This is not American heroin: social illness, chemical therapies, and biomedical pluralism in Ukraine Jennifer Carroll, Ph.C.

(University of Washington) DRAFT COPY. DO NOT QUOTE WITHOUT PERMISSION. The title of this paper comes from the transcript of an interview that I conducted just over one year ago. I was in sitting in the primary physicians office at a Ukrainian methadone clinic a place where I have spent quite a lot of my time in the past 14 months. A man receiving methadone treatment, well call him Sasha, sat across from me. My research into patient perspectives on methadone in Ukraine was just beginning. I was learning the pleasantries and asking all of the broad, general questions that one does when one is just starting out. Sasha sat with me for a long time that day, partly interested in showing off his expertise and partly finding me strange and amusing. During that time, he taught me a number of things. First, if you want to make friends with people like him, dont bring cookies. Bring cigarettes. Second, Sasha understands that the social value of narcoticsand, by extension, of methadoneis different for him than for his American counterparts. This is not American heroin, he said, referring to the sorts of opiates that are common in his district. These are Ukrainian narcotics. He went into great detail to make sure that I understood the difference. In this paper, I will be talking about the effect these small but powerful social differences have on the implementation of internationally funded public health programsspecifically, methadone replacement therapy. Ukraine is home to one of the fastest growing HIV epidemics in the world. Many international organizations have funneled enormous amounts of money into Ukraines civil sector to implement WHO-endorsed HIV-prevention strategies that target injection drug users, as this is the primary route of HIV transmission in the region. These strategies include harm reduction education, needle and syringe exchange programs, and

methadone replacement therapy, an opioid-based chemotherapy for opiate dependence that deliciously blurs the lines between drug and medicine. It is in that blurred space and in our tenacious insistence on acting as though there is a line that clearly runs through it where my main curiosity lies. Foucault famously suggested that social power should be examined where it is at its extremities in those points where it becomes capillary (1976, 96), operating from out of infinitesimal mechanisms (ibid, 99). This perspective is important, and many scholars, like Philippe Bourgois (2000), Nancy Campbell and Susan Shaw (2008), have used Foucaults analytical methods to take US-based methadone programs to task, criticizing them as mechanisms of structural violence and social control. My intentions here, however, are to engage in an approach that is somewhat the opposite, and look at social power not in its most subtle and insidious forms but in its most overtly odd and contradictory forms. I am interested how the social power and discursive force of disciplinary technologieslike methadone replacement therapybecome apparent through our obstinate allegiance to those technologies in the face of technological breakdown. To borrow a term from Erin Koch (2013), one could describe such moments as slippages that occur between the plans and intensions of medical interventions and the social terrain in which they try to take root. Addiction, as both a social construct and as an object of medical intervention, is particularly open to such slippage, because it is a thing that is deceptively difficult to define. Part physical, part psychological, part social, part symbolic, addiction as a singular thingas a state in which persons can exist or a condition that persons can havedoes not fit cleanly or completely into any of our pre-made biological, analytical, or socio-cultural categories. We know that addiction is often fueled by structural factors and social contexts (Bourgois 1995, Brave Heart 2003, Bourgois and Schonberg 2009). We know that substance use is often deeply

rooted in symbolic terrains and cultural discourses (Becker 1963, Spradley 1968, Pilkington 2007). We have theorized psychological components such as wanting (Lende 2005) and choice (Heyman, 2009) and have explored how drug use is connected to neurology, biology, and human genetics (Cloninger 1987, Kendler et. al. 2000). Despite all this, addiction, itself, remains poorly defined. Even the most broadly accepted case definitionsthose found in the DSM-IV-TR (American Psychological Association, 2000) and the ICD-10 (WHO, 2000) rely on culturallybound moral values, such as how much time one spends acquiring drugs or persistent use despite social consequences, in order to assess whether ones priorities or decisions have deviated far enough from the acceptable norm to be considered signs of addiction (Glasser 2011). This categorical messiness matters because internationally supported biomedical treatment programs for drug addictionespecially methadone replacement therapyare being promoted and implemented across many nations, and these heavily standardized programs are all meeting chemical dependence as a differently constructed object in each place, including its own place of origin. In fact, as my own research in Ukraine has shown, there can be multiple addictions at play just in a single clinic. To illustrate this, lets return to Sashas comment about Ukrainian narcotics. Heres the excerpt quoted from his interview in full: Yes its better to live your life without methadone, but whats there to do about it? Of course, its a switch to something better than those narcotics that flow around the streets here, which are more, liketheyre dirty. From a medical perspective they are dirty drugs, so you come here hung up on this muddy swamp water. This isnt American heroin. These are Ukrainian opiates. We have khimiya. We make this narcotic ourselves. I can make it with poppy seeds. I take two other components, an anhydride and a solvent, and Ill make you narcotics with it. In America you dont do this, but we old, experienced addicts, we do. Young folks dont know how to do it, but Im already a long-time addict. Ive been doing this since 1987. In this passage, Sasha highlights a few things about methadone therapy that are key for him. In particular, he notes that methadoneat least the prescription form of methadone that he is

receiving at the clinicis a better, cleaner, safer option than the khimiya that is produced in large batches and frequently sold in pre-packed syringes on the streets. This point is important, because this logic is anchored to a very specific conceptualization of addiction and methadone that is distinct from dominant medical and psychological understandings. In much of the medical discourse surrounding methadone in the US, a line is drawn very firmly between heroina synthetic opiate and respiratory depressant with analgesic and euphoric effects that is deemed by the FDA to have no medical valueand methadonea synthetic opiate with euphoric effects that is federally approved for medical use as a respiratory depressant and analgesic. That line requires a great deal of boundary maintenance, but the line is there. For Sasha and many others like him, this cultural distinction between one opiate as a drug and the other as a medication doesnt hold. Both substances are seen as variants of the same thing, each able to get the same job donestaving off your withdrawal and getting you a little highjust to different degrees and with a different set of circumstances. There are, in fact, numerous substances that fit this bill. Ukrainian narcotics users interact with a spectrum of substances, all of which will get the job done at the end of the day, but which lie along a spectrum of quality, desirability, and ease of procurement. There is heroin in Ukraine, but not too much of it. Because its so expensive, its use is mostly limited to wealthy, upper-class individuals who have no place in the population of injection drug users targeted and recruited by Ukraines methadone programs. Demerol and morphine are the next best thing. Methadone patients call these chistyi narkotiki or clean narcotics. Pharmacies are not supposed to sell these drugs without a prescription, but those that do are so well known that most drug users and social workers can point out those that do on a map. If, for some reason, these higher quality drugs are unavailable (and due to extreme financial strife they are unavailable to most) then users

most often turn to khimiya, the poppy seed extract that Sasha described making. This is the most commonly used narcotic substance in Ukraine. In 2011, over 65% of injection drug users reported having used it within the last week and nearly a quarter reported using it daily (International HIV/AIDS Alliance in Ukraine, 2012). Last but not least, there is krokodil, the narcotic solution that has been so sensationalized by the media both in Ukraine and here in the US. Its made by buying codeine tablets, grinding them up, and then filtering them through various solutions with water, gasoline, and phosphorous in order to (one hopes) produce a clean, injectable, aqueous codeine solution. Its a drug of last resort. Its what you do to get by when theres literally nothing else around. Now, what kind of sense does methadone as medicine make, what kind of technological or therapeutic intervention can substitution therapy even be, when brought into a social field where multiple narcotic substances are already perceived to be acceptable substitutes for each other. Methadone doesnt achieve the status of a medicine or a therapeutic substance; it becomes another element on this spectrum of elements from which opiate users can choose for managing their desires and dependencies. It is distinguished as the choice that is in more steady supply, the choice that is free, but also the choice that can cause bad headaches at night and locks you in to the geography immediately surrounding your clinic. But, as Sasha said about his own experience, its a switch to something better than those narcotics that flow around the streets. For him and for many others, substitution therapy is attractive because it frees addicts from what many refer to as okhotathe daily hunt for money and drugs. The problem that methadone solves for them is not addiction, per se, but the logistical problems that accompany addiction. It frees them from the literal run-around required to manage their withdrawal symptoms and allows them to resolve the negative social and criminal patterns that arise as a secondary affect of their drug use.

The doctors and social workers that treat opiate users in Ukraines methadone clinics dont see things this way at all. The most commonly held understanding of addiction among these medical professionals frames it as a mixture of psychological and spiritual maladies. One social worker described addiction as a state in which a persons volition to act appropriately, to be a good, law abiding, socially integrated citizen is blocked by the physical and psychological compulsion to use. He said: The consequence of [drug use] is that it destroys your constitutionthe thing inside of you that should be the strongest. So, when you are addicted, you understand. You know what is happening to you. But you can do nothing about it If someone is seeking rehabilitation with a psychologist, their success will depend on their motivation. They must want to change. The psychologist cannot do all of the work. But the addict cannot get better without the help of the psychologist. Characterized in this way, addiction is a context-dependent battle between the conscious social and emotional desires of the drug dependent person and the physical, drug seeking behaviors that they find necessarya battle that, with the right support and scaffolding, can be won if the dependent person has conscious desire to change. Methadone solves this problem of the imprisoned will by controlling the opiate users compulsion to use, making it predictable and manageable and opening up the drug dependent patient to the influence of the psychologists or social workers that seek to rehabilitate them. Still further up the food chain, the international organizations that promote and fund methadone therapy around the world construct the problem in yet another way. For these entities, the problem being targeted exists not on an individual level with each drug dependent person, but on a population level. Their main concern is the spread of HIV through the drug using population, and methadone is both perceived and promoted as an effective tool for infection control. In a joint position paper, the WHO, UNODC, and UNAIDS, described methadone substitution therapy as:

one of the most effective types of pharmacological therapy of opioid dependence. There is consistent evidence form numerous controlled trials, large longitudinal studies, and programme evaluations, that substitution maintenance treatment for opioid dependence is associated with generally substantial reductions in illicit opioid use, criminal activity, deaths due to overdose, and behaviors with a high risk of HIV transmission (WHO/UNODC/UNAIDS, 2004). Here, the mechanism of addictionand the mechanism by which methadone achieves its population-level endsrevolves around physical pleasure and the external regulation of that pleasure for behavior modification purposes. For example, a recent Cochrane Review summarizing the available clinical evidence on methadone as a treatment for opioid dependence states that methadone can block the euphoric effects of heroin, thereby discouraging illicit use and thereby relieving the user of the need or desire to seek heroin (Mattick et. al. 2009). The key mechanism here is not relief from constant threat of withdrawal, but impeding the positive physiological consequences of opiate use, and international organizations promote and support methadone in Ukraine on that logic almost entirely. I stated my argument earlier in this paper that these multiple modes of conceiving and problematizing addiction constitute a technical breakdown. It may be tempting to respond to this claim with an appeal to the work of Arthur Kleinman (1988) who lucidly articulated a theory of explanatory models. In Kleinmans theory, a doctor may attribute wheezing to a disease like asthma while her patient attributes wheezing to stress in his personal life. These two individuals hold different explanatory models about whats happening in the patients lungs, but the are still ultimately talking about the same thing. In Ukrainian methadone therapy, this is not so. Drug users, doctors, and international donors have each constructed a unique problem that methadone intervenes upon in a unique way in order to produce unique outcomes, and none of them are the same. So while everyone is able to engage with methadone as a physical, pharmaceutical technology, and everyone can appeal to a disease model of addiction in their narratives, none of 7

these three groups are actually using these words to refer to the same thing at all. Despite these multiple discourses, conversations in clinics, boardrooms, and lecture halls seem to continue a pace with very little understanding, as far as I can tell, of how these different approaches to addiction do or do not match up. I have rarely seen the concept of addiction problematized in biomedical rhetoricnot even by those who hold minority views on the biomedical definition of addiction. I suggest that this situation is not only made possible by discourses of standardized, evidence-based public health interventions, but that evidence-based practice actually fuels our blindness to the pluralisms that attribute multiple meanings to biomedical activities, especially when the outcomes sought by those multiple perspectives dont overtly contradict each other. The principles of evidence-based practice do not necessarily care what mechanism your epistemology attributes to the success of a public health intervention. Ultimately, evidence-based practice only cares that something works or doesnt work to achieve the goals of the person writing the check, and the act of putting ones faith into evidence-based strategies does not require any specific social narrative other than this strategy works. In the case of methadone replacement therapy in Ukraine, what we can see happening is that first the evidence-based intervention is implemented, and then the social fabric takes hold of that intervention and its component partsin this case the disease model of addiction and the therapeutic model of methadoneand renders these technologies meaningful in its local context. The tool has travelled across national boarders, but the perceived utility of that tool did not. That utility is rooted completely in The Local. It seems like methadone substitution therapy programs got lucky. Lots of people are interacting with methadone for a lot of different reasons in a lot of different ways with a lot of

different goals in mind, but none of them blatantly contradict each other. The biggest conflict Ive seen between these multiple approaches to methadone is disagreement between patients and doctors about how long people should stay on it. Its not exactly a high-stakes moral or technological battle. But this outcome contrasts sharply with that which Erin Koch observed in the Georgian prison system. There also was a case in which the problem to be addressed, namely, the high rate of TB infection among prisoners, and the utility of the technologies available for addressing that problem were perceived very differently by the medical staff and the inmate population. Public health professionals saw standardized TB infection control protocols as a way to control TB infection. Prisoners saw the infection control program as an opportunity to change their living environment if they tested positive, and would go out of their way to fake a positive test by sharing bodily fluids with other prisoners they knew to be infected. In this case, the two active paradigms that gave the medical program meaning were in direct conflict. In the end, tuberculosis rates in this prison rose sharply not in spite of but because of the implementation of evidence-based infection control practices. For me, this is the ultimate lesson that I took away from my time with Sasha and everyone else Ive been learning from in Ukraine for the past year. If we are not able to successfully and thoroughly track the diversity of social meanings that are given to evidencebased public health technologies as they are implemented around the world, some efforts, like methadone in Ukraine, will probably be fine. But others wont. Others could turn out to be disasters, adding harm instead of working to remove it, and without a clear picture of what those local pluralisms look like, we would be at a loss to explain why.

References:

American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington DC: Author. Becker, Howard. 1963. Outsiders: Studies in the Sociology of Deviance. New York: The Free Press. Bourgois, P. 1995. In Search of Respect: Selling Crack in El Barrio. New York : Cambridge University Press. Bourgois, P. 2000. Disciplining addictions. Culture, medicine and psychiatry 24: 165195. Bourgois, P. and J. Schonberg. 2009. Righteous Dopefiend. Berkeley: University of California Press. Brave Heart, Maria Yellow Horse. 2003. The Historical Trauma Response Among Natives and Its Relationship with Substance Abuse: a Lakota Illustration. Journal of Psychoactive Drugs 35(1): 7-13. Campbell, N. D. & Shaw, S. J. 2008. Incitements to discourse: Illicit drugs, harm reduction, and the production of ethnographic subjects. Cultural anthropology 23(4): 688-717. Cloninger. C. Robert. 1987. Neurogenetic Adaptive Mechanisms in Alcoholism. Science 236: 410-416. Foucault, Michel. 1976. Lecture Two: 14 January 1976 in Power/Knowledge, C. Gordgon, ed. New York: Pantheon Books. Glasser, Irene. 2011. Anthropology of Addictions and Recovery. Waveland Press. Heyman, Gene. 2009. Addiction: A Disorder of Choice. Cambridge: Harvard University Press. International HIV/AIDS Alliance in Ukriane. 2012. Analytical report: Behavior monitoring and HIV-prevalence among injecting drug users as a component of second generation surveillance. http://www.aidsalliance.org.ua/ru/library/our/2012/me/idu_en_2011.pdf Kendler, K. S., Karkowskim L. M., Neale, M. C., and Prescott, C. A. 2000. Illicit Psychoactive Substance Use, Heave Use, Abuse, and Dependence in a U.S. Population-Based Sample of Male Twins. Archives of General Psychiatry 57:2 61-269. Kleinman, Arthur. 1988. The Illness Narratives: Suffering, healing, and the human condition. Basic books. Koch, Erin. 2013. Free market tuberculosis: Managing epidemics in post-soviet Georgia. Nashville: Vanderbilt U. Press. Lende, Daniel H. 2005. Wanting and Drug Use: A Biocultural Approach to the Analysis of Addiction. Ethos, 33: 100124.

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Mattick, Richard P, Courtney Breen, Jo Kimber, and Marina Davoli. 2009. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. The Cochrane Library. DOI: 10.1002/14651858.CD002209.pub2 Pilkington, Hilary. 2007. Beyond Peer Pressure: Rethinking Drug Use and Youth Culture. International Journal of Drug Policy 18:(213-224). Spradley, James. 1968. You Owe Yourself A Drunk. University Press of America. World Health Organization. 1992. International statistical classification of diseases and related health problems (10th revision). Geneva: Author. World Health Organization, United Nations Office on Drugs and Crime, and the Joint United Nations Programme on HIV/AIDS. 2004. Position paper: Substitution maintenance therapy in the maintenance of opioid dependence and HIV/AIDS prevention. http://www.who.int/substance_abuse/publications/en/PositionPaper_English.pdf

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