Gathering Methadone Maintenance Treatment

2015

Our aim has been to explore the tensions and contradictions entailed in methadone maintenance treatment’s role within Western liberal societies, to consider the ways in which it attempts to produce the proper, law-abiding, autonomous, responsibilised subject ubiquitous to liberal discourse. As the preceding posts attest, these tensions and contradictions exist in abundance. Indeed, perhaps the most significant of the book’s overall themes is the way in which methadone maintenance treatment takes up and then confounds almost every familiar dualism in Western liberal discourse’s exquisitely interlinked series of binary oppositions. As we have argued throughout, addiction or dependence is one of liberalism’s most despised, and most necessary, creatures. After all, dependence is the concept against which the individual is produced. The elaboration of the binary relation between autonomy and dependence is one of the many operations of the concept of addiction, one partially undertaken by methadone maintenance treatment, although, as we have seen, holding this binary stable is no easy feat for this profoundly riven phenomenon. methadone maintenance treatment, then, can be seen as a point of condensation through which a whole range of interrelated dualisms flow, ostensibly led, or perhaps compelled, by the intensely political dualism, dependence/autonomy In the process, these dualisms and their demands shape this site of condensation itself.

Of course, in exploring this central question ― precisely how, and to what effect, methadone maintenance treatment and liberal discourse/society co-exist ― we have also examined a multitude of circumstances, objects and issues related to treatment, and to the experiences of clients, staff and others. By considering in turn some of the major dualisms at work in treatment, and their relation to each other, it is possible to draw out many of these circumstances and experiences. For, while our interest is in the intra-action between the concepts operating in methadone treatment and in Western liberal thought, it is also, overwhelmingly, in the material implications of this conceptual intra-action for people and their daily lives.

The dualisms most commonly encountered in the material collected for this book are:

Autonomy Dependence
Drug free Drug addict
Masculine Feminine
Subject Object
Active Passive
Discourse Matter
Reality Representation
Originality Repetition
Real Replacement

As we have seen (and notwithstanding the apparent order implied in the rather too-neat columns employed above), while these always hierarchically valued dualisms operate in powerful, often intensely disciplinary, ways in methadone maintenance treatment, they are also fundamentally disrupted by it. The autonomy/dependence binary is perhaps the most obvious example, in that, as we saw in the Introduction and in later posts, autonomy is a prime value of liberalism, and while methadone treatment allows clients a degree of autonomy from the demands of an illicit drug-using way of life, it simultaneously imposes a regime that is equally, or more, controlling. As we have seen, autonomy is little more than a fantasy for clients, and this is the case for liberal subjects in general. While clients must shift to daily dosing, and to following the directives of staff, staff themselves are by no means autonomous. They must attend to guidelines and procedures, must answer to others. Our observation here is not a criticism ― we do not present autonomy as an ideal, realisable or otherwise. Instead, we register its elusiveness, and also its questionable merit. We are not the first to note that autonomy is a curious ideal, denying, as it does, the richness and productivity of relation, the inevitability of connection and contingency. As methadone maintenance treatment figures so nicely, there is no way to move into autonomy. Such moves can only take place from one kind of dependence to another. From this point of view, a new question arises: How can we shape and sustain rich, productive forms of dependence?

Equally central to the operations of addiction and drug treatment mapped in this book is the dualism masculine/feminine. As we saw in Substitution, Metaphor and Authenticity, this dualism, and its accompanying denigration of the feminine helps shape public discourse on drug use and drug treatment, in particular through the status of metaphor as feminine, and the status of methadone as itself metaphor. These associations co-produce equally denigrating understandings of drug users and treatment clients, understandings that mirror femininity’s central paradox: the requirement to gain full legitimacy within Western liberal institutions and thought and the concomitant impossibility of doing so. The operations of gender within understandings of drug use and drug treatment come up again explicitly in Repetition and Rupture: The Gender of Agency, where the asymmetrical treatment of male and female clients is described, and the associations and reflexes behind this differential treatment are explored. In between these two posts, however, gender runs as an undercurrent through the phenomena discussed. The links between dependence and femininity within Western thought are robust if often implicit, and these inform the related notion, for example, that drug users require guidance from benign but firm paternal figures (the prescriber, the pharmacist).

In thinking through gender, of course, other associated dualisms emerge. As the link between femininity and metaphor is identified, for example, broader links come into view, such as that between femininity and passivity and repetition. All these terms incorporate the notion of dependence. As femininity is defined as dependence against masculinity’s autonomy, passivity against masculinity’s activity, repetition against masculinity’s originality, it is conceived as intrinsically reliant upon masculinity to provide or provoke those elements of originality, of activity, of autonomy. Within treatment, these links perform, as noted above, in terms of a paternalistic relation. Yet this paternalistic relation does not limit itself to those effects described already. Its implications are, of course, further reaching. Respect (in either direction) between providers and clients is difficult to sustain under conditions of paternalism, and some of the least complimentary images of treatment included in this book can be directly related to the question of what happens when a paternalistic approach comes to be materialised in day-to-day treatment. Indeed, in that drug dependence and treatment tend to feminise all clients (male or female ― albeit in different ways), this materialisation is not focused solely on women clients. Here we are thinking, for instance, of the fortress-like dispensaries; of the poorly explained, arbitrary-seeming treatment decisions; and of the unilateral curtailment of takeaway ‘privileges’. Some instantiations of this link found elsewhere are even more troubling, such as in the US where blind dosing is an accepted practice.

While methadone maintenance treatment operates through these intensely political binaries, it also, however, confounds them, or at least, helps us think differently about them. Substitution, Metaphor and Authenticity reminded us that the representation of methadone maintenance treatment in the media is neither intrinsically good nor intrinsically bad: it is a mechanism for co-producing ideas of drug use, and the materiality of treatment itself. In this sense, and following Barad, the representation/ reality dualism is of limited analytic utility. On a different note, as we saw in Governing Treatment, service providers are not clients’ polar opposite: they share something important with clients in that they describe enduring frustratingly paternalistic relations, in their case with regulators. Thus, mapping power here must be undertaken carefully so as to recognise these complexities without flattening power relations. Again taking a slightly different tack, as Treatment Identities showed, treatment undeniably limits the freedoms of clients but it also enables the production of a range of new identities, and these come both from above and below. More broadly, methadone treatment does, of course, confound autonomy/ dependence, intoxication/sobriety binaries, and in this sense it has been a radical innovation. At the same time, as we have already noted, this disruption of binaries, in particular the latter, does not go unpenalised. It is part of the reason why both methadone maintenance treatment itself and its participants remain marginalised and unable to establish social legitimacy. Nevertheless, it would be a mistake to see methadone maintenance treatment as merely a materialisation of hegemonic dualisms. It has a disruptive, excessive quality that means that, despite many of the indignities and privations associated with it, it cannot be dismissed as merely repressive.

Indeed, methadone maintenance treatment is such a sprawling, contradictory phenomenon that the question that appears at the outset of this conclusion is probably slightly misconceived. We asked, what kind of problem throws up methadone maintenance treatment as a solution? The multifarious, contradictory character of treatment would suggest that it is a series of partially overlapping problems that has thrown up this solution, rather than a single, clearly articulated one. Perhaps, then, it is possible to say that methadone maintenance treatment exists, that, at least in Australia it is growing, some would say thriving, because it responds to a confusion of problems centred on heroin and other opiate use. This confusion cannot quite reach univocality on central questions such as the value of abstinence, the reality of autonomy, the legitimacy of individual responsibility, the merits of conceiving drug use as disease, and clients as ill, the extent of the gap between the respectable ‘us’ and the marginal ‘them’. In this confusion, in this ‘mess’ as Law might put it, lies most of the scope ― most of the potential for becoming otherwise ― of methadone maintenance treatment. This, of course, is no small, no insignificant, claim. What does it mean to describe methadone maintenance treatment as confusion or mess, to focus on its contradictions, and, it must be said, on its shortcomings, as we have done at times in this book?