Care from the Perspective of People Using drugs—Biopolitical care
vs. Everyday Forms of Care in Copenhagen, Denmark
Program: Medical anthropology and Sociology Student: Renée Michels, 10290303,
renee_michels@hotmail.com Supervisor: Jarrett Zigon Second reader: Rene Gerrets Date: 25-06-15
Place: Amsterdam Word count: 20.003
Abstract
In scientific literature there is minimal direct investigation into the experiences with care from the perspective of people using drugs. This is an ethnographic depiction of the experiences with care by members of a user-led drug user organization in Copenhagen, Denmark. I analyze the forms of care experienced by these dependent drug (predominantly opioids) users through the governmental (substitution) treatment system and also the forms of care experienced through the Copenhagen drug users union. Following their stories, I contrast the biopolitical forms of care in the substitution treatment system to the everyday forms of care at the Copenhagen drug users union. Biopolitical care here denotes decisions by political bodies that, under the mask of care, exert control over a population, through governmental decisions, treatment systems and other structures. These forms of biopolitical care were experienced as generalizing, anonymizing, and at times destructive. Forms of care that became available through the Copenhagen drug users union on the other hand—here termed ‘everyday forms of care’—were experienced as personalized and constructive. Furthermore, there was a sense of community at the union that aided members in caring for themselves and for others. Lastly, I explore actions and events through which the Copenhagen drug users union has improved the situation regarding (biopolitical) care for drug users in Denmark. Naturally, we have to situate these incidents within Denmark’s context as being a small, rather liberal and progressive country. Nonetheless, this is hopeful evidence that dependent drug users, who are still often marginalized and treated condescendingly, can collectively take action and demand an improvement to their situation.
Table of contents
Abstract………..p. 2 Table of Contents………..p. 3 Acknowledgements………..p. 5 Introduction………..p. 6 Topic and Research question………..p. 6 Terms and Definitions……….p. 6 Methodology, Challenges, and Ethical Considerations………p. 8 Chapter Overview………..p. 9 Chapter 1: Background………..p. 11
Danish Drug Policy: A Social Matter………..p. 11 Methadone as Medicine: Drug Use as Disease……….p. 13 User Organization: Introducing the Copenhagen User’s Union………p. 15 The First Drug Consumption Room………...p. 17 The Current Situation……….p. 20 Closing words on chapter……….p. 21 Chapter 2: Biopolitical care……….p. 22 Bio-politics and control in Denmark………..p. 22 Biopolitical Care: Anonymous and Destructive………...p. 24 Biopolitical Care and Control in Substitution Treatment ………..p. 26 Methadone Substitution Treatment………p. 27 Buprenorphine Substitution Treatment………...p. 29 Heroin Substitution Treatment………..p. 31 Generalization………...p. 33 Closing Words on Chapter……….p. 35
Chapter 3: Everyday forms of care at the union………..p. 36 Complexity of care for drug users……….p. 36 Being an Active Member……….p. 39 Constructive and Peaceful………..p. 42 Community Care………...p. 45 Criticism from Outside of the Community………..p. 47 Closing Words on Chapter………..p. 48 Chapter 4: Changing the Biopolitical Care Practices………..p. 49 One Politician on Our Side………..p. 49 Welcome to Reality……….p. 50 Constructing Constructive Care………..…p. 52 Closing Words on Chapter………..p. 54 Concluding Remarks………..p. 56 References………p. 58
Acknowledgements
First of all I would like to express my gratitude to the members of the Copenhagen drug users union. Whilst investigating the ways these members experienced care and cared for each other, I was received with an incredible amount of care, openness, hospitality, and warmth. It is by no means a given that this group of individuals, often themselves struggling to get by, should act as friendly as they have. This thesis would not have been possible without your help, so thank you.
Then, I would like to thank my supervisor Jarrett Zigon for providing me with the opportunity to carry out this research. Most of all, I would like to thank you for the insight of writing carefully, about contested subjects such as the one at hand. You have taught me that you have a choice and a responsibility as a writer, which I think is a very valuable lesson. My gratitude also goes to Rene Gerrets for being the second reader of my thesis.
Lastly, I would like to thank each and everyone that has helped me during this year. My family, both emotionally and financially, I could not have done it without you. My friends and colleagues, classmates and all the people I have met in Copenhagen; I always felt
cared for and that, I now know more than anything, is something extremely treasurable. Tak so meget for alt Katrine. Også takket være Filip, Birgitte og Nanne og alle andre.
Thank you Suzka for adopting me and letting me camp out in your gallery with my laptop. And of course, thank you Teun, for always believing in me and caring for me the way you do.
Mange tak,
Introduction
Topic and Research Question
This thesis is about care, describing drug users’ experiences with care from a medical anthropological perspective. It is an ethnographic endeavor into the lives of drug users in Copenhagen, Denmark. The drug users who formed the basis of this thesis are members of a user-led drug users union in Copenhagen, predominantly opioid users, and most described themselves as dependent users. Such drug dependency, denoting drug consumption producing physical craving, has only been witnessed in the ways we do now since the 19th century (Singer, 2012). Human interaction with psychoactive substances (‘drugs’) dates back more than 8 thousand years, but during the 19th century people started preparing drugs in very concentrated forms—as they did with heroin from morphine—to make the drugs more potent (Courtwright, 2001). As Singer points out, this was also when anthropology developed, at first primarily aimed at understanding people from “subordinate colonial status, […] linked historically to the
emergence of global capitalism and its desire for labor control” (2012, p. 1747). Such
control was one of the main reasons drug use was illegalized and criminalized, about a hundred years later (Courtwright, 2001). Here I will write about elements of such control present in care available to opioid1 users in Copenhagen through various political institutions and regulations. Such forms of care aimed at control I will analyze in contrast to care available to drug users through the user-led drug user union in Copenhagen. The latter form of care took on many different shapes, but was overall experienced more positively and was better adjusted to the needs of the opioid users I have come into contact with. In analyzing these forms of care I will make an attempt at answering the question: What forms of care are available to members of the drug user’s union in Copenhagen, and how are these perceived?
Terms and Definitions
Such a direct investigation of the experiences of and with care from the perspective of people using drugs has, to my knowledge, not been carried out before. Perhaps I should here draw a definition of what I have come to perceive as care for drug users; my 1 Opioids include Heroin, Methadone, and Buprenorphine. Opioids are synthetic whereas opiates like Morphine are natural.
working definition of care for this piece of ethnographic writing. However, during fieldwork I found that the care experienced by opioid users takes countless different forms and shapes. As such I fear that defining care a priori runs the risk of excluding practices that are not as straightforward in their intention of care, but could upon closer investigation be understood as an act of care. Stevenson, in her book on care in the Canadian arctic, does formulate a definition of care, namely “the way someone comes to
matter and the corresponding ethics of attending to the other who matters” (2014, p.3). I
do not completely concur with this definition, seeing as ‘coming to matter’ could be interpreted as becoming significant or even important (Matter, 2015). Often, opioid users told me about experiences with the care system of Denmark in which they did not at all feel as though treated important or significant. My research findings do, however, resonate with the second part of Stevenson’s explanation of care: “Shifting our
understanding of care away from its frequent associations with either good intentions, positive outcomes, or sentimental responses to suffering allows us to nuance the discourse on care so that both the ambivalence of our desires and the messiness of our attempts to care can come into view” (2014, p. 3). Here, Stevenson acknowledges that there are many
ways of caring for oneself, someone or something else, which are not always guided by ones intentions or focused on certain outcomes. Furthermore, what is considered ‘positive’ or ‘good’ care, especially in the debate around care for drug users, can greatly influence the types of care allowed. Is giving methadone to drug users a form of care or not? Is providing them with a clean and safe place to use their preferred drugs a form of care? Or providing users with the materials to use their drugs? Is emphasizing the positive outcomes of heroin use a form of care?
For the sake of argument, I have here distinguished between two types of care. Firstly, I will discuss what I have come to perceive as biopolitical or bureaucratic care, following the works of Rose (2001), Stevenson (2014), and Ong (1995), all inspired by Foucault (1979, 2003). Bio-politics is here used to indicate the ways in which political decisions over its population’s vital processes exercise control over this population (Foucault, 1979). Biopolitical care then denotes decisions by political bodies that, under the mask of care, exert control over a population, through governmental decisions, treatment systems and other structures. The aim of such care could perhaps best be understood as designed to limit undesirable consequences for society. Here it is often not particularly important who is cared for, as the care is directed at the population and
not the individual (Stevenson, 2014). This form of care was therefore experienced as anonymous care, resembling Stevenson’s description of biopolitical care available for Inuit in the Canadian arctic. Stevenson describes how the Inuit population at times experienced such forms of care as murderous (ibid, p. 4). Likewise, the opioid users I have spoken to during my fieldwork spoke of events when biopolitical decisions resulted in distress, sickness, or even death of drug users. Therefore, I have come to perceive and define the biopolitical care system as, at times, destructive. In contrast to this form of care, I will discuss forms of care that move away from these forms of biopolitical or bureaucratic care, care I will address as ‘everyday forms of care’, following Stevenson’s description of such forms of care in the Canadian arctic (2014, p. 3), as well as Garcia’s experiences with ‘everyday modes of care’ in a heroin clinic in New Mexico (2010, p. 9). Such everyday forms of care consisted of more diverse practices; instead of being generalizing towards drug users this form of care was characterized by its complexity. Furthermore, these forms of care were perceived as constructive, in contrast to being destructive, and were perceived as more personal as opposed to anonymizing.
Methodology, Challenges, and Ethical Considerations
The field notes that formed the basis of this ethnography were gathered during 2 months of fieldwork at a union run by and for active opioid users in Copenhagen. During my time there, I have observed, communicated, interacted, and participated at this union and its surroundings. As an aspiring anthropologist, I intended to perform a number of ‘semi-structured, in-depth interviews’ with members of this union on their perception of the availability and nature of care. However, the illegality of the subject at hand and the general code of conduct at the union did not suit such research methods. That is why in reality most of the data comes from informal conversations, as well as observation of and participation in activities at the union. During these activities, individuals were at all times fully informed of the reason behind my inquiries and I asked permission for inclusion of their statements. In order to further protect these individuals, I have made use of pseudonyms.
The conversations were mostly English spoken, with a few conversations in Danish. Like most Danish citizens, members of the Copenhagen drug users union were extremely proficient in English. If at times I would take on a more observing,
non-participatory role however, the language of conversation would sometimes switch to Danish. Although undoubtedly I have missed pieces of information when I could not follow these interactions completely, I feel as though this served the situation. When 6 months ago I inquired into the possibility of conducting fieldwork at the union, I was told that there were some members who were opposed to the idea of having an “outsider” intrude the “safe heaven for the tribe of opiate using people” they had created for themselves in Copenhagen. In the beginning then, the language barrier performed a role of gatekeeper. Issues that were at the border of illegality or issues felt as extremely personal were in the beginning predominantly discussed in Danish. Although I could partly understand such conversations, this gave the members of the union a sense of privacy and unburdened me from the feeling of intrusion. Then, moving further into the period of fieldwork, when we had established rapport and a sense of mutual trust, I was more and more included into such conversations and events.
Besides conducting fieldwork at the Copenhagen drug users union, I have through the so-called ‘tag-a-long method’ gathered bits of data at a volunteer-based organization for drug users, at an anonymous health clinic and at an organization primarily aimed at helping drug users and other so-called ‘marginalized individuals’ with legal concerns. Predominantly though, this fieldwork rests on conversations with, observations of and material provided by members of the Copenhagen drug users union. Chapter Overview
In chapter 1, I will give an overview of the history and current situation regarding drug policy in Denmark, focusing primarily on opioid use and the city of Copenhagen. I will also discuss the history and current situation of the Copenhagen drug users union, elaborating on its premises, activities and general aims. Then, in chapter 2, I will further introduce the concept of biopolitical care and explain how members of the Copenhagen drug users union experience such care. Contrasted to the forms of biopolitical care I describe in this chapter, I will in chapter 3 elaborate on forms of care experienced by these members at the Copenhagen drug users union. As I will attempt to show, such care moves away from elements of control and in contrast to being anonymous and destructive it was perceived as personal, constructive and catered to the users needs as opposed to the needs of society. Lastly then, in chapter 4 I will show how the union through such acts of care as well as through connections to political institutions and acts
of activism has managed to change the biopolitical care’s practices. I will discuss the processes through which they achieved such change within the theoretical framework of governance suggested by Houborg (2014), but also through Klawiter’s analysis of social movements and disease regimes (2004). Lastly then, I will end this thesis by reflecting on potential limitations and weaknesses, and give several suggestions for future research.
Chapter 1. Background
In this chapter I will firstly give an overview of the history of Danish drug politics, focusing largely on opioid use in the city of Copenhagen. I will guide you through the road from drug use perceived as a social issue before the 1980s towards the current medicalization of drug use and dependency. Furthermore, I will highlight the ambivalence of Danish drug politics as a combination of welfare politics and control/crime politics. Naturally, I will also introduce the Copenhagen drug users union and elaborate on its premises, aims, and activities. Finally, I will describe the current situation regarding drug politics and opioid use in Copenhagen in terms of its general ideology, available services, and numbers regarding population use.
Danish Drug Policy: a Social Matter
Helle: Do you know how you become a drug addict? Renee: Tell me? Helle: By using drugs that are addictive.
This little dialogue, however short and simple, touches upon a much larger debate within (Danish) drug policy. The question of how to handle drugs, its users and its consequences for Danish society, and the policies delineating the answers to such questions, have been dealt with differently across times. On the one hand, we see an answer like the one Helle gives, namely one that sees drugs themselves as the main issue. Such a framing of the problem—a medical explanation that views drug use as an epidemic to be contained by removing the contagious agent (drugs or drug users) from circulation—is usually answered with increased control, punishment, and (coercive) treatment directed at detoxification of drug users (Houborg, 2013). On the other hand, ‘problem’ drug use may be seen as a social problem, caused by conflicts in the social world of that time or a dysfunctional relationship between individuals and this social world. Policies following this train of thought focus primarily on social reform, institutional change, and social rehabilitation (ibid, 2013). I met Helle at the Copenhagen drug user union during my fieldwork in the beginning of this year, and his remark confirms that currently the medical model of drug use is in vogue. However, when we look back in time in Danish drug policy we see that before to the 1980s drug use was framed primarily as a social issue.
Most articles describing the history of drug use and drug policy in Denmark start their analysis around the 1940s, or later, describing how a new drug problem emerged in the harbor of Copenhagen (Houborg, 2010)2. During and directly after World War II there was a situation of social unrest, and both the black market and the pub scene in Copenhagen were thriving. With the more widespread use of heroin and cocaine in the harbor and vice districts of Copenhagen, ‘the drug problem’ had become what was called a social phenomenon (ibid, 2010). To restore this situation of social unrest, the police began to arrest drug users, and coerced them to detoxification, meaning complete drug cessation. Detoxification was at that time the only form of ‘treatment’ available to drug users in Denmark, though in seldom cases combined with psychiatric counseling. This drug problem was defined as a temporary social deviance phenomenon (ibid, 2010). The Danish Opium Act of 1936, which only made distribution and sale of illegal drugs a criminal offense and not personal consumption, required an update (ibid, 2010). The National Board of Health implemented a new central monitoring system for drug users, and mid 1950s possession of illegal drugs for personal consumption became punishable for the first time in Denmark, through the Act on Euphoriant Substances (Houborg, 2012)3. This situation of the 1940s and the 1950s was perceived as an isolated case, related to the turbulent social circumstances of that time, and hope was that increased social control would restore these deviant individuals to ‘normalcy’ (Houborg, 2010).
Then, in the 1960s, a large number of young drug users called for a reinterpretation of the situation (Houborg, 2013). The description of drug use as a social deviance phenomenon related to the instability of previous times was outdated; public authorities now perceived drug use as a more widespread social problem (ibid, 2013). The dawning hippie movement of the 60s in general stimulated drug use in a number of young people, especially students, artists, and bohemians (Houborg, 2010). Drug use was feared to become an increasingly acceptable activity among more and more young
2 It is important to note that ‘drug problems’ in Denmark prior to the 1940s may very well have
occurred, but perhaps are only discussed in the Danish literature, or not discussed within the academic literature at all. However, here I will follow the available English literature as well as qualitative data from fieldwork, and start the overview of Danish drug policy in the 1940s.
3 Esben Houborg, a sociologist and Associate Professor at the Aarhus University in Denmark, has
produced the majority of the literature available on Danish drug policy. This means that this historical analysis is for a large part based on his work. Despite that a wider variety of authors describing the situation in Denmark would have been preferred, the contention is that his work is an accurate representation of reality.
people. Instead of blaming the Danish youth for this cultural shift and in fear of having to place a large part of the younger population of that time in prison, the Parliament decided to decriminalize possession and use of drugs and increase sanctions for the distribution of drugs (ibid, 2010). Treatment moved from the psychiatric wards to the social welfare system—becoming a job mainly for social workers—and fell under supervision of the Ministry of Social Welfare instead of the Ministry of Health (Houborg, 2013). The ministry of Social Welfare placed drug user treatment under the control of the then 275 municipalities (Frank et al., 2013). Since the 1970s such treatment sometimes also consisted of methadone (EMCDDA, 2014a), a substitution treatment for heroin users that was supposed to be used only for detoxification purposes. This means that heroin users were switched from heroin to methadone within treatment—as methadone was considered to be less harmful than heroin—and tapered off this drug as soon as possible. This situation regarding substitution treatment connoted a shift in the perception of heroin/drug use, as will be described below.
Methadone as Medicine: Drug Use as Disease
Methadone used as a substitution for heroin is officially called Methadone Maintenance Therapy (MMT). MMT was experimented with in New York, as described in an article by Dole, Nyswander & Kreek (1966), but was not yet perceived as a suitable approach to heroin use in Denmark. In 1973, the commission of narcotic drugs (Narkotikarådet) invited a group of ‘experts’4 to create a report on MMT in Denmark, as to conclude whether it was a suitable treatment method (Houborg, 2012; Houborg, 2013). Prescribing such drugs to patients was still perceived as very contradictory; it was thought that such methods would reproduce the drug problem instead of solving it, since drug users were expected to be less motivated for drug free or abstinence focused treatment (Houborg, 2013). The report concluded that MMT could not be introduced in Denmark as it was in New York, because the nature of the drug problem was different. Reasons given for this dismissal were that the Danish drug users were younger than those in the United States and that the Danish welfare state was further developed than the US welfare state. Therefore, it was decided that social welfare institutions should address the problems and not the medical field (ibid, 2013). This was part of a larger
4 Unfortunately, whom this group of experts consisted of is not described in the literature.
resistance to the medicalization of addiction, as is reflected in the following quote by a prominent Danish opponent of MMT:
“First and foremost Methadone maintenance may hide the fundamental causes of
the drug use. It will no longer be urgently necessary to investigate the mental and social causes in this field. The drug users, that are produced by complicated hereditary, family and in a broad sense societal factors just need methadone and the problem is solved or at least hidden. In this way methadone maintenance will easily become chemical feeding rather than social reform” (Jakobsen, 1977, as cited in Houborg, 2013, p. 76).
Regardless of this ‘anti-medicalization movement’, general practitioners continued to prescribe methadone to drug users (Houborg, 2012), and as such an unofficial medical treatment system existed alongside the social treatment system.
Then, during the 1980s, the general view towards MMT changed. This was partly because the group of socially deviant youths described above was getting older, and their use of drugs did not appear to change, and partly because worldwide there was more acceptance of methadone as a substitution drug for heroin users (Houborg, 2013). In addition, the HIV/Aids debate that amplified around 1986 and the connotation to intravenous drug users called for public health measures towards drug use, especially heroin users (Houborg, 2012). Ironically then, in a new report by the Narkotikarådet from 1988 the similarities between abstinence oriented, re-socializing drug free treatment and MMT were emphasized:
“Ignorance about this mode of treatment [MMT], its ends and means, has been and still is significant. There is therefore cause to make clear that the goal of long-term methadone treatment as well as for the social pedagogical treatment is social (re)habilitation. It is therefore not with regard to the end that long term methadone treatment is different from the normal social pedagogical treatment, but with regard to the means” (Narkotikarådet,
1988, as cited in Houborg, 2012, p. 166-167).
This is important because the introduction of MMT connoted a larger shift within drug policy’s debate concerning the nature of drug use: a move from a social explanation to a medical explanation. No longer was drug use seen as primarily a social problem; heroin
users were now seen as patients with a chronic disease and methadone was their required medicine.
User Organization: Introducing the Copenhagen User’s Union
Within medical anthropological literature, such ‘medicalization’ is often perceived negatively. A number of such undesirable consequences of the medicalization of drug (heroin) use I will touch upon in chapter 2 under the header ‘Biopolitical Care’. Here however I want to suggest its potential role in the formation of drug user organizations: when drug use became more commonly known as a (brain) disease, drug users suddenly befell the title of ‘patients’, who were able to organize themselves like other patient movements or organizations had done in the past (e.g. Klawiter, 2004). Indeed, the Copenhagen drug user’s union that is the center of this thesis organized around this time. The union was established in 1993 as a user’s union for people who were actively using opioids (heroin or a form of substitution medication), organized exclusively by and for active opioid users (Johansson et al., 2015). It is a formal organization with an elected chairman, an executive committee, and annual general meetings (Asmussen, 2003). It is the biggest of its kind in Denmark, established with economical assistance from the Danish Social Ministry (Anker, 2006). Currently the union has around 800 members, of which 200 visit almost weekly. Since 2001 they are located on the top floor of a three-storey building, sharing their entrance with a children’s library located on the first floor.
Upon entrance, one finds a large seating area with a lengthy kitchen table and several couches next to a big tropical fish tank. Attached is a fully equipped kitchen; breakfast is prepared and served here every morning from 10 to 12 and dinner collectively cooked on Mondays, Tuesdays, and Thursdays. Further in the
back are a smoking room, injection room, office spaces, a gym, laundry room, library, and lecture room. In the library there are books, journals, dissertations, and pamphlets on drug-related issues. Further down the hallway there is the lecture room, where the union organizes talks, training sessions and seminars to nurses, police cadets, schools and other groups interested in the union or drug-related information. In addition there is a small heroin museum with drug paraphernalia and artifacts.
The union operates a drop-in service and maintains a network for isolated and marginalized drug users (Johansson et al., 2015). They also organize gatherings and meetings for other user (oriented) groups. The union’s objectives are to “further heroin
users’ social, health and societal interests through support, information and advice work for individual users” (ibid, 2015, p. 40). A member of the Copenhagen drug users union
explained that the union both acts as a meeting place for its members and discusses user interests with politicians, authorities, and the care system. When participating in such democratic processes, they put much emphasis on presenting themselves responsibly to act as a credible user voice. This representation of drug users is one of their biggest concerns.
Renee: How do you refer to people that use drugs; here [at the union] I hear a lot of people referring to it as their medicine, and to themselves as patients. How do you prefer to refer to it and to yourself? Some people here say patients, and medicine… Jensen: They can say what they like. I would say dependent, opiate dependent. If we have to put labels, I would say we are opiate dependent, and we are medicators.
As medicators they demand the right to have a say in the discussion surrounding their ‘medication’. In response, they were invited during the 1990s by the Narkotikarådet to be present in their council, which resulted in a number of issues to be felt at higher level and subsequent policy changes. For example, this collaboration produced a policy that gave drug users the right to complain about treatment received (Houborg, 2012). Moreover, instead of ingestible methadone, they argued for injectable methadone, explaining that such methods would be better received by drug users and thus be more successful in resolving illegal drug use (Frank et al., 2013).
When this request was received with consent in 1999 (Houborg, 2012), they moved onto another issue: Heroin-assisted treatment (HAT). HAT is a form of
substitution treatment for heroin users using ‘medicinal heroin’, and it had been shown to be beneficial in reducing drug-related problems in trials in Switzerland (ibid, 2012). In 1997, the Copenhagen drug user’s union conducted a survey amongst its members, in order to show the general view of drug users (ibid, 2012). This survey can be seen as a form of “research in the wild” (Callon & Rabeharisioa, 2003, as cited in Houborg, 2012, p. 171), where lay actors perform scientific knowledge production to make issues at hand more tangible and publicly visible, and thus easier to demand. The survey showed that
“69% of the members said that they did not feel that they were treated as ‘adults’ or in a ‘correct manner’ at the treatment institutions”, “71% thought the treatment staff was too focused on resocialization”, and “76% would choose heroin treatment if available”
(Houborg, 2012, p. 171). Despite initial rejection by the Danish government in the late 1990s, a Danish HAT trial started in 2002. In 2007, HAT was accepted and introduced as a treatment option in Denmark (Houborg, 2012, EMCDDA, 2014a). In spite of this perceived success regarding HAT, the service is not well perceived by drug users today, something I will discuss in chapter 2 under the header of ‘Heroin Substitution Treatment’.
The First Drug Consumption Room
Switzerland enacted an exemplary role not only in the case of HAT trials. The first legal drug consumption room (DCR) was also established in Bern, Switzerland, in 1986 (Hedrich, 2004, p. 15). DCRs are defined as legally protected places, where users can inject their pre-obtained drugs (mostly heroin and cocaine) under hygienic circumstances and with supervision of trained health staff to prevent overdose (OD) (ibid, 2004). The aim of DCRs is to provide drug users with a safe and clean place to consume their drugs, away from the streets. This is done in order to reduce the mortality and morbidity associated with drug use, especially the relation between intravenous drug use and infectious diseases such as HIV/AIDS and Hepatitis C. Moreover, the DCRs aim to establish public order and reduce crime associated with drug use (ibid, 2004). Already in 1988, the Narkotikarådet recommended the Danish government to introduce DCRs (Houborg & Frank, 2014). One of the reasons for putting DCRs on the political agenda was an increase in drug-related deaths in the 1990s, from around 125 in the 1980s to the more than doubled number of 275 deaths in 1997 (Laursen & Jepsen, 2002, p. 25). The Danish Ministry of Health then consulted the
International Narcotics Control Board (INCB) to establish whether such facilities would violate the drug control conventions formulated by the United Nations (UN) (ibid, 2014). These drug policies of the UN emphasize criminalization of drug use, and strive for a drug-free society. Countries that have signed on to these international policies have little flexibility in adapting their national policies when public health crises due to drug situations occur (Zigon, 2013). Two of the three UN treaties on drugs date back prior to the debate on the link between drug use and HIV/Aids. The treaties emphasize treating drug use as a legal problem instead of a public health issue, which often creates problems at the national level (ibid, 2013). Indeed, the INCB decided that such drug consumption facilities would violate Danish obligations to the UN, and the DCR proposal was put to rest.
The subsequent government, a more conservative one, reviewed the question and again decided against DCRs. This time, not international but national guidelines were referred to, as it was stated that DCRs were in direct opposition to the core of Danish drug policy, which was to “counteract all non-medical and non-scientific use of
drugs” (Regeringen, 2003, as cited in Houborg & Frank, 2014, p. 3). The aforementioned
de-penalization of drug consumption and possession that was adopted in the 1970s was also rebutted, as in 2004 a zero-tolerance policy on possession of illicit drugs was established (ibid, 2014). This way an even stricter approach towards drug use was introduced, more closely resembling the war on drugs seen in the Americas. According to the Danish government, de-penalization of drug use had removed responsibility from individuals, a word frequently uttered in drug debates (Zigon, 2011; Zigon, 2014). The new drug policies were to reestablish such responsibility and morality amongst Danish citizens. An action plan put forward by this government did emphasize that Danish drug policy would adhere to harm reduction5 methods such as providing clean syringes and substitution treatment, however, harm reduction was subordinated to “the fundamental
prohibition against all non-medical use of illegal drugs” (Houborg, 2010, p. 798). As such,
there was no ‘room’ for drug consumption rooms at the national political level.
5 According to the website of the International Harm Reduction Association, harm reduction
refers to “policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption” (IHRA, 2015).
Excerpt from field notes: I am at a volunteer-based organization for drug users, and a guy comes up to me and starts talking in rapid Danish. I ask him to speak a bit more slowly so that I can understand him, and then he continues in perfect English. He tells me he works at [the volunteer-based organization], and he tells me that they had the first injection room of Copenhagen: “Everybody wants to have the honor of having the first injection room, but it was actually
us who did it. You see, over here we have always been accepting to our visitors. There are no rules, and everybody just kind of behaves. Of course, when people are being a pain in the ass, we ask them to step outside and take some fresh air, and come back later. But other than that there are no rules. So in the toilet we have here, people were always fixing [using]. Of course, we don’t have health personnel or nurses or whatnot, but we were making sure that these people were not using on the streets. But then 3 years ago this [governmental organization] opened, with all kinds of health personnel, and now they own us. They have opened a number of other injection rooms as well, but don’t let anybody tell you they were the first: We had the first injection room.”
Doing fieldwork in Copenhagen I found that many so-called grassroots organizations claim to have opened or partaken in the opening of the first DCR. When the DCRs were refused at a higher level, stakeholders at local level decided to explore the limits of international and national drug policy. In 2006, the Copenhagen municipality in partnership with the volunteer-based organization described above established a drop-in service for low-threshold social and health care (Houborg & Frank, 2014). However, the same municipality of Copenhagen then closed down this service when news emerged that it allowed the consumption of illicit drugs, and the municipality could not tolerate a violation of national law. A number of other facilities emerged through such acts of civil disobedience. Amongst them was a mobile drug injection facility established by the NGO “Foreningen Fixerum” (translated as ‘Union for Drug Consumption Rooms’), which opened in September 2011 in an old ambulance. In 2012 then, there was again a change of the Danish government. This new government was more positive towards DCRs and put forward a bill in 2012 to allow the Ministry of Health to establish such facilities (ibid, 2014). Still adhering to the zero-tolerance approach towards drug use and possession, the government proposed collaboration with the police to define areas of non-enforcement in Copenhagen (ibid, 2014). That same year, the first DCR opened in
such an area in Vesterbro in Copenhagen, and since then facilities have opened throughout Denmark (EMCDDA, 2014b). The Copenhagen drug users union also operates an injection room, albeit small and located in one of its restrooms. A cupboard exists next to the restroom with injection-related paraphernalia. The Current Situation
The latest developments in Danish drug policy are the implementation of the right to receive treatment within 14 days and the right to choose your own doctor (EMCDDA, 2014a). These developments were achieved in large part due to actions by the Copenhagen drug user’s union, and their implementation is something I will discuss in chapter 4. Nowadays, Danish drug treatment has a diverse set of options for opioid users seeking treatment. Detoxification is still an option, complemented by Opioid Substitution Treatment using methadone, buprenorphine, or medicinal heroin, as well as cognitive behavioral therapy, socio educational therapy, and other psychosocial interventions (EMCDAA, 2014a). Buprenorphine is another form of substitution treatment for heroin users, officially introduced in Denmark in 1999 (ibid, 2014a). Danish main objective is still to counteract the use of all drugs for non-medicinal purpose, as is portrayed in the title of its current drugs strategy document: The Fight Against Drugs II (Kampen mod narko II) (Regeringen, 2010). As the EMCDDA page for Denmark reads:
“The main goals of Danish drug treatment policy are to achieve a reduction in drug
use or to achieve full abstinence through enhanced use of psychosocial interventions, systematic follow-up of treatment, and to tackle problems other than those of drug use”
(EMCDDA, 2014a). Currently, there are an estimated number of 20000 heroin and substitution treatment users in Denmark, around 6000 of which live in Copenhagen (Johansson et al., 2015). Danish drug politics and the way in which the country cares for drug users is worldwide considered to be relatively liberal and progressive, also when compared to other Nordic countries (Houborg & Bjerge, 2011). Nonetheless, as already mentioned,
Picture 2: Drug injection material at the Copenhagen drug users union
Danish drug policies need to succumb to international (UN) treaties, which are generally more repressive towards drugs and drug users. As such, Jepsen & Laursen as well as Houborg & Bjerge describe Danish drug politics as ‘an ambivalent balance between control and welfare’ (2002, 2011). Whereas Danish control or crime policies view individuals as legal subjects, Danish welfare policies address individuals as “social,
biological and psychological subjects” (Houborg & Bjerge, 2011, p. 16). A central issue is
where to draw the line between control and punishment following legal policy, and care and welfare following welfare policy in Denmark. As I will attempt to show, this ambivalence affects the care for opioid users, as members of the Copenhagen users union perceive it.
Closing Words on Chapter
All together, this is an overview of the changes regarding drug policy and its overall ideology over the last 70 years. Embedded within this structure of drug policy, use and treatment are the practices of the biopolitical care framework. In the following chapter I will discuss the practices of these forms of care that I have termed biopolitical or bureaucratic, as they were perceived by members of the Copenhagen drug users union for opioid users, against the backdrop of the situation I have outlined here.
Chapter 2: Biopolitical Care
In this chapter I will elaborate on the types of care I have experienced during fieldwork that I have come to perceive as biopolitical care. I will elaborate on Foucault and other scholars that have worked with the concept of bio-politics. I will show how such forms of care were experienced as un-caring, anonymous, and even destructive, closely resembling Stevenson’s description of biopolitical care for the Inuit population in the Canadian arctic (2014). I will do so by describing the various form of substitution treatment in Denmark, namely methadone, buprenorphine, and medicinal heroin. In all these forms of biopolitical care, I will dismantle the elements of control and surveillance. Lastly, I will elaborate on what was perceived as one of the biggest problems within biopolitical care, namely the generalization of all drug users into one protocol.
Bio-politics and Control in Denmark
“These people [the government of Denmark] do not have real life experience; they make decisions about stuff they don’t know anything about. When you don’t have money, it takes shit long to get help. They don’t care about you. They want more control, they want all your information saved with your social security number; they know everything you do. They know you are smoking Marlboro golds right now, and they know you have already smoked 5 today. They know it all, and that’s shit.” (Rasmus, member of the Copenhagen drug users union).
I had arrived at the Copenhagen drug users union a little after breakfast, and the union was fairly empty. Instead of sitting down at the large dinner table at the entrance of the building, I decided to take a look in the smoking room in the back of the building to see if people were maybe smoking their heroin there. As I entered I saw two men I had not met before sitting at the table. I sat down next to them and lit a cigarette; perhaps to decrease the perceived disparity between me and these two men sharing brown heroin using aluminum foil and a lighter to ingest the fumes, or perhaps because doing so over the past 3 weeks had catered my addiction to nicotine. One of them, Rasmus, started talking to me in a thick Russian accent, and soon we were discussing Danish versus Russian drug politics. We were comparing the situation regarding social aid and treatment for drug users in both Russia and Denmark, and Rasmus said that although
Denmark used to be a much better place than Russia, the new Danish government that was soon to be elected would make the situation just as “shit” as it was in Russia.
As his quote reads at the outset of this paragraph, he argued that governmental decisions were mainly made with the aim of controlling people. The way in which decisions by the state or government directly impact people’s lives and primarily aim at controlling these people is termed bio-politics and draws upon Foucault’s spoken and written work (1979, 2003, among other work). According to Foucault we have entered a biopolitical age, “with [political] institutions to coordinate [or control] medical care,
centralize power, and normalize knowledge” (Foucault, 2003, p. 244). Rose, paraphrasing
Foucault, explains that political authorities have taken on the management of life itself and now deal with “the vital processes of human existence” (2001, p. 1), such as health and disease. Ong likewise draws on Foucault’s work in her article on Cambodian immigrants in California (1995). Ong defines bio-politics as “the strategic uses of
knowledges which invest bodies and populations with properties making them amenable to various technologies of control” (ibid, p. 1243). Biopolitical care then, as I perceive it, is
a form of care that holds elements of such control.
The ‘bio-political age’ from Foucault is linked to the rise of the life sciences, mostly clinical medicine, whose techniques and apparatuses for care adjusts individual bodies to normalizing standards to render them ‘governable’ (Ong, 1995, Rose, 2001). Without the medicalization of drug use, such control through biopolitical (health) care would be more difficult. Through bureaucratic or biopolitical care, the modern democratic state exercises surveillance and control over a population and, as Rose argues, holds the ability to “coerce, restrict, and even eliminate” those bio-political subjects who are believed to be “defective” (2001, p. 2). As Rasmus argues when he states that: “They [the government] don’t care about you”, such forms of care are therefore often experienced as un-caring. Here I agree with Garcia, who states that such actions of state or biopolitical care amount to methods of containment rather than methods of care (2010, p. 192), as I have argued previously when I stated that biopolitical care is tailored to the protection of society rather than the care for the individual drug user.
Drug politics are a form of bio-politics, in that decisions about drugs and for drug users directly and indirectly impact drug users’ lives. Moreover, as I will attempt to show, many bio-political decisions are aimed at increasing control over drug users. As
Bourgois states, “the bio-politics of substance abuse include a wide range of laws, medical
interventions, social institutions, ideologies, and even structures of feeling” (2000, p. 167).
As I have argued, bio-politics is linked to clinical medicine, in that such practices of control over drug users are present mostly within practices that view drug dependency as predominantly a medical issue. The biopolitical care for drug users in Denmark I will focus on in this chapter is exerted through rules and regulations within medical substitution treatment. Nonetheless, it affects other issues than those as well, including but not limited to social aid, (pre)pensions, and social housing.
Biopolitical Care: Anonymous and Destructive
“I can tell you exactly what the problem is with health care nowadays. It’s all bureaucratic stuff doctors are dealing with, paperwork, surveillance. Doctors and nurses are no longer able to do their work, to help people. They are writing stuff down, paper work that could also be done by their secretaries.” (Freja, member of the Copenhagen drug users union).
Stevenson describes biopolitical care as synonymous to bureaucratic care (2014, p.3). On my first day of fieldwork, Freja voiced exactly that word: bureaucratic. During Stevenson’s fieldwork exploring the social, political, and personal complexities regarding the incredibly high suicide rate amongst the Inuit population in the Canadian arctic, she finds that the Canadian state’s response was a form of care that was aimed at decreasing the suicide rate of the population, not directed at the individual. The actual names of the individuals did not come to matter; these individuals became just numbers, their suicides documented anonymously for bureaucratic purposes (ibid, p. 27). Quite adequately then, she also terms these forms of bureaucratic care ‘anonymous care’ (ibid, p. 5).
Opioid users in Copenhagen are also provided with such forms of anonymous care, for instance at a low threshold, anonymous health clinic located in the center of Copenhagen. Here people can come anonymously to get “checked up and treated without
their name”, especially helpful for people that have “jumped from the jail” or those that “don’t come home from their weekend leave”, as I am told in a conversation with a
member of the Copenhagen drug users union. At the health clinic, there are nurses to check on injection wounds or other physical ailments, there is a drug-injection facility
supervised by medical personnel, and there are social workers to talk with about any problems regarding housing, employment, etc. The anonymizing of such care practices is framed as a way to accommodate drug users, “meet them where they are at” (Asmussen, 2003, p. 10). Stevenson however describes how the Inuit perceive anonymous care provided to them by the state as un-caring and even murderous, as it does not matter “to
whom the state cares” (Stevenson, 2014, p. 4). Likewise, a member of the Copenhagen
drug users union told me that “these people don’t care about you, they don’t know who
you are, you might as well be dead”. I have taken on Stevenson’s description of
biopolitical care in the Canadian arctic perceived as potentially murderous by the Inuit population, but refer to such practices in Copenhagen as potentially destructive. Later I will contrast such destructive ways of delivering care to the constructive care available to members at the Copenhagen drug users union.
Taylor, in her essay on caring for her mother with dementia, outlines the ways in which recognition is linked to caring (2008). She troubles the inclination people often have to interpret as uncaring the struggle individuals with Alzheimer experience to recognize friends and family. However, she does acknowledge that recognition on behalf of the caretaker is inseparable from caring (ibid, p. 236). She references Margalit, who in his book on the ethics of memory tells the story of an Israeli officer who publicly confesses to have forgotten the name of the soldier that was killed (Margalit, 2002, as cited in Taylor, 2008, p. 318). The
anonymous death of the soldier was received with outrage: not memorizing the soldier’s name was perceived as not caring for the soldier at all. Here the anonymousness of care is experienced in the same ways as in Stevenson’s Canadian arctic: murderous or destructive.
In a conversation with Morten, one of the more politically active members I have met at the union, he cries out correspondingly: “How many
realize something is wrong and needs to be changed?” During another conversation with
him he similarly described experiencing governmental or biopolitical forms of care for drug users as destructive: “It is so fucked up, you know, they don’t even care, they want us
to wait and die, so that we don’t cost money to them anymore.” Often I have experienced
situations or heard stories from drug users having to wait very long times for forms of biopolitical care. In response to the death of a drug user who was waiting for social aid, a heroin user ironically posted on his Facebook page that a death certificate is often a good start if one wants to obtain an early retirement pension in 2015.
Biopolitical Care and Control in Substitution Treatment
The way in which decisions by the state or government directly impact vital aspects of people’s lives was clearly illustrated during my time in Copenhagen in the debate around buprenorphine substitution treatment. Just like methadone and ‘pharmaceutical’ or ‘medicinal’ heroin, buprenorphine is a substitution medication for heroin users in pharmacological treatment. Such pharmacological treatment aims to either aid heroin users during the detoxification process or is used as an alternative to illegally acquired heroin. Buprenorphine is marketed as Subutex, which is actually a mixture of buprenorphine and naloxone. Buprenorphine is medically termed a ‘partial opioid agonist’, which means it binds to the opioid receptors in the brain to relieve drug craving but without producing euphoric effects. Naloxone is medically termed a ‘pure opioid antagonist’, which means it prevents opioids like heroin to bind to receptors in the brain to counteract its euphoric effects (Diana, 2011). Moving away from such biomedical explanations of the workings of Subutex, we could describe the substitution medication as a pharmaceutical block to pleasure, as Bourgois argued similarly for methadone treatment (2000).
Because of Subutex’ pharmacological combination, one has to be completely free of opioids in the body when starting buprenorphine treatment; otherwise the drug causes extreme agony and sickness. In this way, substitution treatment exemplifies a form of biopolitical control. If individuals in substitution treatment were to use illegal drugs—and in that aspect fail to be well governed by the biopolitical control present in such treatment—this would severely impact vital aspects of their lives. They could get extremely sick from so-called withdrawal symptoms and could even die. Die from what we could call overdose, putting responsibility with the user, or from what we could call
poisoning, putting responsibility with the biopolitical care apparatus here in the form of substitution treatment.
In 2015, a new act passed in Copenhagen stating that 50% of all heroin users in substitution treatment in Denmark should be on buprenorphine. Currently, that number was between 12% and 30%. In order to analyze the ways in which the buprenorphine debate exemplified a process of bio-politics, I will first elaborate on Bourgois’ article on methadone treatment as a form of biopower in the United States (2000). The buprenorphine debate seems almost a replica of the debate around methadone 15 years earlier.
Methadone Substitution Treatment
Bourgois argues that methadone substitution treatment is a concrete example of biopower at work: the differences between methadone and heroin, medicine versus drug, and legal against illegal, rest completely on distinctions made by the state and medical authorities. Distinctions that mostly work to increase control, decrease pleasure and ensure productivity (2000, p. 176). As previously explained, biopolitical care links to the emergence of clinical medicine. Here as well, the distinctions above are based primarily on the biomedical theory of addiction, originating from two American doctors during the 1960s who defined addiction as a physical disease caused by a pharmacological “imbalance” in the subject’s brain (Dole & Nyswander, 1967, as cited in Bourgois, 2000, p. 169). Heroin use—originally a cure for morphine addiction—could now be cured by taking yet another opioid, namely methadone. In the same ways that heroin is more addictive than morphine, methadone’s medical potential in the treatment of heroin dependency rests on the fact that it is much more physically addictive than heroin. As it powerfully triggers the same neural pathways heroin would, methadone actively blocks the euphoria heroin consumption would trigger (ibid, p. 170).
Besides these better-defined biological forms of control, methadone substitution treatment exerts control over its users in other ways. In his article, Bourgois gives numerous ethnographic descriptions of individuals feeling constraint by methadone’s rigid institutional regulations. Often users need to visit a clinic 2 or 3 times a day to pick up their ‘medication’, sometimes obliged to take said medication under supervision. Obedience to such rules implies an extreme difficulty for users to organize their lives around the clinic visits. Borgen, an older Norwegian heroin user who moved to Denmark
and was now a member of the Copenhagen drug user union, explained how his MMT had stood in the way of him getting an education:
“It [methadone] takes away your freedom you know, you have to get it everyday at the
clinic. Two, sometimes three times a day. That is why I couldn’t finish my studies. I was studying Egyptology, but the clinic and the university were at opposite sides of the city [Copenhagen], so I would always miss my morning classes. Especially when it is so busy at the clinic in the morning, everybody tries to come before work or school, so you end up waiting 1,5 hours. They say you can get it at 8, but that is not true. It always takes so long. In the end I just stopped going [to class].” (Borgen, member of the Copenhagen drug users union).
An aim of bio-politics is to implement good conduct into the heart of its population. Foucault termed this governmentality, describing the ways in which individuals and populations are governed by certain techniques and procedures (2013). The biopolitical care system rewards those individuals instilled with governmentality and punishes those that do not succumb to its means of control. In line with this aim, exceptionally compliant and well-governed methadone users are allowed to take their medication with them (Bourgois, 2000). Such take-home methadone is sometimes sold on the streets, its profits used for the procurement of heroin. Authorities often perceive such selling of one’s medication as criminal, deviant, and illogical behavior. However, users perceived it quite contrarily:
“It’s quite logical, this [points to heroin], is the stuff we want. If we cannot get that, of course we will make some extra economy by selling this [points to methadone].” (Member of the Copenhagen drug users union) “I came back from Norway 8 years ago, and I completely quit my criminal [activity]. I came back, did the substitution treatment, and started my normal life. It was hard, you know, but I did it. But then started the toothaches, and I had to sell the pills [methadone], and
self-medicate with this [heroin]. But that is not criminal, because I have gotten it from my doctor.” (Member of the Copenhagen drug users union)
One of the reasons Buprenorphine was now promoted as a preferred substitution medication was the claim that it was not likely to seep into such illegal drug markets. I learned however, that this and other claims about Buprenorphine were not the truth, as I will elucidate below.
Buprenorphine Substitution Treatment
Speaking to drug users in Copenhagen has taught me that every substitution method has its advantages and disadvantages, and different substitution methods work for different individuals. As Bourgois argues, a significant minority of opioid users experience methadone as helpful to stabilize their lives and withdraw from heroin use. A majority however finds the effects much more mixed and most find them counter-productive (2000, p. 170). Likewise, a social worker at the anonymous health care clinic described before told me that some users find buprenorphine to be extremely helpful, and are satisfied using that form of substitution treatment. However, a new rule passed court in Denmark in 2015, which stated that 50% of people
in substitution treatment should be on buprenorphine. Apparently, this 50% kvoter (=quota) had just been a wild guess, a guesstimate if you will, by a politician in an interview in 2013. Though not scientifically grounded, this guesstimate was now used as a guideline. Currently, 12% of individuals in substitution treatment in Copenhagen receive buprenorphine. In other Danish cities that number was up to 30%. This meant that some individuals on other substitution medication would be switched to buprenorphine, causing withdrawal symptoms
through the neural mechanisms outlined earlier. Besides this, the majority of new individuals requesting substitution medication would be put on buprenorphine— regardless of whether this type of medication would suit them best when looking from other perspectives. Doctors and medical institutions receive money from the government following these guidelines and as a result the new rule would make doctors more inclined to prescribe buprenorphine to their new patients, pushing patients to
Picture 4: "Should there be a quota for Buprenorphine?"
meet the quota. Several organizations for drug users were having a meeting about this decision and I was invited by Morten to join the discussion. As he proclaimed: “I won’t let
these fuckers control me. I’m fighting this war6. I’m fighting it for all the people [drug
users] that cannot even do this anymore [mimics opening a door].”
Morten and I met up the morning of the Buprenorphine debate in front of Claus Ankersen’s artwork on Enghave Plads. Enghave Plads is close to the so-called Big Pharmacy behind the central station (Hovedbanegården) where people go to buy and sell their drugs. From Copenhagen’s Hovedbanegården, the long street called Istedgade brings you to the square with Ankersen’s poem written on the wall. Istedgade is famous for its sex workers and ‘ragged people’, and Ankersen’s poem describes exactly that: praising the street and the square for its street boys (gadedrenge), urine smell (stinkende pissoir), and shit in its gutters (skider I renderne). Morten tells me he met Ankersen during a trip in Bratislava with a woman he was introduced to at the Copenhagen users union, and that they are great friends since. “Ankersen is a great artist
(kunstner), he is not afraid to discuss difficult contemporary topics such as alcoholism and drug use.” He then said, jokingly: “I am a kunstner too, you know. A tusind-kunstner [con-artist]!” We laugh and make our way to a shelter for homeless and drug using women. At
the shelter there are several showers, a kitchen, places to sleep, and today the room looks like a conference room, with a big beamer and several rows of chairs occupied by a wide variety of people. A member of the organization that aids marginalized individuals with legal matters is present as well, and one of their members explains to me:
“We are not saying that buprenorphine should be banned altogether. The way we see it, it is like a menu: the more choice the better. But forcing people to take a certain substitution medication, or worse yet: to switch from one substance to the other, causing terrible withdrawal symptoms as well as various side effects, that is wrong. Today we will go through the Kommune’s [Danish government’] arguments to do so one by one, and see if what they claim is in fact actually true.” (Member of the organization dealing with legal matters for marginalized
individuals).
6 Here Morten is referring to the War on Drugs, popularized by Nixon’s statement in a press conference in 1971 (Nixon, 1971) but originating around 100 years ago in the first US prohibition act on psychoactive substances through the Harrison Narcotics Act (Keys, 2009).
“What they claim” is threefold. First and foremost, the Kommune argued that it is nearly
impossible to overdose on buprenorphine. Sadly though, this claim is not true, explained the presenter as he showed numbers and figures from Denmark and other countries. In one of the latest numbers on the causes of death by overdose in Finland for example, 34 out of 156 deaths per year per million were caused by buprenorphine: the “hyppigste
dødsårsag” (leading cause of death), higher than methadone and heroin. Secondly then,
buprenorphine as a substitution medication was promoted because it is believed to have zero potential to trickle down to the illegal drug market. This is because the political authorities do not believe in the euphoric inducement of buprenorphine. The speaker also rebutted this claim, showing how in countries like the United States and Norway, there is a big illegal market for buprenorphine. The last, but perhaps most important reason, links back to buprenorphine’s potential for the black market. Because the treatment system considers buprenorphine to lack euphoric inducement ability as well as illegal market potential, drug users in substitution treatment with buprenorphine will be able to take it home with them. This in contrast to the rigid institutional regulations at clinics where drug users have to take their ‘medication’ under supervision. As such, it could be the case that drug users will choose or at least not make efforts against being told by their doctor to take buprenorphine. People who are seeking less control over their lives, or those that do not fit the time schedule of the clinic, would rather take buprenorphine, regardless of whether this is the right substitution treatment for them when viewed from other perspectives. All together, those present at the meeting agreed that ‘the 50% kvoter’ should not be installed, due to the forms of biopolitical care I have outlined above; care that is aimed at control and is potentially destructive.
Heroin Substitution Treatment
The last form of substitution treatment and its links to biopolitical care I will discuss is the medicinal heroin treatment that was introduced in Denmark in 2007. Here too, the problems lie in control exercised through institutional regulations regarding pick up times and frequency, and in chemical as well as institutional blocking of euphoria. During one day of fieldwork, Jensen sat me down and told me that I had to write about the following scenario in my thesis. He told me to imagine a situation in which the government told a couple of heroin users that they would give them free heroin. “What
of such services in the form of HATs, I replied with a question, asking him why not all members of the Copenhagen users union would get their heroin at these clinics. If we recall the ‘research in the wild’ conducted at the Copenhagen drug users union in 1997 and discussed in chapter 1, we see that 76% of its members would choose heroin treatment if available. Today however, only around 25 of opioid users received HAT.
“Indeed, we have HAT, but the Swiss heroin, the medicinal heroin we have here in
Denmark, it is straight diamorphin. There is no other alkaloids in it, it is 99 percent pure. The one we favor is about 80 percent pure, and then it has about 20 percent other alkaloids, morphine, codeine, and there’s one more. It gives it another euphoria. The one they get in a clinic is minimal euphoria. Typical, right? But still, why would people go on the street if they can get it for free at the clinic? It is because they treat you condescending at the clinic, and the clinics are always far away. They control you and can have your children taken away.” (Jepsen, member of the Copenhagen drug users union).
Although the heroin within HAT does not work to prevent inducement of euphoria, it still attempts to minimize the euphoria experienced by its users. The number of individuals in HAT in Copenhagen was very low, which is counterintuitive given the fact that these individuals are heroin dependent and want precisely the substance offered within HAT. Only one of the members of the Copenhagen drug users union received HAT, and it took her an hour to get to the clinic and another to get back to the union, twice a day. Like Jensen argues, she reported feeling treated condescendingly at the union and had difficulty finding occupation and as such generate income due to the institution’s rigid regulations regarding medication pick up times and frequency. Another member told me that she decided not to enroll for HAT because the surveillance at those clinics was very strict, and as she had children she did not want to risk losing them. Since she could just as easily get heroin on the street, she decided that this was a safer option.
During a visit at the anonymous health clinic, I spoke to one of their social workers. We discussed the heroin trials and he compared the way heroin is treated at heroin clinics to the way weapons are treated in other places:
“Nobody knows when the heroin arrives, the heroin is always guarded by a large number of guards, and people have to come in twice a day. In the morning they take their fix, they cannot take it outside with them; they have to take it inside the building. Then in the afternoon they come in again, for their second fix, and they get methadone for the night or the next morning. But it is quite weird that they treat it like that, like weapons. Heroin is the stuff they want, why would they sell it, you know? A lot of people want to be able to take it home with them, to be able to have a job and stuff. Also, you can only get
heroin-assisted treatment when you prove not to benefit from the methadone treatment.” (Social worker at the anonymous health care clinic).
Medicinal heroin treatment, although implemented as a form of care for drug users, was not enjoyed due to its elements of control and the patronizing and condescending ways the individuals were treated at the facilities; again, an example of bio-politics at work. As I described in chapter 1, the Copenhagen drug users union argued for injectable methadone instead of ingestible methadone, because that method of consumption would be better received by drug users and as such be more successful in resolving ‘drug problems’ like the illegal procurement of drugs at places such as the Big Pharmacy at Copenhagen’s Hovedbanegården. Similarly here, an improvement of the (biopolitical) care within HAT, i.e. treating its users less condescending, less rigid institutional pick-up regulations, and an overall decrease in elements of control, would probably lead to an improvement of the situation regarding illegal and unsafe opioid use.
Generalization
“Substitution treatment should be individually tailored to drug users’ needs in order to ensure the best outcomes. Otherwise we keep switching people on their medication, which could lead to irritation, deregistration, pain, sickness and even death.” (Social worker at the anonymous health care clinic)
Decisions about substitution treatment, made by what Rasmus called “people with no
life-experience, making decisions about stuff they don’t know anything about”, directly
impact the users vital aspects of life. Here, biopolitical care potentially leads to
“irritation, deregistration, sickness, and even death.” This point also illustrates the
