ to consume illicit substances on the basis of these substances’ threat to the governing ideals that define ‘normal’ health (Race, 2008). Individuals and groups that breach these ideals not only infringe the criminal law, their behaviour must also be stigmatised for its indifference to the normative principle, enshrined in drug policy, that illicit drug use is wrong.

Many have questioned, however, whether this principle still holds, and whether drug policies still reflect a consensus regarding how health ought to be maintained or promoted (O’Malley and Valverde, 2004; Race, 2009). In raising these objections, critics often observe how the widespread practice of infrequent and controlled illicit drug use has undermined the nexus between abstinence and good health that lies at the heart of all drug policies (Aldridge et al., 2011). Evidence from all over the world indicates that significant numbers of people maintain controlled patterns of drug use over long periods of time, while upholding the obligations of ‘normal’ life, such as paid employment, stable housing, diverse social networks and a meaningful sense of health and wellbeing. These findings have prompted an interesting re-appropriation of the language of normalisation (Aldridge et al., 2011) to describe what is perhaps best understood as mass civil disobedience. Following Foucault (2000), the normalisation of drug use that has now been documented in several countries may be said to reflect an interest in being governed otherwise, in ways that depart from the modes of governance evinced in contemporary drug policies (Alaszewski, 2011). The widespread flouting of the criminal law, necessary for the spread of normalisation, would seem to suggest that drug users are increasingly dubious of any automatic conflation of consumption and harm (Duff, 2005). Yet this does not mean that consumers are indifferent to the problems that sometimes follow from illicit drug use. Studies in numerous settings reveal strong interest among drug users in practical techniques for managing drug problems in ways that depart from formal strategies for governing drug use (Keane, 2003: Race, 2008).

Interest in the identification of alternative grounds for the governance of drug problems has also inspired academic critiques of the normativity of drug policy and the normalisation it legitimises (Brownstein, 2013). While concerned with a broader sweep of ‘bio-ethical’ problems, Alan Petersen (2013: 266) has recently identified four options for a ‘more contextually sensitive approach [to] a normative sociology of bio-knowledge’ that are well suited to the task of reimagining drug policy proposed here. These four positions are virtue ethics, communitarian ethics, an ethics of care and what Petersen (2013: 266) calls a ‘human rights focused approach’. Petersen (2013: 268) makes the case for the last approach, arguing that it offers the best means of exposing the ‘bases of the global injustices that arise with the increasing entanglement of the life sciences with the capitalist mode of production’. Without disputing this conclusion, I find his brief introduction to an ethics of care more fruitful in terms of the directions it suggests for an alternative means of governing drug problems. Besides, discussions of the utility of human rights frameworks for reforming drug policy are well advanced (see Jürgens et al., 2010 for a review), while much remains to be done to articulate approaches to drug policy grounded in ethical praxis. Briefly, an ethics of care rejects ‘principlist’ approaches to bio-ethics for their indifference to the cultural contexts in which principles such as autonomy, justice or beneficence are applied to ethical problems. Principlism obscures the contexts in which ethical judgements are made by upholding the universal veracity of notions like justice and autonomy. This approach has little to say about how justice is defined, contested or reworked in ethical debate, and so provides few insights into the novel ethical dilemmas occasioned by the rise of the ‘bio-economy’ (Petersen, 2013: 264).

Filling in Petersen’s (2013: 267) sketch, an ethics of care differs from principlist approaches by emphasising the everyday practices, procedures, relationships and rhetorical strategies by which ethical problems are identified, debated, managed and sometimes resolved. It asserts that ethical and moral problems are rarely resolved by recourse to abstract principles that enjoy universal adherence and respect. Rather, ethical problems ought to be regarded as the product of specific failures to develop and sustain relationships of trust, compassion, fairness and respect among the parties to such problems (Mol, 2008). Importantly, notions like care, compassion and trust must not be treated as inviolate, abstract principles, but should instead be understood as provisional relational achievements that depend on the ethical labour of all members of a community (Koopman, 2013: 189-91). Care, as such, must be invented, refined, practised and defended in ethical relationships. What it means to be caring, and what it means to exercise care in the management of ethical problems, always reflects the actual contexts in which ethical problems emerge. Further reference to Foucault’s (1997) account of the care of the self (and others) should help to clarify the basic features of this ethical approach.

In describing an ethics of care, Foucault (1997: 254) makes a distinction between normative and aesthetic understandings of care, favouring the latter for avoiding the normalisation endemic to the former. An aesthetics of care acknowledges the contingencies that shape the relationships and contexts in which care is practised as a particular mode of solicitation and concern. Care cannot be grounded in a distinctive moral philosophy because no such philosophy can anticipate the variety of contexts in which individuals may be called upon to exercise care, either in relation to themselves or others. This is not to ignore the value of moral reflections on care. Rather, Foucault (1997: 256–8) is interested in how care is practised in relations of trust and reciprocity, and the ways these relations are framed by aesthetic judgements to do with the quality of life, pleasure, hope and choice. The primary concern for any practitioner of an ethics of care is identifying which techniques ‘I have to use in order to live as well as I ought to live’ (Foucault, 1997: 260). Even so, the identification of techniques or practices of care is never completely voluntary, in that discourse, power and knowledge inevitably shape ethical conduct in any context. Foucault (1997: 260) is equally convinced, however, that an aesthetics of care enables the elaboration of ethical practice ‘without any relation with the juridical per se, with an authoritarian system, with a disciplinary structure’. The point is to establish a ‘certain relation to oneself’ (Foucault, 1997: 260) capable of sustaining care throughout one’s affective, social, aesthetic, practical and political relationships and commitments.

The care of the self (and others) is exercised through practices and relations that embody care as a distinctive kind of value, quality, ethos or orientation. Moreover, to care for oneself is to become more capable of responding to others in ways that promote trust, respect, reciprocity, love or pleasure. Care is never solipsistic in this regard, in that care is always relational. One always needs others in order to realise the goals towards which the care of the self is oriented. To care for oneself requires that one nurture the affective relations, practices and connections that sustain the self within a community of ethical subjects. It is for this reason that care may never be codified in moral terms, for the practice of care is forever negotiated or performed in the context of interactions. What it means to exercise care is contingent on the social and affective context is which care is realised in practice (Koopman, 2013: 185–8).

Such analysis paves the way for more innovative approaches to drug use and the governance of drug problems. In the first instance, it dispenses with the habit of characterising drug use in relation to problems by opening up the prospect of analysing drug use in relation to care. Kane Race (2008: 421) has developed this argument by discussing how drug users come to articulate novel practices of care in the elaboration of discrete ‘techniques of pleasure’. Race (2008: 420) adds that these techniques break with the ‘pathologizing logic’ of drug policy by refusing to position harm or danger as the primary corollaries of drug use. In this spirit, I draw from Foucault’s ethics to investigate the experiences of regular polydrug users in contact with health and social services in Melbourne. Without ignoring the problems that many drug users experience, I wish to reassess the links between drug use, health and normality as a way of critiquing some of the assumptions that inform contemporary drug policies. This focus will enable further scrutiny of how drug users govern their own drug use, and how they respond to problems associated with this consumption. In tracing the ethical relationships participants reported maintaining to (or with) drugs, I will begin to elaborate alternative political and ethical criteria for the governance of drug problems.

Methods

Accounts of regular polydrug use were drawn from in-depth interviews conducted during the ethnographic component of a mixed methods study investigating methamphetamine use and health service provision in Melbourne. Ethnographic research had two aims: to explore the social contexts of methamphetamine use in Melbourne; and to assess the scale and effectiveness of service responses to methamphetamine related problems. Despite a focus on methamphetamine, all interview participants disclosed a history of polydrug use, with most reporting ongoing use of a range of substances including heroin, prescription opioids, alcohol and cannabis, in addition to methamphetamine. Following approval from the Curtin University Human Research Ethics Committee, in-depth interviews were completed with 31 consumers (17 men, 13 women and one transgender woman; average and median age 36 years, range 22–56 years); and 15 service providers. Consumers had used methamphetamine (among many other substances) at least once a week in the six months preceding the interview. Twenty-six consumers reported being born in Australia, with all but two identifying with an Anglo/European background. Four had attended a tertiary institution and three had completed secondary education. Four consumers were employed full-time, with 20 in receipt of either a disability or unemployment pension. Fifteen were enrolled in opioid substitution therapy. Consumers were reimbursed $30 for their time consistent with local research practice (Fry and Dwyer, 2000).

Interviews were conducted with drug service providers to elicit data on problems related to methamphetamine consumption in Melbourne, and the effectiveness of local responses to these problems. Service providers were recruited from needle and syringe programs (NSPs), drug treatment and residential rehabilitation centres. Of the 15 service providers who completed interviews, five reported working as nurses, four were employed as NSP workers, two worked in outreach roles, two worked as counsellors, with one social worker and one general practitioner (GP). Interviewees reported working in drug services for a period of 3 to 26 years (average of 13.2 years). Ten of the providers were currently employed in services in St Kilda, with the remainder working in Fitzroy. Three reported being employed in management positions. Interviews with both consumers and service providers were conducted in cafes, local services and private homes and lasted an average of one hour (range 27 to 128 minutes). Interviews were digitally recorded and transcribed to facilitate data analysis and reporting. All data were analysed using techniques drawn from Adele Clarke’s (2005) Situational Analysis. Situational Analysis permitted more sensitive treatment of consumer accounts of their drug ‘careers’, and the views of local service providers regarding the clients they serve, their lives and circumstances.

The practice of care

Interviews with consumers and service providers focused on local contexts of illicit drug use, the circumstances in which individuals initiate consumption, and the kinds of benefits and costs associated with this use. In considering these issues, a number of participants observed that individuals often initiate drug use in response to a distinctive set of personal needs or interests. Cited examples included the desire for intimacy and connection; the alleviation of feelings of boredom, frustration, isolation or uncertainty; the pursuit of pleasure, entertainment or fun; and respite from illness and its symptoms. A common feature of these discussions was the rejection of the association between drugs and poor health, described earlier in terms in the conflation of consumption and harm. While many consumers identified a range of health and social problems when describing their drug use histories, these problems were rarely attributed to drugs alone. Reflecting on the causes of individual problems, consumers more commonly spoke of disadvantaged childhoods, problems at school, economic marginalisation, poor social support, inadequate housing and/or relationship problems. Many consumers added that they first started using drugs in response to these problems, either as a way of coping with them, or gaining some brief respite from them. Drugs provided functional benefits in this respect, helping individuals to address or satisfy their personal needs in the face of varied problems and disadvantages.

Indications of the functional benefits of drug use do much to undermine the nexus between abstinence and health that provides the principal rationale for drug policy in Australia and elsewhere. Participants did not dispute the link between drug use and the experience of health problems, with many describing instances of poor health attributable to their drug use. However, participants also spoke of periods where drug use helped them to sustain a sense of physical, emotional and/or social functioning, which they regarded as an important way of maintaining their health, as they understood it. This was especially common in discussions of mental health, as one provider noted:

A lot of my clients are really trying to medicate their mental health symptoms. They’re constantly trying to balance all the drugs they’re taking, both prescribed and street drugs, with the management of their mental health. So speed can give them that ‘up’ that increases their function for a period of time. It helps them achieve things they want to achieve or just pulls them out of that low depressive rut. I think the drugs are mostly just a response to that [rut].

Numerous consumers made similar observations regarding what they perceived to be therapeutic or functional benefits of drug use. Jennifer said:

My medication, I have to take that, but that’s why I like taking speed on top of the medication because I get really tired, lethargic and I just need something to pick me up. Otherwise, I won’t get out of bed. I can sleep for 15 hours a day.

Paul was equally adamant about the beneficial effects of his drug use, although he also referred to his capacity to make his own decisions about drug use, to exercise greater self-governance as Foucault would have it:

It’s like they’re [drugs] made for a reason and not for doctors or the cops to hold onto and say ‘no it’s too addictive, you can’t have it’. You know the drugs aren’t destroying my life, they’re making it better and easier for me rather than full of suicidal thoughts and everything because you know I do get these thoughts. I am a very suicidal person. I’ve always been like that and they [drugs] help me even if I feel like I’m trying to get away from the problem, it’s helping and I don’t think that anyone should judge that and be able to say no you can’t have them.

Belinda and Steve spoke also of the benefits they derived from their drug use. Belinda described a kind of therapeutic ‘head space’ provided by drug use:

I don’t have a mother and I don’t have a father you know. So it’s a pretty sad story my past, the whole thing. What I want with drugs is the space that it gives me while I’m on it. That’s the reason I do all this, for the head space it gives me, away from the past, my family, everything.

Alluding to the stigma associated with drugs, Steve commented that:

You know, people say I’m a druggie. But I’m not a criminal. I don’t jump in people’s houses. I don’t steal people’s wallets. Yeah, I use drugs. I’m a bit fucked up in the head. I have some problems, and I don’t know how to work them out. I’d like to work them out. But really this is who I am. I’m just trying to live better. And drugs help, like a lot sometimes.

Rebecca highlighted the extent to which illicit drug use may help individuals cope with endemic social and economic disadvantage:

I love it [methamphetamine]. I enjoy it. I like getting scattered off my head, it puts me out in my own little world. I’ve got a real sick sense of humour … and if that brings a smile to somebody’s face then it’s worth it because of the grief, what people have got to put up with around here.

One option for analysis is to treat these reports as rationalisations grounded in the logic of self-medication. Yet this assumes that Jennifer, Paul, Belinda, Steve and Rebecca felt any need to justify or explain their drug use. No such motivation was apparent in their interviews. Instead, each participant described instances of what may be regarded as functional drug use, evinced in part by the tangible health benefits these participants derived from their drug use. Functional benefits reported by participants included more energy, respite from ‘suicidal thoughts’, a positive ‘head space’, or a means of living ‘better’. These functional benefits promoted a sense of health or wellbeing for participants by alleviating suffering associated with mental or physical illness, by helping them ‘feel better’ about their immediate circumstances, or by promoting a sense of hope and ‘energy’. In other words, the idea that drug use is always unhealthy was routinely contested, if not rejected outright, among many of the consumers and some of the service providers interviewed. These participants spoke of circumstances in which drug use is congruent with the promotion, maintenance or restoration of health in ways that trouble the pathologisation of drug use that characterises so much of contemporary drug policy (Race, 2008). Insofar as health may be understood to encompass wellbeing, functioning, freedom or capacitation (Gorin and Arnold, 2006), many participants spoke of instances in which their drug use enabled the realisation of these qualities. Another way of making this point is to argue that the drug use described by Jennifer, Paul, Belinda, Steve and Rebecca constitutes a practice of care. These practices emerged in social and economic contexts in which problems of all kinds proliferate; financial problems, relationship problems and health problems, including problems partially attributable to drugs. Drug use reportedly offered many participants a means of caring for the self in spite of these problems and their effects.

Such analysis relies on the move described earlier in which the notion of care is stripped of any normative (or ‘principlist’) content in favour of a more constructivist stance that emphasises the contingencies shaping how care is negotiated, contested and refashioned in ethical practice. This includes the varied practices of self-care described by participants. This more pragmatic ethics of care draws attention to the contexts in which practices of care emerge, and the circumstances they respond to. Paying closer attention to these circumstances allows one to make sense of the claim that illicit drugs help to moderate the symptoms of mental illness, for example, or to help one live a ‘better’ life. The analytical benefits of this stance are particularly compelling in light of the conditions of material and social disadvantage described by most participants. Such conditions arguably help to explain why drug use may be regarded as an effective means of caring for the self in the context of enduring disadvantage (Race, 2009). Without a means of accessing more familiar modes of self-care, drugs figure as a pragmatic substitute.

A second set of care practices emerged in reports of the importance of learning how to manage the effects of a long drug use career. The effects described by consumers encompassed both the perceived benefits and costs of illicit drug use. Discussing their own drug use careers, many participants alluded to the normalisation of illicit drug use in their social networks, and the sense that drug use was an inevitable part of everyday life. Equally inevitable, reportedly, was the periodic onset of problems occasioned by this drug use. Describing this process, and the ubiquity of drugs in her social environment, Fiona spoke of the importance of developing ways of coping with drug effects:

A lot of people binge, you know whatever they can get their hands on. And the only thing you can do to recover is to start eating again and then sleep. If you don’t eat and you don’t sleep for six or seven days, that’s why you feel so bad. So you need to go home and sleep and eat and it’ll get better over time. Mostly you learn this stuff the hard way, but after that you just need to look after yourself a bit. So I try and tell people this, you know people I meet, and people do listen eventually.

Fiona’s frank assessment of the ubiquity of drug use in her community has as its corollaries the importance of learning more about the effects of drug use, along with ways of taking care of oneself in light of these effects. Mention of the apparent inevitability of illicit drug use often entailed discussion of the importance of self-care among participants, and how they had come to develop particular care practices. In talking about these practices, most participants indicated that they had been prompted to adopt specific techniques after experiencing the more ‘unpleasant’ effects of illicit drug use. Developing ways of looking after oneself was thus understood as a critical part of sustaining drug use over long periods of time. As Mark said:

People who have been there know, they sort of understand. Like you’re always going to have it [drug use] in your head aren’t you? Maybe you can do all right for a year or two, but you’re always going to go back and have a dabble or a taste, maybe even just once a year, but you’re always going to take it. You just have to learn what your body can take, how to look after it, where to get good meds, that kind of thing.

A number of participants also alluded to the ways that practices of care circulate among networks of drug users. Consumers were said to ‘share the high and the come down’, creating opportunities for the dissemination of care practices among consumers. Otherwise, tips for recovering from episodes of use, or for managing longer-term health problems, were reported to pass by word of mouth between consumers, and between consumers and service providers. Sarah emphasised the importance of sharing information gleaned from formal sources, such as health care providers, with other consumers:

I think because I’ve been using these services for so long, and they all know me and that, I’m expected to educate younger people if I think they need help. I think I put that on myself actually, that I should make sure they’re educated because if they’re going to be, if they’re going to do it [use drugs] then you gotta learn how, you know? And the only way I’ve stayed alive all these years is because the needle exchanges have taught me properly right from the start. That’s huge you know?

Many service providers acknowledged the importance of this kind of informal dissemination of health care (or ‘harm reduction’) information among consumers. These providers indicated that they actively encouraged clients to share harm reduction information with peers in order to promote the adoption of ‘safer’ or ‘less risky’ forms of drug consumption. Brian argued that this was particularly important in light of clients’ typical alienation from more mainstream forms of health care, education and support. He observed that:

Well yeah, look this is a niche area [outreach/harm reduction] because you can do very little, but still it helps a lot because again it goes back to the, these people, they don’t feel comfortable accessing normal services, so my little bit of knowledge goes a long way.

Endorsing Brian’s assessment of the efficacy of formal and informal harm reduction strategies for long-term drug users, Sue argued that initiating discussions with clients about harm reduction and self-care can also play a crucial role in engaging consumers in conversations about their health-related beliefs and the circumstances in which they use drugs. Acknowledging the normalisation of illicit drug use in disadvantaged communities, Sue added that it was important to try and encourage the adoption of harm reduction strategies among clients in order to ‘mitigate some of the risk factors in their environment’. Describing how this task is managed at her work, Sue said that:

The fact that clients are really involved in their health is critical. Like how do we make health accessible to those who need it the most but have the least of it? So we have to start with a conversation about what people want, do they want to stop using drugs, cut down a bit, how does their drug use affect their health, do they know how to look after themselves, do they know about free services in their area, you know.

Foucault’s discussion of an ethics of self-care provides important insights into the health care practices described by Brian and Sue. These insights relate both to the consumption of illicit drugs, and the ways individuals manage drug effects. Foucault’s ethics (1985: 10–11) concern ‘those self-forming activities’ by which individuals ‘seek to transform themselves’. Few activities are as transformative in this regard as drug use. The consumers who participated in the present study described long relationships to drugs that were governed to a greater or lesser extent by unique practices of self-care. Given how widespread these practices were reported to be, it is arguable that care functions as a discrete mode of self-governance for many drug users. I would add that this self-governance prefigures an alternative logic for drug policy.

For an ethics of care

Contemporary drug policies entail a mode of governance that seeks to promote health by defining the very quality of life and how it ought to be understood and maintained (Alaszewski, 2011; Keane, 2005; Race, 2008). Yet as Foucault (2000: 49) observed in a sympathetic context, adherence to a universal morality, such as one may discern in the interdictions of contemporary drug policy, is ‘now disappearing, has already disappeared’ from cultural and political life in many nations. Drug policy may, indeed, be said to be enduring a protracted crisis insofar as its legitimacy is routinely contested on legal, technical and humanitarian grounds, just as it is eroded in the habits and customs of those individuals who regularly flout its dictates (see also Duff, 2004; Keane, 2005; Race, 2008). To the extent that select forms of drug use have become ‘normalised’ among large sections of the population, and tolerated or ignored among many more (Duff, 2005), one may argue, with Foucault (2007: 43), that the contemporary crisis in drug policy partially reflects a desire among individuals ‘not to be governed like that’.

What’s more, widespread defiance of drug laws and policies arguably indicates a preference for self-governance in which individuals and groups identify their own ‘principles’, ‘objectives’ and ‘procedures’ (Foucault, 2007: 43) for managing drug use, and the problems that occasionally follow from it. Certainly, the participants in the present study would assert their ‘right’ to make up their own minds about drugs in deciding when and how to use them, and for what purposes. For these participants, illicit drug use reportedly provides a range of functional benefits that satisfy select needs or interests more effectively than available alternatives. Such needs – including a desire for social contact, intimacy or entertainment, more energy, positive affect, relief from boredom, and the mitigation of suffering – constitute powerful ends for which drugs provide a ready means. In these sorts of circumstances, drug use must be construed as a method of promoting health and of restoring wellbeing rather than threatening to diminish it. Another way of making this point is to conclude that drug use provides many individuals with an effective means of caring for the self. As long as health is divested of its narrow normativity, its reduction to conventional biomedical constructs (Gorin and Arnold, 2006), it is possible to argue that drug use is indeed congruent with a practice of care.

This gesture is critical to the work of articulating an ethics of drug use more sensitive to the contexts that frame consumption practices. It also provides a way of elaborating new avenues for drug policy reform by extending the terms of debate beyond harm reduction (Race, 2008) and human rights agendas (Jürgens et al., 2010) as the only viable means of promoting change. As important as these two discourses have been in challenging the normativity of contemporary drug policies, each in its own way endorses the conflation of consumption and harm, as if the role drug use sometimes plays in promoting health cannot possibly be acknowledged (see Duff, 2004). It is certainly true, as Race (2008: 420) argues, that the pleasures individuals derive from drug use often involve ‘modes of care, education and safety’ that suggest novel grounds for innovative harm reduction initiatives. However, I would stress that the modes of self-care identified in the present study exemplify practices of health that have no necessary logical or pragmatic orientation to harm. My point is that grounding the discussion of drug users’ care practices in the logic of harm reduction obscures the role these practices play in the promotion of health. Moreover, conflating an ethics of care with the identification of novel harm reduction strategies (Race, 2008: 421–2) only reinforces the normativity of drug policy by foreclosing discussion of the relationship between drug use and health, such as the practices identified in the present study. It is not a question of deciding a priori whether drug use is healthy or unhealthy, rather it is a matter of describing the conditions in which drug use is linked either to practices of health or to the incidence of harm.

Examples of the former abound in the present study, whereby drug use provides a means of caring for the self and its problems, just as participants described learning how to cope with the health, social or financial problems illicit drug use occasionally causes or exacerbates. In making this argument, I have not ignored participants’ experience of social and economic disadvantage, nor am I indifferent to arguments for greater investment in the provision of health care in disadvantaged communities (Race, 2009). Rather, I have been concerned to explore how some drug users manage their consumption in relation to varied practices of care and support; practices that ultimately furnish an alternative logic for governing drug problems. Central to this logic is a concern for the welfare of drug consumers, without demanding that they adhere to universal norms of behaviour. Requiring that consumers adhere to a narrow set of norms, which they had little part in determining, and then punishing those who deviate from these norms has only served to undermine confidence in drug policy and erode its legitimacy (Keane, 2003). The logic of care advanced in this article would make care itself, and the promotion of health, the goals of drug policy rather than the prevention of use, or even the reduction of harm. Such a logic draws on the practices consumers have themselves devised to advance novel means of governing drug problems. Drug use is not itself a problem, at least not a very significant one. The lack of adequate means of caring for oneself is surely a far greater concern for governance. As advocates for drug law reform turn increasingly to the language of human rights (Jürgens et al., 2010), it may be that a logic of care, and not a concern for reducing harms, offers the best hope for reform.

One might add that a logic of care informs much of the therapeutic activity common to existing health and social services for drug consumers. Despite an explicit focus on treatment and harm reduction, many of the service providers interviewed for this study highlighted the importance of cultivating self-care among clients. The advantage of such a focus lies in its refusal to engage in controversies regarding the relationship between drugs and harm. As I have argued throughout this article, ideas of harm are laden with normative claims regarding the quality of life, which fail to account for the social and economic disadvantages experienced by many long-term drug users, or the functional benefits many consumers derive from this drug use. While the notion of care is hardly less prone to normative over-reach, Foucault’s discussion of an ethics of self-care offers scope for the elaboration of drug policies more alert to the health and social benefits illicit drug use may avail. This is to argue for policy approaches that do not presuppose a linear causality between consumption and the incidence of problems, and seek instead to promote practices of care equal to these problems. Long-term drug users often encounter health and social problems, and yet drug policy affords few effective options for the self-management of these problems. Left largely on their own, drug users must devise their own ways of solving problems in a practice of self-care. Promoting the elaboration of such practices through the adoption of more ethical modes of drug use gives rise to an alternative logic for drug policies more concerned to promote health than to reduce harms.