“The definition of methadone maintenance as “drug treatment” is a particularly concrete example of biopower at work. The state and medical authorities have created distinctions between heroin and methadone that revolve primarily around moral categories concerned with controlling pleasure and productivity: legal versus illegal; medicine versus drug. The contrast between meth- adone and heroin illustrates how the medical and criminal justice systems discipline the uses of pleasure, declaring some psychoactive drugs to be legal medicine and others to be illegal poisons. Ultimately, it can be argued that the most important pharmacological difference between the two drugs that might explain their diametrically opposed legal and medical statuses is that one (heroin) is more pleasurable than the other (methadone).”
- DISCIPLINING ADDICTIONS: THE BIO-POLITICS OF METHADONE AND HEROIN IN THE UNITED STATES, Phillipe Bourgois, 2000 (x)
originally posted by @bioethicists
POLITICS OF OPIOID MAINTENANCE: PLEASURE, PROHIBITION, SURVEILLANCE & CONTROL, a revised response/extended commentary. Avi Yocheved, 2021.
in “Disciplining Addictions”, Bourgois discusses Pleasure vs. Medicine: one of many binaries that guide our cultural understanding of replacement/maintenance therapies for opioid addiction. whatever you call them: binaries, dichotomies, double standards- as a woman whose body and behaviors have often been classed as troublemaker, junkie, addict, non-compliant, treatment failure… these conflicted frameworks have always been fault lines underneath my feet, troubling any sense of stability or “recovery” I have sought to carve out for myself. chemically and psycho-socially. regardless of my resilience, self-advocacy or desire to thrive, these frameworks are used to dismiss me as my own enemy, and remove my agency.
additionally, as a harm reductionist whose advocacy walks a fine line between formally hired peer support worker and drug user rights agitator, I interact with hundreds of community members forced to stand on those same fault lines.
in this commentary, I will explore the other dichotomies that exist alongside/entangled with “pleasure vs. medicine”, and how they dictate our society’s understanding of (and policy around) heroin versus methadone. drug versus medicine. sickness versus cure.
1. Legal vs. Criminalized
drug laws do not respond to the realities of drugs, they create them. chemicals exist in nature, but the ways we corral and police them shape their risk profiles, as well as the relationships we form with using them. Legal vs. Criminalized is a binary that should be at the top of the list in order to understand differences between heroin & methadone. it is what makes methadone a “solution” to the “problem” of heroin in this conversation.
to go any further in discussing maintenance medication, myself + readers must share knowledge of certain realities about “problematic,” “chaotic” or “disordered” opioid use. drug dependencies, especially ones that become chronically problematic, are heavily influenced by environmental and systemic issues.
people who use opioids habitually or compulsively are usually responding to their environment in some way: collective trauma, like marginalization/oppression. individual trauma. pain. unmet needs. isolation. resource deprivation. for a portion of people, opioids don’t feel like occasional medical or recreational tools, the way they might for people who have developed with more consistent access to various kinds of respite and pleasure. instead they feel like a revelation. a lifeline. people in this position begin to take them frequently, often at any risk or cost.
like any class of drug, opioids do have natural risks. however their biggest risks are largely preventable, and appear through prohibition and policing. a chaotic street supply. a lack of practical risk reduction education. social isolation and stigma. medical and other resource disparities. a lack of trauma-informed care, or any sort of healthcare that acknowledges systemic impacts on health… a society that could be working to reduce the risks of opioid use, instead throws it into a pressure cooker.
all these things lead to negative feedback loops. systems of oppression impact our wellbeing, leading us to encounter drugs in more desperate ways. risks + health problems increase. the drug supply itself is made more risky by criminalization. resources that might prevent or reduce risk, are criminalized, stigmatized & generally discredited, and deprived of funding. all this suffering leads to even more relief-seeking and compulsive or “problematic” use. all of this is blamed back on two main places. the drugs, and us. the drugs must be innately evil, and some of us must have innately broken or diseased biology. this blame becomes fuel to continue the same harmful prohibitionist policies. the cycle continues.
a large number of people use opioids for years amidst these vicious cycles. this affects them physically (including neurologically), psychologically, developmentally, and socially.
this goes beyond a simplistic brain disease model. I myself resent being labeled with an Opioid Use Disorder, while the broken systems that once put my relationship to opioids in a desperate space aren’t labeled as disordered. but these patterns do leave a long term impact on our behaviors and wellbeing.
it is possible to emerge out of these harmful patterns via total abstinence. but some people find this incredibly difficult, especially in the absence of other social supports, and under the same oppressive and resource-deprived conditions. others simply do not measure their healing process in terms of rigid abstinence.
so we seek maintenance medication to stabilize. either short-term, while adjusting to life with no (or less) illicit use, or long-term. maintenance medication allows us to build new patterns and habits, even if we are unable to face a lengthy and grueling detox process that may affect our chemistry for months to years.
maybe most importantly, maintenance meds allow us a degree of freedom from those vicious cycles of criminalization.
before I dig too deep, I want to note that I will absolutely speak on the limitations and injustices of the methadone clinic system. but first, I want to explore the benefits of the chemical itself as a tool, especially as it relates to escaping high-risk realities of drug prohibition.
for many, methadone means no more living in constant scarcity, knowing for once that we won’t have to be dopesick today. no more constant overdose risk, consuming something immeasurable without an ingredients list. no more infections from dirty cut, or being thrown out of hospital waiting rooms for being “drug seeking” while trying not to die of sepsis. no more struggling to find sterile supplies and sterile environments to use. less risk of being thrown out of housing. the potential to get a job in the “straight” world that we might have been barred from while actively using street drugs… the list goes on and on.
this emancipation is especially life-saving for people who are trying for abstinence/sobriety from illicit opioids, whether this lasts months, years, or a lifetime. many people who stop using will return to use sometime in their life. no matter for how long, how chaotic or controlled that use is, or whether they consider it a relapse or not - returning to use under the conditions of prohibition can be risky and vulnerable. the illicit supply has created an overdose epidemic. when our tolerances have been reduced to nothing by intentional or unintentional (jail, probation, hospitalization) sobriety, picking up a bag of street dope with no way to confirm the potency or ingredients is a major gamble. to top it off, fear of stigma, incarceration, loss of housing, loss of employment, loss of family, etc., leads us to use alone.
into this grim landscape, methadone shines a startlingly bright light. research on patients diagnosed with Opioid Use Disorders found that methadone prescriptions cut overdose rates by 59%. not even taking into account other protective harm reduction resources that could be added on top of it- even methadone by itself reduced the number of fatal overdoses in patient cohorts by maintaining them on a regulated opioid as they went about their lives.
but here is where the next troubling question comes in. if we understand that the primary magic/medicine in methadone is simply stability, regulation and consistency… why couldn’t less adulterated, more consistent heroin (and other opioids of choice) be helpful in the same way to active users? wouldn’t that save lives too, and if so, why don’t we have greater access?
here lies the false dichotomy being named in Bourgois’ writing.
a safer opioid supply would indeed answer parts of the same public health mandate as methadone. overdose prevention. stability. reduced interaction with the “criminal” world. less collateral health damage.
HAT- Heroin Access Treatment/Therapy- grew out of places like the Netherlands, Switzerland and Liverpool, and has been studied selectively in Canada as well.
the data from these programs has been consistent with the rest of the evidence on maintenance meds such as methadone and buprenorphine (suboxone/subutex). on medical grade heroin, patients’ lives stabilized. overdose risk fell. patients readily made a variety of self-effective changes to their lives, and accessed an array of other community resources, which the HAT clinics referred them to. some reduced their drug use. others eventually stopped completely. others still, used more safely and without major consequences.
yet these miraculous results have been dismissed, mocked, or almost worse, met with resounding silence, especially in parts of the world most heavily influenced by the US’ War on Drugs. when American Harm Reduction activists discuss “Safe® Supply” initiatives, even highly medicalized ones, the conversation becomes downright hostile.
by anyone’s definition of treatment, medicine, or intervention, the data on HAT should be seen as a resounding success. providers bearing witness to the cresting death toll of our current overdose crisis should be rushing to cut the ribbon on HAT clinics. but heroin feels good. heroin gets you higher. no amount of positive data can penetrate the stubbornness of an America that would rather see us dead than high.
less medicalized Safe Supply initiatives are treated with even more scandal and controversy. one example is BC’s Drug User Liberation Front, and their buyers/compassion club model. DULF pools the knowledge and tools of seasoned drug user rights activists, such as online sourcing and drug checking machines, to test and provide the “cleanest” heroin, meth, and cocaine available from within existing underground markets to other local drug users. their compassion club model is complete with labeled ingredients and percentages, and sliding scale prices.
every so often, on a local day of awareness or action, DULF brings their model into the public square in a show of carefully planned civil disobedience. in response to the refusal of our culture to see treatment or medicine as compatible with pleasure, DULF takes their Safe Supply movement out of the framework of treatment completely. instead, it frames its actions as a defense of civil liberties and bodily autonomy.
the refusal of our communities to make space for this conversation on any level presents a big problem. no matter how many people dismiss it, there is a whole population not being reached by traditional maintenance spaces like methadone clinics. people who use drugs don’t wish to have our bodily autonomy taken from us. we struggle to meet near-impossible standards of patient compliance. and yes, we want our pleasure.
to be fully transparent, methadone is a full opioid receptor agonist, and provides more potential pleasure than other maintenance options. most clinic patients have too much of a tolerance to catch a buzz, but it is possible to get high on an amount that surpasses your maintenance dose. the myth that no one is catching a nod on methadone is a defensive exaggeration, mainly to pacify those who believe the drug should not exist.
but setting that confession aside, it is far easier to get pleasure out of heroin and other opioids. and that means everything, especially to people whose lives have been chronically deprived of rest and pleasure. if recovering from chaotic use means being forbidden from a beloved source of rest and pleasure, even under safer circumstances, many of us find that to be too great a loss. we forego resources we otherwise may have been willing to try. you will never find us in a clinic waiting room.
also falling through the cracks in maintenance treatment options, are people who feel left behind by addiction or substance use disorder (SUD) labels in the first place. our drug use doesn’t line up with that pathologizing definition, but we are still at high risk for things like overdose under the conditions of prohibition.
similarly, there are people whose use could be called problematic at one point or another, but we resist diagnosis, and anything having to do with the words “treatment” “rehabilitation” or“ recovery.” this relates intimately to the indignity and trauma endured within the treatment world. I will always say, until the cruel institutions that shaped my behaviors are diagnosed as terminally disordered, I refuse to be.
the needs and desires of those of us falling through the cracks are not so unreasonable. we want to begin healing in various areas of our lives without ultimatums. we want to take our preferred substance(s) in our own spaces, socially or privately. we want to choose our method of use, and our dose. and we want our substance to feel good.
again, even just from a limited public health view, it would make sense to offer other opioids to populations disinterested in methadone and buprenorphine for these reasons. shoring up that gap in resources would save thousands of lives. but as I have already begun to unpack, the pleasure/medicine dichotomy restricting maintenance treatments is entangled with an even more sinister one:
social & medical coercion, policing + surveillance.
this is another piece of that puzzle: what makes a methadone clinic (tenuously) “okay”, and not clean heroin clinics or Safe Supply buyers clubs? along with our pleasure, institutions that police us reject any situation where we can control setting, dose, reason for use, privacy, etc. for ourselves.
now it’s time to talk about the clinic system.
earlier I listed lifesaving functions of methadone, the chemical itself. but the spaces that dispense it come with all the red tape, surveillance and abuse in the world.
under the watchful eye of drug war architects like the DEA, methadone clinics tirelessly surveil you. they take your urine. some try to pass it off as overdose prevention, but more people would participate in overdose prevention strategies if they could sit down with their clinician and be honest about other substances they may use.
clinics are full of physical and social barriers. they try to act not just as dispensers of medication, but “reality checks” teaching “addicts” to “function in the real world again.” patients are held to draconian expectations: showing up to the clinic at 5 in the morning even if you live two hours away. wearing business casual, of course. it punishes poverty, and all expressions of personal agency. it labels those things “non-compliant.” “treatment resistant.”
the punishments are medical in nature. if you piss “dirty”- for any drug regardless of legality or reasoning- your dose might get lowered. if you show up late, your dose might get lowered. if you don’t consent to a urine screening, or simply can’t pee… your dose might get lowered. if your bus is late. if your mom died. if your job schedules you during the clinic’s only hours. if you wear the wrong clothes. if you criticize your counselor. if you miss a payment. in fact, you might get kicked off the clinic entirely for any of those things.
here too, you will find vicious cycles.
a methadone patient uses heroin once. it shows up on a piss test, and her dose is cut. she finds herself experiencing restless legs, bone-deep pain, nausea, insomnia… withdrawal symptoms. she uses more heroin to get well, so that she can get through work without puking and spasming. her dose is cut again. eventually she finds herself kicked off the clinic and back on the streets. she is told that she “failed” her course of treatment, and is mandated by drug court to an abstinence-based rehabilitation program which will bill her for thousands of dollars. the rehab tells her that methadone was only there to “enable” her anyway, then kicks her on to the streets again, poorer and more vulnerable, hurting physically and emotionally, with a lower opioid tolerance. if she uses again, her overdose risk is through the roof. she will have to crawl back to the clinic, and claw her way back up to a half-human dose, to regain even some of the benefits of a medication that could very well save her life if the barriers weren’t hell-bent on killing her.
methadone is a tool reserved for patients who are willing to comply with every social, political and medical mandate that our culture foists on to people who use drugs. even the most compliant patients are bound to be punished eventually, for something outside their control.
even within the complex world of maintenance med options, the hierarchies and dichotomies I have been exploring in this piece replicate themselves with alarming tenacity and antipathy. providers and patients alike hold fierce biases, and blame each other for the harm being inflicted on them by the same overarching institutions.
some proponents of buprenorphine (suboxone) look over at the clinic system like a flaming wreck on the side of the highway. they wonder why anyone chooses methadone over bupe at all. bupe can be dispensed from (some) pharmacies instead of a clinic. bupe can be taken at home, although some degree of clinical surveillance still comes with the package. bupe even has a lower risk of accidental overdose.
but just like methadone doesn’t “work” for every heroin user, bupe doesn’t either. as one of my mentors put it once, bupe didn’t “click” with her the way methadone did. methadone also has a wider therapeutic dose range, and less risk of precipitated withdrawal when transitioning back and forth from the street supply, due to bupe’s partial agonist chemistry. additionally, steep race and class disparities exist in accessing bupe, or physicians/clinics with the power and willingness to prescribe it. for these reasons and more, many people fight day after day to keep their head above water within the methadone clinic system.
all this goes to show, there are many reasons why maintenance patients are deemed “non-compliant.” and while the world of treatment reform may be ready for critiques of clinics’ punitive measures toward factors outside patient control, it seems less ready for a conversation about autonomy. the rights of patients deliberately not complying.
when a clinic patient chooses to use street opioids, it is completely delegitimized. cast again as a symptom of their disease. in reality, there are many legitimate reasons why someone might choose to access the illicit supply while on methadone.
one is fear of the punitive nightmare I described above. at a certain point, the stabilizing benefits of methadone are outweighed by the trappings of the institution.
another, once again, is pleasure. methadone can be someone’s pragmatic maintenance, reducing the amount of interaction they have with illicit supply. but they may still want to encounter opioids in a pleasurable way. in a ritual way. I know many clinic patients who take their morning dose, and later enjoy an evening shot, or line, or foil. they don’t have to contort their life around street use, but can opt into it at times.
this often goes unrecognized as a genuine middle ground between total abstinence and totally chaotic/compulsive use. a middle ground which actually describes a good portion of the opioid-using population. wanting stability, wanting to recover from more chaotic use, but still feeling attached to certain rituals and experiences. the positive changes this subgroup of patients makes to their lives are unfairly dismissed.
I fall into this category myself, although less traditionally. I have resisted being on a clinic because of the medical and social policing that happens there. as a harm reduction worker, I have followed some of my needle exchange participants through the clinic doors as a peer advocate, but I have never taken a medically sanctioned dose myself. I buy diverted methadone sometimes (another concept that can raise a room full of stern eyebrows), to lessen having to interact with the street supply OR the clinics. I also make use of kratom at times, as a similar tool. I still retain my ability to use more potent and euphoric opioids when I want to, but having options for stability has changed the ways in which I do that, and reduced the risks I have to navigate.
I am not so different from my father, who stopped drinking chaotically after college, but still has drinks on occasion. he also happens to take medication for anxiety, which interacts with similar receptors in the brain to alcohol. this undoubtedly sheds some insight into his prior reactive/compulsive alcohol use. similar context, different drug(s) of choice. different stigmas, different baggage. my father can tell his story in many rooms where I cannot tell mine.
at the end of the day, most of us, even leftists, were not taught language to talk about substances (or any behavioral health), outside of carceral punishment or pathology/diagnosis.
the following are frequently asked questions that arise in conversations (out loud or implicitly) about methadone, and other maintenance medications. I will try to answer them outside of carceral OR pathologizing lenses.
Q: can methadone be used recreationally? (connotation: “this would be bad and ruin the therapeutic benefits”) / why should we accept something as “treatment” or therapy if it can be used recreationally in any way, or is related to the same drug a person was having problems with?
A: yes, it can be. methadone is an opioid agonist, it does produce opioid effects. recreational effects would be rare for someone who is already opioid dependent. for most clinic patients, methadone is medicinal with their tolerance. but no, the slight potential for a “high” at certain doses, even for opioid dependent patients, does not necessarily ruin the therapeutic benefits.
the “disorder” within so-called disordered opioid use is NOT the desire for pleasure. problematic patterns start with an attempt to meet urgent needs. a large part of the chaos that ensues comes with the conditions people are forced to use under. prohibition, resource deprivation, etc.
some of the most important therapy methadone has to offer as a tool is stability. transparency re: ingredients and dose, and consistent access. these things can stabilize them long-term, or in early “recovery”- whatever that means to them- as they are working on other change processes.
which means yes, access to other “clean” opioids, including heroin itself, also have therapeutic potential for people with past problematic use. not every person wants this, and some prefer and thrive better with total opioid-abstinence. but none of these tools should be discounted.
Q: what should happen to people when they use other drugs on methadone/maintenance meds?
A: anyone in a medical or advising role should build a relationship on trust and confidentiality. not only should surveillance-as-punishment end, but patients should feel safe coming to advisors up-front, not the other way around, to ask advice on things like overdose prevention. people who are threatened don’t cease a behavior, they hide. overdose risk skyrockets when people hide.
not every drug combination with methadone is a sign of a problem, either. some drugs do not compound the risks of overdose or other adverse effects. others slightly compound a risk, but it can be managed. and if a high-risk combination does keep popping up in someone’s history despite warnings, there is usually a need they are trying to meet. a trusted provider, well-versed in harm reduction, could listen openly to that patient’s reasons for going back to that combination over and over, and even brainstorm alternatives.
and just because someone had a problematic relationship with opioids in a certain context, doesn’t automatically mean they had a problematic relationship with every other drug. my friend should not have been kicked off her clinic for managing pain with weed. my other friend should not have had her dose cut in half because she had champagne at her wedding. I should be able to go to a clinic and say “I sometimes still use heroin, but I think access to methadone could really help me reduce harm and heal from chaotic use.”
data shows that people are a lot more likely to reach whatever change goals they may have around their use (whether that has anything to do with abstinence or not) when they are met where they are with low barrier resources and information.
we need to start looking at counseling/healthcare as making sure people have plentiful resources and information, not pathologizing them as individuals and leveraging control over them.
Q: Wouldn’t we rather help people break their dependencies, than maintain them?
A: dependency isn’t always a dirty word, first of all. a dependency can be helpful, harmful, or partly both. it becomes more of a problem when things you depend on are stigmatized. when you aren’t given the support you need to reduce harm around your dependency. when instead of a supervised, slow taper (IF/when needed), you are facing sudden withdrawal at every turn due to scarcity and poverty. so your dependency looks more chaotic.
secondly, the consequences of these lifelong vicious cycles stack up. between the natural risks of a drug, and the greater social risks imposed upon it. people should have a choice in how they deal with the impact this has on their system. whether or not they want certain tools to support their healing/stability.
some people will use a given tool, others won’t, others will for a time before they realize that a given tool no longer serves them. at that point, they are likely to have an easier time breaking the dependency than if they had been coerced into it earlier. that doesn’t always mean they need to regret having accessed it in the first place.
at the end of the day, you’d be hard pressed to find a proponent of methadone or any other maintenance therapy who claims that it works best in a vacuum, without other tools, resources, and strategies. that’s a strawman.
Q: which drugs are good and which are bad?
A: this is an unnecessary and unanswerable question. what are the conditions under which we encounter different drugs? what are the innate risks, versus risks that are a result of social conditions? how can we build environments and ways of relating to each other that reduce the risks of behaviors we have as humans? am I centering bodily autonomy in any of this? am I thinking of how to care for people, or how to police them? is this really about risk? if there are better ways to reduce risk, why am I not open to them? where am I not seeing the harm caused by control? where have I been told coercion reduces harm, where it as actually producing it? why am I angry about pleasure?
Q: is it healthy to be on methadone/maintenance meds?
A: health should not be a moral mandate. health should not exclude someone’s agency and happiness. most of the moral mandates around “health” that we hold in this culture, hold people back from health, wellbeing and happiness. there are many variables that go into what is “healthy” for someone. everything has costs and benefits. two people might look at the same costs and benefits, and come to different end conclusions.
again, we should look at the available options and provide the best resources available to reduce risk and maximize benefit for each.
we should also accept that people have every right to decide things that may look “unhealthy” to you, and finish a cost benefit analysis a different way than you might. you may be overlooking the benefits someone else is getting from a choice, because you are standing in a different context, and only looking at the costs you personally experienced. or assuming the costs, with no personal experience. or evaluating them on a different metric that means very little to someone else.
one person may strive to eliminate all dependencies on external chemicals. another person may have one particular chemical dependency that improves their quality of life, especially when compared to the alternative.
Q: why are so many people failing to get better?
A: it is unfair to indict people for individual failures, as they navigate systems that have failed on a grand scale. especially while keeping silent about the failures of those systems. why don’t people have the many resources they need? why are spaces hostile and circular where they could be nurturing? are people being offered therapy, or subjected to another form of policing? which false dichotomies could be replaced by an array of options? which disparities are we blaming on the people suffering from them? why is it so important to define “getting better” for other people, to the point where we block off some of their avenues to thriving on their own terms?
lastly, returning to the initial quote, does someone have to prove to you that they’re “better” by rejecting forms of pleasure you don’t approve of?
if they do manage to access that pleasure without much detriment to their wellbeing, why do you still see them as sick?
Home | Urban Survivors Union (druguservoice.org)
THE-METHADONE-MANIFESTO.pdf (ohrn.org)
the Urban Survivors Union, their methadone advocacy and Methadone Manifesto
Episode 16: Goodbye Dave – Crackdown (crackdownpod.com)
episode on the legacy of a late participant in the North American Opioid Medications Initiative (NAOMI) study on Heroin Assisted Treatment
National Alliance for Medication Assisted Recovery (methadone.org)
NAMA - a Methadone patient advocacy group
(11) Drug User Liberation Front DULF | Facebook
Why the Drug User Liberation Front Gave Out Free, Checked Drugs in Vancouver (filtermag.org)
BC Drug User Liberation Front and their Safe Supply demonstrations / buyers club project
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