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“They Medicated Me Out”: Social Flesh and Embodied Citizenship in Addiction Treatment

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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.
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“They Medicated Me Out”:
Social Flesh and Embodied Citizenship in Addiction Treatment
Allison V. Schlosser
Case Western Reserve University
Department of Anthropology
Cleveland, Ohio 44106, USA
avs29@case.edu
Contemporary Drug Problems
DOI: 10.1177/0091450918781590
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 psycho-pharmaceuticals are now commonly used to
treat addiction alongside longstanding approaches such as 12 Step mutual aid. These biomedical
interventions re-shape 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
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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 re-assert bodily connection and control, deriving a
modicum of power—albeit constrained and risky—in a treatment system that strictly limits it.
Keywords
Biomedicine, Medication Assisted Treatment, Embodiment, Social Flesh, Social Citizenship,
Agency
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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.
(Michael & Rosengarten, 2012, p. 7)
Lola
February 2, 2015
“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.”
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 percent (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 (ODH, 2015). Meanwhile, clients entering treatment with a primary
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diagnosis of opioid dependence have increased dramatically (Massatti, Beeghly, Hall, Kariisa, &
Potts, 2014).
As opioid-related problems intensify, policymakers and advocates have promoted
medication assisted treatment (MAT) with greater urgency (Volkow, Frieden, Hyde, & Cha,
2014). Ohio policymakers have made efforts to increase access to MAT, including the expansion
of Medicaid publically-funded healthcare 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 longstanding
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 A. Jamie 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 re-shape 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 post-industrial city in northeast Ohio where I conducted
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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, peers, and parallel healthcare, social services, and
criminal justice systems co-exist 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 re-imagined, 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
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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 re-assert 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
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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 longstanding 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 co-exist. 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
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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 socio-political inclusion, re-conceptualizing 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 non-state institutions and political
cultures (Good, Fischer, Willen, & DelVecchio-Good, 2010; Nguyen, 2010; Ong, 2006).
Nicholas Rose and Carlos 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 de-contextualized
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). Anne
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).
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Suzanne Fraser and Kylie 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, stable/chaotic.
Instead, they emphasize that the agency of “addicts” is often obscured by structural explanations
and narratives of drug user “disobediencein which gendered assumptions about “the malign
agency of (some) men is foregrounded, and that of women is backgrounded” (Fraser & Valentine
2008, p. 162). Tammy 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; Walmsley, 2016; Vrecko,
2016). Fay 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). Ian 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.
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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). Mike Michael and Marsha 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 inter-action. Through this lens, medicine co-
produces 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).
Chris Beasley and Carol 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, 2002, p. 324). 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
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call for greater attention to bodies in feminist citizenship studies, and to the political and social in
feminist studies of the body (Beasley & Bacchi, 2000). 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)
This concept foregrounds intra-acting material and embodied subjects, linking analyses of bodies
with analyses of citizenship.
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.
Methods
This research is based on person-centered ethnography (Levy & Hollan, 1998) conducted in and
around Sunrise, a publically-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
three to four 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 percent Euro-American and 25
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0
percent African American. At least 90 percent 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 sub-sample of 10 clients purposively selected
to balance gender, race, and age. Fieldwork with clients in the sub-sample 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 sub-sample 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
(Registration Number: IRB00000683). The program and all participant names are pseudonyms to
protect client confidentiality.
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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 sub-sample 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 Nancy
Campbell and David 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 publically-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
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(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 re-assert 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 Step 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).
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At Sunrise, sleeping, eating, group participation, and even free times are at once strictly
scheduled and inconsisent. This institutional temporality is a mix of over-scheduled and empty
time that Amy Cooper (2015) argues threatens clients’ sense of dignity and humanity. Clients are
required to wake up and sign in for the day at 6:30am and must stay in their rooms after
10:30pm. Medication dosing times, three times a day, are strictly scheduled with significant
conequences 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 cancelled or delayed
with little or no notice, leaving clients with unexpected free time with 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 cancelled 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).
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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 also 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
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children, 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 re-made 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.”
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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 [sic] 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.
While Bev sought grounded-ness in her body through drug use, the ways her body and affective
experiences were entangled with drug use challenged her attempts to stop using illegal drugs.
The experiences, intertwined with bodily sensations, that she enjoyed in daily life during drug
use threatened her abstinence. Her love of music, in particular, became a “trigger” for use:
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.
These (dis)embodied experiences underscore clients’ close body connection established through
drug use practices.
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At Sunrise, the 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.
Yet she felt her experiential, embodied knowledge of drugs and their effects was disregarded by
the physician. “I know me. I’m a hardcore heavy,” she stressed, as she described her tensions
with the doctor:
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.
Debates over Bev’s buprenorphine dosage continued as she moved out of Sunrise and into a
transitional housing program. During this period, she was kept at 16 mg of Subutex by the doctor
despite reporting continued withdrawal symptoms and requesting an increased dose. As she
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experienced the stresses of transition to everyday life outside of Sunrise, Bev reported
heightened anxiety and withdrawal symptoms and requested a dosage increase with added
urgency. When the physician responded that she was at an appropriate dosage, she felt her bodily
and experiential knowledge was being disregarded. The stresses in Bev’s life mounted after she
left Sunrise: she ended her relationship with a partner of ten years, her children struggled with
troubled romantic relationships, a roommate at the “sober house” where she lived returned to
heroin use, and she struggled to access care for her mental health. She feared she would soon
return to heroin use to ease her anxiety and buprenorphine withdrawal symptoms, and be “cut
off” from the medication entirely.
Intersubjectivity and Estrangement
Bev’s case highlights some of the ways Sunrise clients experience medication in a “social grid”:
an inter-subjective matrix of formal and informal social networks—from counselors and
physicians to peers and kin—that co-produce 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 “co-
dependent” 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 inter-dependency central to alternative socialities that form
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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 YMCA and games of kickball in warm
weather—this was logistically complicated and inconsistent. Common medication regimens such
as poly-pharmacy and anti-psychotics2 with the known side effects of weight gain and sedation
amplified these problems.3 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 anti-psychotic medications due to their stigmatised 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 (anti-psychotic) 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
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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.
These practices reflect “pharmaceutical confidence” (Jenkins, 2010) intra-acting with practices
of self-modulation via drug use common in “the Life,” where medications were distributed
through the underground economy in which people “doctor themselves” (Schlosser & Hoffer,
2012).
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 “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
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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.
Like many of the other women at Sunrise, Lola was accustomed to closely controlling her weight
with amphetamines and other (il)legal drug use (e.g., over-the-counter diet pills). She also used
her body to survive through poverty by exchanging intimacy and sex for essential resources.
Lola experienced her body in relation to forms of exchange and inter-dependency in “the Life” in
ways that facilitated her survival, and also provided her with a sense of social connection as she
maintained friendly relationships with some of the men involved in these exchanges. In
treatment, she became alienated from these aspects of her body, sociality, and self. She wished
she could, in her words, “take my skin off and hang it up and put it on somebody else’s.”
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—
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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.4 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 in Sunrise:
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.
Methadone is often understood through the metaphor of “liquid handcuffs,” with people who use
drugs describing those taking methadone as prisoners to the legal drug in a “battle” against
addiction. Lola’s case reflects an extension of this metaphor, showing how being “medicated
out” is akin to being a prisoner to one’s own incapacitated body. Fraser and Valentine (2008)
argue that “these metaphors have significant implications for the materialization of methadone as
substance” (p. 50). At Sunrise, the medication experiences of treatment peers, and the stark
metaphors that emerge in response, contribute to the materialization of medications, including
but not limited to methadone, as instruments of control in this institutional setting that strictly
delimits client agency.
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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.
Lola became a social pariah and a common topic of discussion among treatment peers. Some saw
her experience as a cautionary tale against allowing oneself to become dependent on “candy
man” doctors and others who watched her “nodding out” in groups wondered if she was “drug
seeking” and enjoying the sedation. Still others feared they themselves would be tempted to seek
sedation in this way and questioned starting medications (MAT or psychiatric).
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 did
clients draw on their bodies in efforts to enact agency, seek social belonging, and survive, within
the highly constrained environments in which they live?
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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 healthcare. Specifically, she quietly refused certain psychiatric medications
based on her embodied knowledge of their effects.5
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 re-start 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
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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 the
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 agencies6, 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:
Lola: 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.
Interviewer: Why? Did you ask them why?
Lola: 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
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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
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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 longstanding 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 system,
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
potentializes 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 pre-existing oppositional subjectivities in relation to formal institutions and leave people
dependent on underground economies for survival and social inclusion (Bourgois & Schonberg,
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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 co-produced 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
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with a history of illegal drug use.7 Like Lola, Bev resorted to risky agency in the underground
economy when alienated from formal healthcare. Both women’s bodies, inscribed by
processually constituted social positions, emerged anew through these processes.
Lena 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. (Gunnarsson, 2017, p. 119-120).
From this lens, I argue that the experiences of Bev and Lola emerge from stable systems of
inequality based in intersectional gender, race, and class marginalization entangled with
processes of intra-action.
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
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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.
Conclusions
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 longstanding 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.
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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 socio-economic
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
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bodily connection and efforts toward bodily and social survival, and not simply as “non-
compliance.” 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 overdoses 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.
Acknowledgements
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 and Eileen
Anderson-Fye. Finally, I thank the anonymous reviewers of this article for their constructive
feedback.
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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.
1 MAT induction in the first 30 days of the program was a regular practice because residential
treatment is a common agency prerequisite for MAT access, particularly when clients are unable
to access safe, stable housing.
2 Kelly Ray Knight (2015) proposes “addict time” – a temporality structured around patterns of
drug use – in contrast to alternative temporal frames such as “pregnancy time,” “jail time,” and
“biomedical time.” Helen Keane (2002), however, cautions against the, “distinction between the
disordered temporality of addiction and the natural, unthreatening passage of normal time” (p.
105). Fraser and Valentine (2008, p. 97) similarly critique this dichotomy as reinforcing
stigmatizing distinctions between drug users and non-drug users.
3 This experience echoes what Antonia Lyons, Carol Emslie, and Kate Hunt (2014) found
regarding women’s experiences of alcohol use: “The participants positioned themselves as
experienced drinkers who, through accumulated knowledge of their own physical bodies, could
achieve enjoyable bodily sensations by reaching a desired level of intoxication (being in the
zone). These mid-life adults, particularly women, discussed knowing when they were
approaching their limit and needed to stop drinking. Experiential and gendered embodied
knowledge was more important in regulating consumption than health promotion advice” (p.
264).
2 The most common psychiatric diagnosis given to clients by the program psychiatrist was
Bipolar Disorder, often treated with anti-psychotics. Anti-psychotics were also prescribed by the
psychiatrist when clients reported trouble sleeping, a very common experience when clients
transition to this institutional setting.
3 See Janis Jenkins & Elizabeth Carpenter-Song (2008) for a detailed examination of the stigmas
and dilemmas people experience when treated with psychiatric medications for schizophrenia-
related illnesses (e.g., the choice between being “fat or crazy”).
4 Counselors expressed frustration with client sedation in groups, and concern about clients’
psychiatric medication treatment and MAT. They sometimes attempted to help clients
communicate concerns about medications to the psychiatrist, but also reported little ability to
influence these situations based on their role within the structure of the treatment program.
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5 Soon after leaving Sunrise, she stopped taking all prescribed psychiatric medications.
6 Felony drug charges also prevented her from qualifying for some housing.
7 See Rebecca Tiger (2017) for an examination of the limits of class privilege in the U.S. opioid
epidemic.
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Author Biography
Allison V. Schlosser is a doctoral candidate in medical anthropology at Case Western Reserve
University in Cleveland, Ohio. She earned a bachelor of science degree in psychology from the
University of Illinois Urbana–Champaign in 2002 and a master of social work degree in gender,
health, and community practice from Washington University St. Louis in 2007. She has
conducted research on the sociocultural and political–economic dynamics of drug use and related
interventions for the last 10 years, using ethnographic methods to examine residential treatment,
community-led prevention, and harm reduction programs. She is currently completing her
dissertation, Subjectivity and Moral Personhood: An Ethnography of Addiction Treatment in the
U.S., examining the moral politics of treatment for drug dependence, as cultural understandings
of “addiction” and beliefs about appropriate intervention are in flux.
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