Articulating addiction in alcohol and other drug policy: A multiverse of habits

Making addicts: critical reflections on agency and responsibility from lawyers and decision makers

Various activities are increasingly characterised as 'addictions', including within the law, and raise important questions. Do 'addicts' have agency? Do addictions shape social problems such as family and sexual violence? And how do those involved in legal systems perceive addictions? This paper explores these questions. Drawing on qualitative interviews with lawyers and decision makers (N = 48), it explores addiction in law. Lawyers and decision makers see themselves as playing important roles in making addiction and 'addicts'. Addiction is an effect principally of legal strategy, and other forces. Legal processes bring differing conceptions of agency and responsibility into being, problematising understandings of agency as an 'effect' of addiction, or as pre-existing legal processes. There are also important variations in approach regarding different addictions. Alcohol or other drug addiction is seen as 'genuine', and a major factor in family violence, while sex addiction lacks credibility. I explore some implications of these approaches.

Noticed and then Forgotten: Gender in Alcohol Policy Stakeholder Responses to Alcohol and Violence

In this article, we analyse interview data on how alcohol policy stakeholders in Australia, Canada and Sweden understand the relationship between men, masculinities, alcohol and violence. Using influential feminist scholarship on public policy and liberal political theory to analyse interviews with 42 alcohol policy stakeholders, we argue that while these stakeholders view men's violence as a key issue for intervention, masculinities are backgrounded in proposed responses and men positioned as unamenable to intervention. Instead, policy stakeholders prioritise generic interventions understood to protect all from the harms of men's drinking and violence without marking men for special attention. Shared across the data is a prioritisation of interventions that focus on harms recognised as relating to men's drinking but apply equally to all people and, as such, avoid naming men and masculinities as central to alcohol-related violence. We argue that this process works to background the role of masculinities in violence, leaving men unmarked and many possible targeted responses unthinkable.

A matter of craving-An archeology of relapse prevention in Swedish addiction treatment

This article concerns how craving is approached and handled, how it is 'made up', in the practice of so-called relapse prevention (RP) for addiction problems. There is a lack of research on what RP in general, and craving in particular, 'is' and can become across settings. Drawing upon science and technology studies (STS) and critical addiction research, we analyze how craving is enacted in manuals and training material related to the intervention, and in interviews with professionals in the Swedish treatment system. Adopting an archeological approach, we scrutinize different layers of craving enactments in RP, in search of assumptions that give rise to what John Law refers to as 'collateral realities'. We identified three collateral realities: 1) 'The materialization of craving'; 2) 'The transcendence of the individual' and 3) 'The merging of treatment and everyday life' The data show that the brain, cognition, emotions and behavior are enacted in RP as demarcated targets of intervention that the individual can transcend and control. This approach, in turn, relies on the more foundational tenet that there are no clear-cut boundaries between different identities (I/me/self; body/brain/cognition), between different settings (inside/outside treatment; real/imagined situations) or between different points in time (now/then/before). We discuss the relevance and usefulness of addiction treatment realities where craving is approached as a stable object that can be effectively treated, and where interventions inaugurate neoliberal governance of responsibilized individuals.

Holding 'new recovery' together: Organising relations and forms of coordination in professional sociomaterial practices of addiction recovery

Questions about what addiction recovery is and the mechanisms by which people 'recover' have long animated alcohol and other drug research and policy. These debates became even more intense following the advent, and increasing influence in some quarters, of the 'new recovery'. Starting from the position that recovery is ontologically multiple (Mol & Law, 2002), we trace how alcohol and other drug professionals attempted to make sense of 'new recovery' as a concept and set of professional practices during a period of Australian drug treatment system reform. Drawing on Annemarie Mol's (2002) account of organising relations and forms of coordination (addition, translation and distribution), we explore how the new recovery was enacted and coordinated in alcohol and other drug professionals' sociomaterial practices, and highlight the ontological work involved in holding such an unstable object together. First, we argue that the addition of multiple enactments of addiction and recovery contributed to the formation of a singular and serviceable problem (that was simultaneously heterogeneous and complex), making the 'disease-to-be-treated' amenable to diverse treatment approaches, including new recovery. Second, we analyse the role of metaphor in translating authoritative logics and obligations into an enactment of new recovery suitable for application in clinical settings. Lastly, we track how incompatible enactments of recovery, both new and old, were kept apart through distribution. Although new recovery ultimately failed to gain policy traction in the Australian context, we focus on the ontological work undertaken by professionals in response to its introduction as such case studies can be useful for analysing other powerfully governing policy objects and their operations.

"Undisciplined" drinking, multi-sectoralism and political power: Examining problematisations in the Botswana alcohol policy

The Botswana government has recently ramped up efforts to control alcohol consumption through various measures. These include the alcohol tax levy, reduction in trading hours for bars and other licenced premises and increased penalties for alcohol-related road offenses. Whilst these efforts have recently received considerable attention, the processes of alcohol policy development remain unknown and understudied. In this paper, I examine the alcohol policy processes in Botswana using What's the Problem Represented to be (WPR), a poststructural analytic approach that emphasises problematisations in policies. Drawing on alcohol-associated policy documents, I identify two key problematisations that relate to, (1) an emphasis on an "undisciplined" drinker, and (2) an appeal to an internationally-endorsed multi-sectoralism. I explore these problematisations as political formations and periodise them to the year 2008 when they were canonised. I argue that "undisciplined drinking" and an internationally-endorsed multi-sectoralism neglect the social and cultural contexts of drinking, pathologise drinking and do not consider other forms of knowledge. Unmaking current alcohol policy representations is needed to allow for the 'emergence' of alternative conceptualisations of the alcohol 'problem' in Botswana.

Towards an ontological politics of drug policy: Intervening through policy, evidence and method

Increasing attention has been paid to matters of ontology, and its accompanying politics, in the drug policy field. In this commentary, we consider what an 'ontological politics' might mean for how we think about what drug policy is and what it might become, as well as for how we think about (and do) research in drug policy. Thinking ontopolitically questions the tacitly accepted status of 'drug problems', calls into question the realist presumptions which underpin much drug policy analysis, and provokes thinking about what counts as 'evidence' and the 'evidence-based policy' paradigm itself. We call attention to the inventive possibilities of method when grappling with the challenges thrown forth by the ontological turn, with a renewed focus on practice and relations. An ontological politics disrupts consensual claims and draws critical attention to objects that might otherwise appear 'finished' or 'ready-made', not least the things we call 'drugs' and 'drug policy'. Working with 'drug policy multiples' invites new thinking and dialogue to provoke an ethico-political mode of intervention in the field of drug policy and drugs research.

Mapping the Drugged Body: Telling Different Kinds of Drug-using Stories

Drugged bodies are commonly depicted as passive, suffering and abject, which makes it hard for them to be known in other ways. Wanting to get closer to these alternative bodies and their resourcefulness for living, I turned to body-mapping as an inventive method for telling different kinds of drug-using stories. Drawing on a research project with people who inject heroin and crack cocaine in London, UK, I employed body-mapping as a way of studying drugged bodies in their relation to others, human and non-human, in the injecting event. I invited participants to draw their bodies in describing these otherwise hard-to-articulate experiences. Following Donna Haraway, I conceptualise body-mapping as a more-than-human mode of storytelling where different kinds of bodies can be known. Here, I look at three such bodies - sensing-bodies, temporal-bodies and environment-bodies - and argue that it is through being able to respond to such bodies that more hospitable ways of living with drugs can become possible.

Consumption in contrast: The politics of comparison in healthcare practitioners' accounts of men who inject performance and image-enhancing drugs

In recent years, Australian researchers' interest in the use of performance and image-enhancing drugs (PIEDs) has grown, in part because PIEDs use is thought to be on the rise. In much existing research, PIED consumers are described as a new and unique cohort of service users, with distinct needs, expectations and views regarding service provision, harm reduction and risk. There is some evidence that policymakers and service providers have been unsure of how best to support this seemingly distinct cohort. Are their needs different to those of people who use other illicit drugs, or the same? How so? And how might we design services with these similarities and/or differences in mind? As these questions suggest, understandings of PIED use and our efforts to address it are often heavily reliant on comparisons, including between people who consume different kinds of drugs. This article engages with the central role of these comparisons in shaping understandings of PIED-related service delivery and design, and considers what is at stake in the drawing of comparisons. We explore these issues through an analysis of 20 interviews with Australian healthcare professionals conducted for a major research project on PIEDs. As we explain, comparison was a tool commonly used by many of our participants - a way of thinking through who PIED consumers 'are' and what they need. Drawing on the work of philosopher of science Isabelle Stengers (2011) and an application in research on the politics of comparison in drug treatment (Fraser & Ekendahl, 2018), we argue that such comparisons can work to reproduce normalising ideals and flawed hierarchies, with PIED consumption positioned as less desirable than 'mainstream' ways of being and living, but more desirable than other forms of drug use. The comparisons we identify may also concretise or naturalise differences between consumers, positioning difference as somehow linked to the individual attributes or capacities of people who use different kinds of drugs, thus foreclosing questions about the political contexts in which comparisons are made and which give them their meaning. In concluding, we encourage other ways of thinking about difference, including whether the differences identified by our participants might be shaped by forces beyond those raised in their accounts, and what this means for both future policy responses to PIED consumption and future PIED research.

Role of non-specialist nurses in supporting people who misuse drugs

In their practice, nurses are likely to encounter people who misuse drugs, but they may find it daunting to support these patients. While specialist drug treatment services have an important role in providing substitution treatment and talking therapies, referral is not always appropriate for some patients. Non-specialist nurses are well placed to use techniques such as brief interventions and motivational interviewing to engage patients in discussions about their drug misuse and prompt them to consider how they could reduce it. This article defines drug misuse, describes the contributing factors that can lead to it and its associated health issues. It also discusses how non-specialist nurses can manage and provide optimal support for patients who misuse drugs.

Neural imaginaries at work: Exploring Australian addiction treatment providers' selective representations of the brain in clinical practice

Although addiction neuroscience hopes to uncover the neural basis of addiction and deliver a wide range of novel neuro-interventions to improve the treatment of addiction, the translation of addiction neuroscience to practice has been widely viewed as a ‘bench to bedside’ failure. Importantly, though, this linear ‘bench to bedside’ conceptualisation of knowledge translation has not been attentive to the role addiction treatment providers play in reproducing, translating, or resisting neuroscientific knowledge. This study explores how, to what extent, and for what purpose addiction treatment providers deploy neuroscientific representations and discuss the brain in practice. It draws upon interviews with 20 Australian treatment providers, ranging from addiction psychiatrists in clinics to case-workers in therapeutic communities. Our findings elucidate how different treatment providers: (1) invoke the authority and make use of neuroscience in practice (2) make reference to neuroscientific concepts (e.g., neuroplasticity); and sometimes represent the brain using vivid neurobiological language, metaphors, and stories; and, (3) question the therapeutic benefits of discussing neuroscience and the use of neuroimages with clients. We argue that neurological ontologies of addiction, whilst shown to be selectively and strategically invoked in certain circumstances, may also at times be positioned as lacking centrality and salience within clinical work. In doing so, we render problematic any straightforward assumption about the universal import of neuroscience to practice that underpins narratives of ‘bench to bedside’ translation.

Great expectations: The bureaucratic handling of Swedish residential rehabilitation in the 21st century

Background and aims:

Increasingly, efforts to counteract perceived problems in drug treatment at residential rehabilitation centres have come to rely on measures drawing on evidence-based practice (EBP). However, the Swedish media, government inquiries, and international research have identified a number of problems regarding both residential rehabilitation and EBP. This suggests that caution should be exercised when placing expectations on EBP. The aim of this study is to investigate how the responsible authorities have handled increasing demands for EBP with administrative control while facing critical evaluations of their steering and implementation efforts. The study examines the maturation of a widespread treatment ideology, which aims to be based on evidence, in a country known for its restrictive drug policy and its goal of becoming a drug-free society.

Methods:

Through a qualitative textual analysis of 17 years (2000–2016) of inquiries, directives, and authority archives we have traced the interplay between problem descriptions, intended goals, and implemented solutions.

Findings:

The analysis shows that the ambition to provide care and welfare based on EBP is still an ambition. Also, the authorities’ control over the care actually provided still leaves room for improvement. Recurring criticism and the empirical material indicate that the expectations have not been met.

Conclusions:

We would like to suggest that continued frustration can be traced to the misconception that EBP is the opposite of values and ideology, and hence preferable. As drug treatment strives for scientific credibility to give it legitimacy, some types of “evidence” are preferred above others. We would like to suggest that we need to bring ideology to the fore, and openly discuss our restrictive policy goals and choices of “evidence”.

Drug and alcohol treatment providers' views about the disease model of addiction and its impact on clinical practice: A systematic review

ISSUES

Addiction treatment providers' views about the disease model of addiction (DMA), and their contemporary views about the brain disease model of addiction (BDMA), remain an understudied area. We systematically reviewed treatment providers' attitudes about the DMA/BDMA, examined factors associated with positive or negative attitudes and assessed their views on the potential clinical impact of both models.

APPROACH

Pubmed, EMBASE, PsycINFO, CINAHL Plus and Sociological Abstracts were systematically searched. Original papers on treatment providers' views about the DMA/BDMA and its clinical impact were included. Studies focussing on tobacco, behavioural addictions or non-Western populations were excluded.

KEY FINDINGS

The 34 included studies were predominantly quantitative and conducted in the USA. Among mixed findings of treatment providers' support for the DMA, strong validity studies indicated treatment providers supported the disease concept and moral, free-will or social models simultaneously. Support for the DMA was positively associated with treatment providers' age, year of qualification, certification status, religious beliefs, being in recovery and Alcoholics Anonymous attendance. Greater education was negatively associated with DMA support. Treatment providers identified potential positive (e.g. reduced stigma) and negative (e.g. increased sense of helplessness) impacts of the DMA on client behaviour.

IMPLICATIONS/CONCLUSION

The review suggests treatment providers may endorse disease and other models while strategically deploying the DMA for presumed therapeutic benefits. Varying DMA support across workforces indicated service users may experience multiple and potentially contradictory explanations of addiction. Future policy development will benefit by considering how treatment providers adopt disease concepts in practice.

Prehending Addiction: Alcohol and Other Drug Professionals' Encounters With "New" Addictions

This article investigates the ways new forms of addiction are encountered by professionals working in the area of alcohol and other drugs. Combining interviews with policymakers, service providers, and peer advocates in three countries (Australia, Canada, and Sweden), and Mike Michael's utilization of the notion of prehension for science communication, we track the notions of addiction, drugs, and subjectivity that emerge when alcohol and other drug professionals encounter what Fraser, Moore and Keane call the addicting of nonsubstance-related practices. The analysis has three parts: constituting addiction unity, questioning addiction unity, and conflicting logics of addicting processes. We argue that specific articulations of drugs and health and specific health professional and addiction subjects are made anew in these encounters. These notions of drugs, health, and subjectivity shape how alcohol and other drug professionals engage with substance-related addictions. In concluding, we consider the implications of new addictions for professional practice.

Ayahuasca's entwined efficacy: An ethnographic study of ritual healing from 'addiction'

BACKGROUND

A range of studies has demonstrated the efficacy of the psychoactive Amazonian brew ayahuasca in addressing substance addiction. These have revealed that physiological and psychological mechanisms are deeply enmeshed. This article focuses on how interactive ritual contexts support the healing effort. The study of psychedelic-assisted treatments for addiction has much to gain from ethnographic analyses of healing experiences within the particular ecologies of use and care, where these interventions are rendered efficacious.

METHODS

This is an ethnographically grounded, qualitative analysis of addiction-recovery experiences within ayahuasca rituals. It draws on long-term fieldwork and participant observation in ayahuasca communities, and in-depth, semi-structured interviews of participants with histories of substance misuse.

RESULTS

Ayahuasca's efficacy in the treatment of addiction blends somatic, symbolic and collective dimensions. The layering of these effects, and the direction given to them through ritual, circumscribes the experience and provides tools to render it meaningful. Prevailing modes of evaluation are ill suited to account for the particular material and semiotic efficacy of complex interventions such as ayahuasca healing for addiction. The article argues that practices of care characteristic of the ritual spaces in which ayahuasca is collectively consumed, play a key therapeutic role.

CONCLUSION

The ritual use of ayahuasca stands in strong contrast to hegemonic understandings of addiction, paving new ground between the overstated difference between community and pharmacological interventions. The article concludes that fluid, adaptable forms of caregiving play a key role in the success of addiction recovery and that feeling part of a community has an important therapeutic potential.

‘Naloxone works’: The politics of knowledge in ‘evidence-based’ drug policy

For over 20 years, drug policy experts have been calling for the wider availability of naloxone, to enable lay overdose witnesses to respond to opioid overdose events. However, the ‘evidence base’ for peer-administered naloxone has become a key point of contention. This contention opens up critical questions about how knowledge (‘evidence’) is constituted and validated in drug policy processes, which voices may be heard, and how knowledge producers secure privileged positions of influence. Taking the debate surrounding peer-administered naloxone as a case study, and drawing on qualitative interviews with individuals (n = 19) involved in the development of naloxone policy in Australia, we examine how particular kinds of knowledge are rendered ‘useful’ in drug policy debates. Applying Bacchi’s poststructuralist approach to policy analysis, we argue that taken-for-granted ‘truths’ implicit within evidence-based policy discourse privilege particular kinds of ‘objective’ and ‘rational’ knowledge and, in so doing, legitimate the voices of researchers and clinicians to the exclusion of others. What appears to be a simple requirement for methodological rigour in the evidence-based policy paradigm actually rests on deeper assumptions which place limits around not only what can be said (in terms of what kind of knowledge is relevant for policy debate) but also who may legitimately speak. However, the accounts offered by participants reveal the ways in which a larger number of ways of knowing are already co-habiting within drug policy. Despite these opportunities for re-problematisation and resistance, the continued mobilisation of ‘evidence-based’ discourse obscures these contesting positions and continues to privilege particular speakers.