PRESCRIPTION OPIATE ABUSE IN RURAL CANADA: AN ANTHROPOLOGICAL PERSPECTIVE

Benjamin E. Prichard

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1+1 Canada Abstract

This study is centred around field research conducted in a small Ontario town. The majority of participants were health professionals who have worked with prescription opiate users in some capacity. Another significant group of participants were grassroots anti-drug activists, most of whom have been personally affected by prescription drug use.

This project seeks to explore the ways in which local history, biomedicine, and governentality have intertwined to influence current drug use trends. In exploring these subjects, work from a variety of anthropologists (and medical anthropologists in particular) has been utilized.

Definitive conclusions as to what has contributed to a spike in prescription opiate abuse could not be drawn. Instead, my research points to the need for critical engagement with concepts such as addiction and health.

iv Acknowledgements

To the members of GHA, who have inspired this project from the outset. I am also indebted to all the people who have agreed to participate in this project, and consequently, made it possible. I would also like to thank my fantastic supervisory committee for helping me painstakingly navigate through draft after draft.

v Table of Contents Title Page i Copyright Page ii Certificate Page iii Abstract iv Acknowledgements v Table of Contents vi Chapter I - Introduction 1 Awakening 1 Summary of Chapters 3 Intentions 5 Theoretical Framework 6 Oxycodone Abuse and the Town of Cartref 11 Chapter II - Methodology 20 Section 1 - On My Positionality 21 Working With GHA f ? 26 Section 2 - Ethics and Preparing for ' the Field' 28 Section 3 - ' The Field' 31 Entering ' The Field' 31 Immersion in ' The Field' 33 Exiting ' The Field' 35 An Introduction to the Informants 36 Section 4 - Challenges and Limitations 40 Chapter III - A Medical Anthropological Perspective 44 Section 1 - Some Medical Anthropological Outlooks On Biomedicine 44 Section 2 - Critical Medical Anthropology and Biomedicine. 47 Conclusions 50 Chapter IV - A Chemical Solution to a Discomforting Experience 52 Section 1 - Logging and the Early Years: 54 Section 2 - Industrial Fordism Comes to Town 61 Section 3 - The Customer is Always Right: Service Work, Tourism, and Cartref. .67 Chapter V - Biomedicine and the Production of Truth 78 Section 1 - Biomedical Definitions of Disease, Drug-use, and Addiction 79 Section 2 - Nikolas Rose on the Construction of Biomedical Truth 85 Section 3 - The Profit Motive in Relation to Addiction and Pharmaceutical Drugs 89 Conclusions 94 Chapter VI - Governing Drug Use 95 Section 1 - The Art of Government 97 Section 2 - Addiction As Power 100 Section 3 - Governing With Methadone 102 Section 4 - Social Morality, Fear of Addiction, and Power 110 Section 5 - Biomedicine, Drug Use, Addiction, and Social Control 112 Conclusions 118 Chapter VII - Conclusion 121 Appendix A - Interview Schedule 124 Typical Questions Asked of Interviewees 124 vi Works Cited 125

vii Chapter I - Introduction

Awakening

My conception of the town of Cartref changed forever when I watched one of my friends shoot up one summer afternoon. For years I had been witness to an intensifying drug scene there, and I already knew that people such as my friend were shooting up oxycontin (among other opiates), but something about witnessing the practice firsthand really made an impression on me. This could partly be explained by the fact that I had no time to prepare myself mentally for this event, but was more likely due to the fact that it put a personal face on drug use. I felt that under different circumstances my friend and I could - quite literally - have been be sitting in opposite seats.

That incident took place right after I had returned from a year living and working in Turkey and

South Korea after completing my undergraduate degree. I was back in my hometown, a place I have always regarded as safe and idyllic. My buddy picked me up in his car and we were going to go sit out and drink a few beers on a lake in the summer sunshine. He knew I have always been fascinated with drug culture, so in a weird way, he may have thought that was doing me a favour. He pulled his car in behind a local marina and told me that he needed to shoot up. He was already tying his arm off with his belt as I began explaining that, while I was curious, I had reservations about even playing the role of witness in the whole thing. He assured me it was no big deal and flipped the car floor mat to reveal a small kit. I was wondering how this was going to work. Would I have to drive after he injected and would he turn into a drooling mess the minute the opiates kicked in? What if we were pulled over by the police? Did he even own this car? Things progressed quickly, he popped two 40 mg OxyContin

1 pills into his mouth and sucked the coating off. He then crushed them and put them into a blackened spoon. Following this he asked me to hand him a water bottle from the back seat and he poured some water into the spoon mixing the powdered pills into it. I was now complicit and began to feel guilty.

What if he died? Among the myriad thoughts that went through my head, I couldn't help but think how unsanitary it was to inject days old water from a normal bottle of drinking water into your veins. The contents of the spoon boiled, and he asked for a filter from my cigarette. He then said; "You shouldn't smoke; that shit will kill you." I was pretty sure he was trying to get a rise out of me, but he said it in such a dead pan manner that I couldn't be certain. The question nags at me, what could be worse than what he's doing? He then sucked the liquid up into an insulin needle, fully tied off his arm, and exposed the veins. I looked at his arm and was surprised when I didn't see any awful purple track marks, just a little scab. He pushed the needle into it and injected the drugs. While it was evident that the drugs had a psychoactive effect he was not nearly as "high" as I had expected. He definitely seemed more relaxed than a moment before. His eyes were glazed and he had an aura of contentment surrounding him. However, he was still capable of carrying on a conversation, and - much to my horror

- driving.

Over the course of the summer I learned that my friend had a prescription for methadone that he took regularly. The methadone was ostensibly prescribed so that he would no longer use illicit opiates.

This placed him in a weird nexus, somewhere between patient and addict. He described the process of obtaining a prescription for methadone. He explained how he had to visit an out of town doctor (at the time there was no local doctor who could prescribe methadone), and the difficulty, expense, and embarrassment associated with filling the prescription in town. Up until this point in my life it had never really occurred to me how many shades of grey there were between patient, addict, criminal, and

2 ideal citizen. I had always been interested in the ways the state interacts with people who choose to use illicit psychoactive substances, but until this point I had only really considered the relationship between people who use these substances and the criminal justice system. I began to see, and become interested in understanding, the multiple layers of government and private interest involved in shaping the interactions we have with drugs. I began thinking about the ways addiction is talked about and imagined by a variety of stake-holders, as well as the ways in which treatment is offered and support networks are built for addicts. I was particularly interested in understanding the ways addiction is conceived of in small towns, and specifically in the town of Cartref where I grew up. Four months later

I began my Masters studies in anthropology and after careful thought I decided that I would explore the subject of how opiate addiction is conceptualized, enacted, and treated in a semi-rural environment such as Cartref.

Summary of Chapters

This thesis is comprised of seven chapters. The first chapter is concerned with introducing the subject matter and framing the arguments contained in this research. Chapter II provides an analysis of the methodological approaches employed in this thesis. Careful attention is paid to investigating the ways in which my positionality has influenced this research. That is, being a life-long resident of

Cartref brings with it certain emotional investments, insights, and hindrances that will be unique to this project. The nebulous distinctions between entering/exiting the "field," participant and acquaintance, data and small-talk are thus major topics of investigation in this chapter.

Chapter III gives a general overview of some of the ways biomedicine and disease are talked about within the field of medical anthropology. This chapter begins by introducing several different

3 models from within medical anthropology which are used to explain disease. The second half of this chapter focuses on a particular movement within medical anthropology termed critical medical anthropology. This is important for framing the remaining chapters of the thesis as critical medical anthropology implores researchers to question biomedical truths and investigate the social origins of disease.

Accordingly, Chapter IV is an exploration of the role played by Cartref s political, economic, and historic context in local oxycodone use habits. This begins with an investigation of the industries upon which the town was founded, and more importantly, the way this work is remembered today.

Consideration is given to whether the changing nature of work available to young men in Cartref today has influenced the ways in which they perceive themselves.

The next chapter also argues for a critical medical anthropology approach. Specifically, the writings of Foucault are employed in order to critically engage with the production and dissemination of biomedical discourses of truth. The chapter begins by exploring the ways in which conceptualizations of addiction and drug use have changed over time. Following this, a section is devoted to exploring the ways in which profit motives can influence larger biomedical systems which generate truth. The final section of this chapter concerns itself with exploring the profit motive in biomedicine as it specifically pertains to pharmaceutical drugs. Here the contested nature of biomedical truth is rendered visible as the struggles between healthcare professionals, large pharmaceutical companies, and academics to define biomedical truth in relation to opiate addiction is elucidated. Thus, this chapter concludes in noting that the profit motive is not the sole influence on the production of biomedical truth.

Chapter VI is the final substantive chapter of the thesis. This chapter is concerned with

4 analyzing the issue of governmentality and drug use. It is thus an investigation of some of the other powerful interests that influence biomedical knowledge and our relationships with drugs. The chapter begins by explaining Foucault's concept of governmentality. Following this is an exploration of how some of the more pervasive drugs in our society (such as caffeine, nicotine, and alcohol) have been used to influence human behaviour. The next section investigates the ways in which prescription opiates used to "treat" addicts can also be used to govern the behaviour of patients. The proceeding section elucidates the ways in which fear of particular substances and addicts/others have been used in the process of governmentality. The final section of this chapter explores some of the ways that biomedical discourses on addiction serve a social control function by disguising the social origins of disease. In Chapter VIIII provide my final conclusions on this study. This entails a review of the research in an attempt to link the various ideas together.

Intentions

The primary goal of this thesis is to describe oxycodone abuse and its increased usage in rural settings like Cartref. One of the main contributions of this research lies in the fact that to date the bulk of research into oxycodone use has been quantitative (e.g. Cicero et al. 2005; Grau et al. 2007; Havens et al. 2006; Havens et al. 2007; Sigmon 2006). The qualitative analysis of this phenomenon is important because it allows us to understand the social and individual aspects of this phenomenon.

Previous studies on this subject identify the percentages of people in communities who use these drugs recreationally, the age of the average user, their ethnicity and their income (Cicero et al. 2005; Grau et al. 2007; Havens et al. 2006; Havens et al. 2007; Sigmon 2006). However, many important substantive questions have been left unexplored. For example: Why has this become a drug of choice? When and

5 why do users decide to access treatment? How do professionals charged with helping these people conceive of this particular addiction? How are their conceptions shaped by their professional training, and how does this affect their interactions with users? Therefore, at its core this thesis is concerned with examining the ways in which oxycodone abuse is talked about, imagined, evaluated, treated, and experienced in semi-rural environments. In my attempts to address these questions I have interviewed and worked with doctors, police officers, social workers, judges, drug councillors, local anti-drug activists, probation officers, priests, children's aid workers and federal prosecutors, among others. The variety of participants I interviewed helped to provide unique kinds of information and valuable insights.

In contrast to a lot of research on prescription drug use, this thesis is not centred around the study of addicts. Instead, the majority of the data was obtained in talking to professionals in order to map out some of the ways in which professionals understand and shape the experience of drug addiction. In addition, I investigate addiction in Cartref by analyzing the historical, political, and economic context in which it is occurring. Moreover, because biomedical discourses around health and addiction are at times presented as objective truths in medical and scientific literature, a critical engagement with these discourses became another important goal of this project. Finally, this project also seeks to investigate some of the ways in which drugs, and conceptualizations of drugs, can be used to influence people's behaviour.

Theoretical Framework

All of the primary research upon which this thesis is based was conducted in a town in North-

Central Ontario. Everyone I interviewed lives or works within close proximity to the town. However, a

6 proper understanding of the phenomenon of oxycodone abuse as it occurs locally cannot be produced without considering the broader context as well. That is to say, while this thesis seeks to examine the topic in a particular location, much of what has affected the character of oxycodone use began outside of the town, and this document must speak to those factors as well. This is in keeping with the "trend theory" advocated by anthropologists Agar and Reisigner (2002) to analyze the dynamics behind clusters in heroin use. They argue that "explanation of a phenomenon of interest is not available in the location where that phenomenon takes place. Instead, events - most of them at remote social locations

- unfold and interact over time, and the local phenomenon is only one of a number of factors involved"

(372). Thus, while the ethnographic research provides insights into how this form of drug use is conceptualized locally, I also examine how these conceptions link up with powerful actors and events which may at times be very large in scale, even global. To properly address particular questions - such as why this drug has recently become so popular among both addicts and physicians - processes which originate far beyond the borders of the town of Cartref will need to be considered. This orientation has important implications for the applicability of this research.

Anthropological sources that deal specifically with the subject of oxycodone use are scarce.

That said, in my research I have come across several anthropological sources that are relevant to understanding narcotic analgesics more generally. Under the Counter: The Diffusion of Narcotic

Analgesics to the Inner City Street (Vivian, Saleheen, Singer, Navarro, and Mirhej: 2005) highlights the necessity of a research project such as this by stating that there is a "compelling need" for more research on this subject (2005: 113). The goal of the authors was to determine the extent to which prescription narcotics are circulated on the street (2005: 102). In contrast, I begin my research from a position that acknowledges the prevalence of this trend. Moreover, my research is focused on rural

7 contexts rather than inner cities.

A second relevant source that specifically explores the topic of prescription opiate abuse is entitled Addiction Markets: The Case of High-Dose Buprenorphine in France. Lovell argues that what an opiate antagonist is understood to be by people changes as it crosses markets (2006: 137). In a particular time, context, and location a drug can be perceived of as a valuable medical tool. However, in a new context under new patterns of consumption a commodity such as buprenorphine can rapidly change from medicine to psychoactive substance. That is, while this drug is used in France to treat opiate addiction (and advocated by some of my own informants as the most foolproof medication available for this task, especially when mixed with naloxone) it is also frequently sold and used illicitly.

Lovell terms the process where the drug leaves one market and enters another - and in the process receives a new status - as "leakage" (2006: 156). Her research underscores the complex and socially constructed nature of the consumption patterns of prescription opiates.

The work of Philippe Bourgois has also been immensely important to this research. His work investigates the abuse of methadone in order to understand the ways in which it is employed within the biomedical framework "to inculcate moral discipline into the hearts, minds, and bodies of deviants who reject sobriety and economic productivity" (2000: 167). The theoretical insights of Foucault are central to his argument. Bourgois is concerned with investigating the ways in which powerful actors like the state attempt to shape the way people interact with drugs, and why. This is relevant to my own goals of understanding how and why oxycodone addiction might be conceived of and experienced in particular ways in particular contexts. Moreover, Bourgois' commitment to "break with much of the tradition of second generation Foucaultian scholarship" and instead to follow Foucault's call for "specific intellectuals" to take political positions and fight back is also alluring (2000: 188).

8 The work of anthropologists not directly concerned with studying prescription opiate abuse - specifically the Critical Medical Anthropology (CMA) approach defined and advocated by Merrill

Singer and Hans Baer - has also been helpful in thinking through the issues raised in my research.

Many of their insights have been generated out of their monograph entitled Critical Medical

Anthropology. Singer and Baer state that CMA rejects idealistic or postmodern tendencies to spurn materialist perspectives in science. By contrast, CMA seeks to create socially informed analyses of these phenomena. However, this does not entail an uncritical acceptance of science as truth. They understand science to be culturally constructed, incorporating features of the dominant ideology (1995:

49-50). Their critical outlook on health and sickness is heavily influenced by theoretical contributions from Marx and Gramsci. Thus, inherent to the CMA perspective is Marx's recognition that the most prevalent modes of thought within a given society largely embody the interests of the dominant social class. Additionally, they employ Gramsci's notion of hegemony in order to examine the ways in which these capitalist conceptions gain disproportionate representation in the ways some have come to conceptualize health and illness (1995: 60). Instead of abandoning a method of thought altogether for having been in many ways co-opted by powerful interests, this method recognizes a certain degree of value in critically engaging with it. Thus, CMA might be viewed as an attempt to disentangle scientific meaning from those powerful actors that use it to promote their own interests. Thus, a large part of this thesis will concern itself with examining the ways in which oxycodone abuse has, and is, made possible within the current biomedical framework. That is, the ways in which professionals under the influence of powerful hegemonies conceive of the process of addiction, and how this affects treatment options and outcomes.

The theoretical outlook advocated by Singer and Baer is also relevant to the current project in

9 several other ways. The first is related to the fact that CMA is highly concerned with analyzing the social origins of disease. That is to say, CMA seeks to elucidate the ways in which political and economic forces shape our conceptions of health and illness, as well as the methods available to us for healing (Singer and Baer 1995: 5). Addiction is one of the most striking examples of a "sickness" whose origins and definitions are socially constructed by powerful interests. OxyContin is developed and marketed by a multi-national pharmaceutical company and prescribed and dispensed by people with powerful social positions. Moreover, definitions of addiction to this drug and what this implies can change drastically depending on where a person's experience is located with respect to this drug. Thus, based upon an actor's positionality oxycodone can be understood to be an indispensable medical tool, a greatly feared menace to youth, or a much sought after pleasure commodity. Furthermore, the definitions pertaining to who is sick and who is deviant and how this comes to be are at the centre of highly politicized debate at the moment. This fact is evidenced by the political controversy surrounding whether addicts should be treated as patients or criminals. For instance, Tony Clement, Member of

Parliament for Parry Sound/Muskoka, created quite a controversy in his capacity as the federal Minister of Health when he stated publicly that he feels "supervised injection site[s] undercut the ethics of medical practice" (Blatchford 2008). It is not uncommon for the process of defining any disease to become highly politicized (Singer and Baer 1995: 77). However, with the aid of insights garnered through interviews with several key informant I will demonstrate this to be especially true in the context of prescription opiate addiction. More importantly, it is hoped that by demonstrating and critically engaging with the process by which this illness is socially constructed, valuable insights might be produced. Thus, one might say that this project is an exercise in Critical Medical

Anthropology insofar as the primary purpose of this thesis is to examine power and the social origins of

10 the experience of prescription opiate abuse.

Finally, this project also follows a CMA perspective in that the desired outcome goes beyond the production of knowledge for knowledge's sake. In Critical Medical Anthropology Singer and Baer state that "CMA asserts that its mission is consciously emancipatory and partisan: it aims not simply to understand but to change culturally inappropriate, oppressive and exploitive patterns in the health arena and beyond" (1995: 60). I hope that this research will generate rethinkings of commonly held truths about addiction and pharmaceutical drugs. I recognize that most physicians are genuinely motivated by a desire to alleviate suffering.1 However, as will be discussed later in much greater detail, their ability to help their patients is in many ways circumscribed by their positionality. This is because of the fact that many of the people I spoke to have been trained to seek solutions within the "existing institutional context" (Singer and Baer 1995: 36).

Oxycodone Abuse and the Town of Cartref

It is crucial to understand how disheartening the experience of addiction to oxycodone can be.

The following is a reflection written by a man I met by working with a group from Cartref named

Giving Hope to Addicts (GHA) in the summer of 2008. This individual has stopped using opiates for several years after a long and hard-won battle. He published this reflection on the social networking website Facebook and gave me permission to use it in my thesis as long as he was given credit. Thus, a brief look what the experience of opiate addiction felt like through the eyes of Justin Emery:

Like the world is a track, and everyone is lined up ready to take off at the blunt bang of an empty being fired from the starter's pistol. Everyone takes off, running towards success and happiness. A few individuals including myself start running as well, but we are going the opposite way on the track, backwards, the wrong way. No one notices at first because they're busy taking in the success that is building slowly. They may wonder where you

' Indeed, it was apparent to me that this was true of everyone I interviewed for this project.

11 are, but the human nature is to take care of one's self before others. Time goes by and the inevitable is going to happen. All those running the track backwards will eventually come in contact with the other runners. A few odd looks at first, possibly questioning the choices of the backwards runners, but they continue to run on, no need to stop at this point. Another lap. Very demanding, but the rewards are worth it. The track is scattered now, laps have gone by, we begin crashing into the forward runners, causing pain and resentment on both our parts. Exceptional worry begins to take place in those running forward, it is evident something is not right. Out of kindness and compassion the forward runners attempt to turn us around, but it fails, they can not comprehend what is happening. The backwards runners begin to hold grudges against the forward runners, no need for change, still able to run, not quite as fast, and the shoulders are starting to weigh a lot. More laps bring chaos as we can not maintain our pace, and we begin staggering from one lane to another, knocking over the other runners without stopping. Something is very wrong, why are they getting in my way. I am not doing any harm. The mind is acting curiously, telling us what to do, am I in control? Is it me or us? We or I? By the time that has been contemplated we are no longer on the track. Others keep running by, staring, whispering to each other. Very few stop. We have been interfering with their regular regiment of running towards the goal of success. We feel unworthy. It is clear however that there are others who have fallen off the track as well, possibly acquaintances, friends, enemies. It makes no difference at this point. Unable to get back on the track ourselves, it takes us all to do it, a small number become willing and proceed to start running again, forwards. Many laps behind, but on our way. We begin to catch up with the other who seem proud and resentments begin to fade. It is a very long track, the end is not in sight, but hope is. Taking twelve giant steps proves to be beneficial. Success is in reach.

I believe this quote to be a good place to begin to understand the realities of oxycodone addiction.

While it does not answer many of the specifics, I believe it is useful to illustrate just how opiate addiction might be experienced for a young man in Cartref.

Recreational oxycodone use is prevalent in Cartref. All of the individuals I interviewed who work with addicts in Cartref reported coming across increasing numbers of oxycodone addicts in the last five years. Probation officers, doctors, pharmacists, police officers, social and mental health workers, judges and prosecutors I spoke to were unanimous in their observations that oxycodone abuse was a significant and growing problem. They were also unanimous in their observation of just how destructive this addiction can be and how difficult it is for their clients to kick the habit. It was also

12 identified as a major problem in a 2006 report compiled for a local Addiction Services group. This report was undertaken by a private consulting firm using funding provided partially from a local drug awareness group named Giving Hope to Addicts. The purpose behind commissioning such a study was to assess the nature of all forms of drug addiction in Cartref and assess what can be done to help. While many other drugs are listed and studied as having potential to cause problems in town, OxyContin is singled out as particularly important. Thus, while the authors observe that many forms of drug use are prevalent in Cartref, OxyContin is deserving of "special mention as it seems to be a significant drug of abuse" in Cartref (Addiction Services 2006: 23).

The chemical oxycodone was first synthesized in 1916. It was synthesized from the toxic chemical thebaine which is present in ninety percent of the opium produced by a type of poppy named papavar bracteatum (Kalso 2005: S47). Through a chemical synthesis, thebaine is converted into oxycodone which was found to have medical applications, in contrast to thebaine which was pharmacologically useless. Thus, oxycodone first began to be used medically in 1917 when it was prescribed in Germany in order to treat acute pain (Kalso 2005: S47). However, in North America and

Australia oxycodone was used mainly as a combination drug for treating moderate pain (Kalso 2005:

S47-S48). Thus, until relatively recently oxycodone was only prescribed in Canada in small doses and in combination with other drugs. For instance, Percodan which was first introduced in 1959 contains 5 mg of oxycodone and 325 mg of ASA (popularly known as Aspirin) (CPS 2009: 1722). In 1978, a drug named Percocet was introduced to the Canadian market. Percocet is similar to Percodan, except that in this instance the 5 mg of oxycodone are combined with 325 mg of acetaminophen (popularly known as

Tylenol) (CPS 2009: 1722). The potential for abuse of these drugs became clear early on. Indeed, many people I interviewed stated that Percocet was used for its psychoactive effects prior to the invention of

13 OxyContin. However, both of these drugs are less than ideal candidates for frequent psychoactive use for two reasons. First, because they offer relatively small doses of the psychoactive agent (oxycodone) it would be difficult to repeatedly obtain prescriptions for enough of these pills to fulfil a full fledged opiate dependency. Second, because these drugs are combination drugs one cannot repeatedly abuse these pills in the way one can with non-combined opiates without serious health consequences. That is, while it is possible to take several of the 5 mg pills simultaneously to achieve the desired high, taking any more than eight Percodans (40 mg of oxycodone) would mean consuming more than the 2.4 grams of ASA per day which is safe for human consumption (CPS 2009: 257). In a similar way, taking thirteen Percocets (65 mg of oxycodone) would mean ingesting more acetaminophen than is safe for human consumption (CPS 2009: 24). While it may be possible to abuse drugs such as these on occasion, developing a physical addiction to oxycodone that demands hundreds of milligrams of oxycodone in a single day would quickly result in death. However, with the introduction of OxyContin in 1996 high dosages of oxycodone unbound to any other drug became available in North America for the first time. OxyContin (which is simply oxycodone in its pure form combined with inert fillers) became available to consumers in dosages of 10 mg, 20 mg, 40 mg, and 80 mg tablets (CPS 2009:

1665-1666) making systematic abuse of oxycodone more accessible to drug users.

Thus, it is not surprising that soon after the introduction of OxyContin to the North American market reports began to emerge about the appearance of a new demographic of opiate abuser. In contrast to the common conceptions previously held of opiate abusers - most generally associated with heroin abuse - these people tend to live in rural or semi-rural locations, are typically young and male, and most commonly describe themselves as "Caucasian" (Sigmon 2006; Havens et al. 2007). The trajectory of use is different for each individual, but some of the professionals I interviewed explained

14 that most people started using oxycodone first by swallowing the pills. However, they stated that as dependency grew, financial constraints generally push the user to ingest the pills more efficiently. For instance, if the pills are crushed the coating that ensures the chemical is released into the bloodstream slowly will be circumvented, allowing for a more instantaneous high. Friends and acquaintances that I have talked to also stated that crushing up the pills and snorting the powder gets them high faster and more efficiently than swallowing the crushed pill. Finally, because OxyContin is easily rendered relatively safe to inject by dissolving the crushed pills in water, many addicts will resort to this behaviour as the addiction progresses. This is because it takes significantly less oxycodone to get high when it is ingested in this way. Thus, a friend of mine explained to me that at the height of his addiction he could choose to snort four 80mg tablets of OxyContin or simply inject a single 80mg tablet to get high and prevent withdrawal. Therefore, it seems quite reasonable that most addicts on a limited budget would resort to injecting the drug because using it in this way reduces the price of sustaining their habit by three quarters. Moreover, the fact that users often inject this drug is alarming because the potential negative health implications for oxycodone users rises drastically when people start using the drugs intravenously.

Oxycodone enters the street market via myriad routes. Some users will seek out prescriptions for OxyContin by visiting their family doctors. Here they can exaggerate or lie about chronic pain

(among other ailments) to secure a legitimate prescription. Through my interviews I have also been made aware of the fact that there are a certain number of people in town who seek out OxyContin prescriptions with the sole intention of selling the pills to a drug dealer. Moreover, there are some individuals who are prescribed OxyContin by their doctors to treat the pain related with chronic illnesses such as cancer who do not like the effects of the drug. Many of these people are elderly and

15 unemployed so the money they can secure by selling these pills on the black market is very attractive to them. A friend told me about a man he knew suffering from cancer pain who preferred marijuana to the

OxyContin he was prescribed to treat his pain. Consequently the man arranged a deal with a local drug dealer whereby he could trade his prescription for the large amounts of marijuana he had trouble acquiring and affording under the current system. Prescription papers for OxyContin are also forged or altered. For instance, a Cartref resident was recently charged for altering the dosages on a legitimate prescription for OxyContin (Mahood 2008: 3).

Finally, prior to beginning this study I was told by a friend that some of the OxyContin that is abused in Cartref is not actually prescribed or dispensed there. He reported working for suppliers who had him drive to nearby communities to acquire large quantities of the drug. Moreover, this same acquaintance of mine reported being sent to border towns such as St. Catharines where he was to trade relatively large quantities of marijuana for bags of the pills that had come across the border from the

United States. Another instance where the 'War On Drugs' drives the prices up on a relatively benign psychoactive substance making it valuable enough to be traded for a seriously dangerous one. Once these pills hit the black market in Cartref they become highly valuable where they can sometimes fetch up to forty dollars for an 80 mg pill.

The reason that this problem with OxyContin has emerged must be in some part due to the fact that many mistakes were made in the way this drug was introduced and advertised in the North

American market. The American division of Purdue Pharma (the company which made OxyContin available to North Americans) has been found criminally guilty of misleading doctors and patients in claiming that OxyContin was less likely to be abused than traditional narcotics. Purdue Pharma has agreed to pay out more than 600 million dollars in fines and other payments, while the company's three

16 executives have also been found guilty and ordered to pay out 34.5 million dollars in fines (Meier

2007). While a lawsuit has yet to be brought against the Canadian division of Purdue Pharma, it is reasonable to assume that these mistakes have affected how OxyContin is prescribed in Canada, especially considering that similar patterns of abuse arose in semi-rural locations across Canada.

Indeed, this argument was made in a document produced by the Government of Newfoundland and

Labrador to study the rise in OxyContin abuse. In this document it is stated that even though

OxyContin may not have been marketed as aggressively in Canada for the treatment of non-cancer pain, it seems the marketing of OxyContin in the United States may have indirectly resulted in increased rates of prescription in Canada (Government of Newfoundland and Labrador 2004: 22).

Thus, physicians prescribed this drug in ways that would never be dreamed of for a similar drug such as morphine.

Whatever the reason, the number of oxycodone based pills being dispensed by pharmacists in

Ontario continues to grow. In 2005 there were 103 086 749 tablets of oxycodone mixed with Tylenol, and 43 574 576 tablets of pure oxycodone dispensed from pharmacies in Ontario. By 2008 the numbers of these pills prescribed had reached 142 127 886 for oxycodone and Tylenol and 68 946 771 for pure oxycodone. This represents an increase in prescriptions for each of these drugs of 28% and 37% respectively (IMS Canada 2009). This is an alarming increase in prescriptions over a period of only four years. Moreover, this trend becomes even more unsettling when one considers the fact that during the time that this increase was being realized, alarm bells about the potential for addiction related to this drug were being sounded (for example: Government of Newfoundland and Labrador 2004;

Lockwood 2007; Weekes 2006). The sheer quantity of this drug being prescribed is obviously a contributing factor in its abuse. This is because this drug can often find it's way onto the street from

17 legal prescriptions making the rampant legal dispensation a contributing factor in its non-medical use.

Indeed, a recently published study in The Canadian Journal of Public Health found that between 2002 and 2005 there had been a twenty four percent increase in the use of prescription opiates for non­ medical purposes. The authors further estimate that there are between 321 000 to 914 000 Canadians using prescription opiates for non-medical purposes (2009).

Finally, this form of drug use is of serious concern because of the damaging effects it has on those who use it in this way. Few would disagree with the fact that heroin addiction has traditionally been represented as a serious threat to public health.2 However, in terms of raw numbers oxycodone abuse currently kills more people in Ontario than heroin. Between 2004 and 2008 it is estimated that

464 people in Ontario died from overdoses of oxycodone, compared to 49 people who died from heroin overdoses in a similar period of time (Aulakh 2009). Furthermore, despite uncertainty around the exact number of oxycodone users who inject the drug intravenously, there was consensus among my informants around the fact that an injection culture has begun to take root in this demographic of opiate abuser. Thus, all of the same health concerns surrounding the spread of Hepatitis and HIV through sharing needles apply to this new form of opiate abuse as well. An additional risk to people who are physically addicted to opiates is the possibility that they will engage in risky behaviours in order to obtain money to feed their habits. Thus strategies like prostitution and stealing (and the consequences of being caught) develop that can put the user at risk of further physical harm. Finally, people who become addicted to oxycodone rarely only use oxycodone, at least in its pure form. They become poly- opiate users sourcing opiates from anywhere they can to prevent withdrawal. An informant explained to me techniques ranging from back alley water distillation of over the counter Tylenol with codeine to

2 What is contentious are the social and structural reasons that this is a threat to public health, a debate which will examined extensively later on.

18 injecting the liquid gel extracted from fentanyl pain patches (a very powerful opiate). I have also heard from another informant that addicts will make tea from ornamental poppy heads to prevent withdrawal.

Thus, in the quest to prevent withdrawal, all sorts of chemicals are ingested by addicts, many of which prove considerably more harmful than the opiate itself. For instance, an acquaintance of mine suffered liver damage from ingesting too much Tylenol while desperate to quell his cravings. While oxycodone abuse has not entered the public imagination as a threat to public health in the same way that the abuse of heroin has, it is evident that oxycodone is a significant drug of abuse in Cartref- and across Ontario

- and that the illicit use of oxycodone brings with it the possibility of serious health consequences for users.

19 Chapter II - Methodology

It has become something of a tradition for anthropologists to begin a project by attempting to identify the ways their positionality may have affected their research. Indeed, the understanding that knowledge relating to the interpretation of human experience is not scientific was one of the features that most attracted me to the discipline in the first place. That is, Clifford Geertz's statement that "man is an animal suspended in webs of significance he himself has spun, I take culture to be those webs, and the analysis of it to be therefore not an experimental science in search of law but an interpretive one in search of meaning" (1973a: 5) was very persuasive to me as an undergraduate student. I felt that once any facade of objectivity was eliminated we could get on with the important task of interpreting meaning from human experience. Thus, prior to offering up an interpretation of the things which inform drug use in Cartref, it is important to elucidate the ways in which my identity may have affected not only my interpretations, but also the data available to me. Different anthropologists have done this to different degrees, at different times. For instance, Geertz identifies how running from armed police after a raid on an Indonesian cock-fight allowed him to interact with villagers on a level that might not have otherwise been possible (1973b: 416). More than a decade later Rosaldo Renato argued that it was only after his wife died in the field - and he experienced the rage elicited of grief firsthand - that he could adequately understand and explain the practice of headhunting among the Ilongot. From this experience he drew the conclusion that "all interpretations are provisional; they are made by positioned subjects who are prepared to know certain things and not others. Even... good ethnographers still have their limits, and their analyses always are incomplete" (1989: 19). Therefore, in keeping with anthropological tradition, in this chapter I will attempt to be reflexive about how my positionality has affected this project. This chapter will also be used to describe the key elements of my methodology.

20 Section 1 - On My Positionality

I was interested in understanding drug use even before I began studying anthropology. I have family members that have been attending Alcoholics Anonymous meetings for almost as long as I can remember. However, it was after watching a video in my Introduction to Anthropology course about

Canadian anthropologist Wade Davis that my interest was solidified. In this video I watched Davis ingest hallucinogenic drugs (a bark containing DMT) in the Amazon. It was the first time I saw someone in a position of authority - a Harvard trained anthropologist - question whether or not those distinctions we make between drugs were inherently valid. In the years after viewing this film, oxycodone use became more and more prevalent in the town where I grew up. One of my close childhood friends started to use and I watched his life transform. I had always had a particular interest in opiates. In fact, we both did. I can remember watching the film Trainspotting together almost every day one summer. However, this interest culminated in very different results for each of us. He began using and I was left searching for answers. When I first tried to find information on this drug almost nothing was available. I would watch him use and what seemed like an endless stream of questions would be generated, burning at me. Thus, in the wake of a surge of oxycodone use in Cartref, it was these experiences that compelled me to develop a project that might answer some of the questions that myself, and a great deal of other people, were left asking themselves.

The fact that I grew up in Cartref has undoubtedly influenced the course of this project. Some of the interviews were conducted with people I knew fairly well, and almost all of the interviews involved people I was aware of to some degree prior to beginning. Consequently, I probably had a much easier time identifying and accessing participants than an outside researcher would. However, I believe the fact that I am from Cartref has most significantly impacted my research in lending me an a priori awareness of relevant local phenomena. This is in keeping with Noel Dyck's observation that "while a

21 fair amount of attention has been given to the role of biography in shaping fieldwork interactions, too little attention has been paid to the role of biography in shaping our awareness of research possibilities"

(2000: 49). It was my background as a resident of Cartref that made me aware of this problem in the first place.

Initially, I wanted to create a project that focussed on the addicts themselves. I felt that this would be the easiest route to understanding the phenomenon. Moreover, it being the case that I was friends with several people who were currently or formerly using I felt that I could access information which might not be available to many other researchers. However, as I began preparations for 'entering the field' I realized that this approach was not going to be feasible for two reasons. First, I realized that interviewing these people would be ethically dubious. This was because some of these people had stopped using oxycodone by the time I wanted to interview them, and I realized I could not talk to them without putting them at risk. That is, how could a person with no training in counselling ensure that conversations encouraging people to critically engage with their former drug use not result in cravings anew? Second, as I began to investigate the topic of oxycodone use I realized that much of the research published to date was already centred around talking to addicts culminating in too few critical analyses generated about the health care aspects relating to this issue. For instance, there were a plethora of quantitative studies on who used the drug recreationally (Cicero et al. 2005; Grau, et al. 2007; Havens et al. 2006; Havens et al. 2007; Kalso 2005; Sigmon 2006). I felt that my 'insider' status in Cartref (as a local and as the son of a well respected health professional) would also allow me a special ability to access professionals in town. It being the case that oxycodone use is mediated by professionals almost every step of the way - from acquiring a prescription from a doctor, to filling the prescription at a pharmacy, to getting caught up in the criminal justice system, to receiving methadone treatment -1 felt that a study which focussed on how professionals understand and shape the experience of oxycodone

22 use was extremely important.

My political beliefs have shaped this project right from the outset. As most people who know me are aware, I am a politically active and outspoken individual. I have long believed that the drug laws in Canada are flawed (insofar as it is criminal offence to consume certain drugs), and while I never attempted to influence the responses I received during interviews, I made no attempt to conceal my personal beliefs. When queried I would be quite open with research participants that I felt drug use ought to be considered a public health issue rather than a criminal issue. In keeping with this position, I also became heavily involved with a local group as an advocate for constructing a local detox centre.

When interviewing professionals about their views on the need for constructing a local detox centre I often made my own desire to see a detox centre known. Thus, I am an advocate of decriminalization, or at the very least, an advocate of incorporating a much more health-care oriented approach into the criminal justice system. Like anthropologist Merrill Singer, I am also firmly committed to the theoretical position that one must examine larger social structures - and specifically how people are affected by changing structures - to understand drug use (2006: 27). I am therefore also an advocate of the notion that larger structural dilemmas, like the power imbalances surrounding the way pharmaceuticals are marketed and approved, need to be addressed in order to effect change. However, while my beliefs surrounding drug use and the need for harm reduction based policy have certainly influenced what sorts of literature I will cite in this thesis, I do not believe it has negatively influenced the interview process. Though unwilling to mislead people about my beliefs, I was always quite cordial when discussing them with participants. I tried to ensure that my interviews and interactions with participants were framed as an honest and open discussion rather than a debate. Many participants were quite comfortable explaining the ways in which they might disagree with me, and frankly, given their professional experience obtained from working with addicts on a daily basis, I was often willing to re-

23 evaluate my own beliefs in their presence.

From day one I have also been interested in creating a project which was politically useful.

However, defining for myself and others what it means for a project to be 'politically useful' has been a difficult task to say the least. Initially I wanted to design a project in the tradition of applied anthropology that attempted to directly influence government policy. At first I was interested in creating a project along the lines of Participatory Action Research (PAR). In this sort of project the researcher attempts to empower participants through the very process of doing research. Generally the researcher works with a local community group with a commitment to instigate change (Kedia and Van

Willigen 2005: 15). Thus, instead of generating my own policy document I hoped that I could work with a local group to instigate policy change by aiding them in their efforts to lobby government.

However, I decided that designing a project of this nature was much too ambitious for a Masters student to engage in over the course of a single summer. Subsequently, I considered doing what is referred to as 'policy research.' This is research where the intended outcome is the creation of a document capable of directly evoking policy change in government. In most 'policy research' it is not the case that an anthropologist penetrates or becomes involved in policy making networks (Trotter and

Schensul 1998: 692). Nonetheless, given my lack of experience in working on academic projects to influence policy I felt that designing a project such as this would fail to meet my goals. It is for these reasons that I finally settled on doing a project which might most aptly be referred to as advocacy or action research. This type of research is "specifically directed toward identifying, critiquing, and addressing imbalances in allocation of power, economic resources, social status, material goods, and other desired social or economic elements in a community, society, or globally" (Trotter and Schensul

1998: 693). Merrill Singer, the academic who has had the most theoretical influence on this project, is known for using this approach (Trotter and Schensul 1998: 693).

24 Consequently, I decided to attempt to make this project 'politically useful' by identifying and critiquing some of the power structures that may have resulted in this dangerous form of drug use becoming increasingly prevalent in semi rural areas like Cartref. It is hoped that the process of collecting data (and the rich and critical conversations this entailed), working with local anti-drug groups, and writing and sharing this document will encourage people to critically engage with the ways they think about the deeper structures that influence drug development, treatment, and prevention.

Furthermore, I believe this document may prove extremely useful in demystifying the beliefs held by relevant actors.

Gupta and Ferguson note that the discipline of anthropology is particularly useful for generating politically engaged intervention. This is because anthropology is useful for giving voice to those who are affected by - or for that matter who enact - these policies (1997: 36). For instance, I spoke to a local police officer who stated:

I don't think we'll ever get rid of drugs. It's kind of like, for lack of a better term, it's like porn, are you ever gonna remove that? My own personal opinion is that we should decriminalize it, not legalize it, but decriminalize it. Givin' a kid a record for smoking a joint is ludicrous I think, we're tying up the courts and wasting too much money that could be better spent.

The police officer in question (another officer I spoke to was not an outspoken advocate of decriminalization) later explained that this was a fairly common sentiment within the local police station. Prior to conducting this interview it had not occurred to me that this outlook was present within law enforcement. Therefore, it is also hoped that intimate knowledge of actors' positions, which is inaccessible to much of the public, can be generated by elucidating the complex and unexpected positions held by different types of professionals who work with drug users. By grounding the decriminalization debate in conversations I had with professionals knowledgeable in its practical application, the public can come to appreciate decriminalization as a viable option instead of a purely

25 academic position. Therefore, change might not be effected as a direct result of this document, but it is hoped that this project may be useful in grounding the critiques of people who continue to demand better criminal and corporate drug policies from the Canadian government. That is, people may be more comfortable in demanding structural change when they realize that many people working within these structures are also interested in re-evaluating them.

Working With GHA

My goals and positionality have also been influenced by experiences I gained through working with a local anti-drug group. That is, during the summer of 2008 I was given the unique opportunity to undertake an internship in my field site with an organization named Giving Hope to Addicts (GHA).

GHA was formed in the summer of 2005 in response to the suicide of a local youth. This suicide was a final act of desperation on behalf of a young man who felt it was impossible to continue to fight his addictions to a variety of substances. In the wake of this tragedy the mother of this boy, the mother of another boy struggling to overcome substance abuse, and other community members in similar situations formed a group in an attempt to effect change. Jude, one of the ladies I interviewed who is involved with GHA, described the formation of the group in the following manner:

Ben - Can you tell me how GHA came to be? Jude - So after my son had gone to detox, the lady that helped me get him in there approached me and said that another lady had approached her who had lost her son to suicide, because of his addiction, and said they wanted to start some kind of group up in Cartref, they weren't quite sure but something like Mothers Against Drunk Drivers, would I be interested? And I said sure. So basically we started in each other's kitchens. You know we sat down and said what do we want to do? We made up our mission statement and fine tuned it a few times. Our first public meeting was probably our most well attended meeting. And it was actually umm... very emotional because we had some recovering addicts speak, we had people stand up in the audience who had friends or family members and they didn't know what to do or where to turn, so we provided some information and you know that's how we started.

The ranks of this organization have grown in the time since its initial formation. For instance, the

26 mother of another boy who took his life after struggling with mental illness and drug use has become actively involved in GHA. Moreover, various other members of the community engage with - and lend support to - GHA from time to time.

The members of GHA formed this group with several different goals in mind. First and foremost the members of GHA wanted to make it evident to addicts in Cartref that they are not alone.

The experiences of GHA's members have taught them that it is a sense of hopelessness that can lead to the most tragic outcomes for addicts. For this reason they try as much as possible to make it known that there is a group of individuals in the community who will provide unconditional support to an addict in need. Moreover, GHA engages in a lot of activities which are centred around raising awareness about our local drug problem and the dangers of addiction. Thus, they expend a lot of effort on making better drug education available to schools and raising awareness within the community that there is a serious drug problem that often goes unnoticed. They have met these goals in the past and intend to continue to meet them into the future. This is demonstrated by the following exchange with Jude:

Ben - And so what would you say with GHA are your proudest achievements so far? Jude - Well... I think, from my perspective is being able to provide first of all, information to the public. We were able to access a lot of information, and go into the schools, and let them borrow the DVDs, hand out the information. We would go and stand at the high school and hand them out to the parents. And our first year, we brought in from Montreal Alvin Powel the ex NFL player. And personally... one gal who phoned me a few years ago, I helped her get into a detox in [a nearby city], and she sent me a card about a year ago to say thanks. And I talked to her mother a few weeks ago and she's still clean.

Finally, the members of GHA have vowed to lobby all levels of government until such a time as a detox facility has been built within the community. This goal is important to GHA because it is an attempt to address what they feel are structural problems making it difficult for community members to overcome addictions. They argue that the availability of local detox beds is both desirable and necessary because local youth need the option of healing with the support of their loved ones close at hand. Moreover, it is felt that doctors need more training in how to help patients deal with addictions.

27 This was elaborated upon in an interview I conducted with another GHA member named Lisa. This interview was difficult for me because Lisa's son (a peer of mine) took his life after fighting with addiction and other mental health issues for years. While she was willing to identify certain things that were frustrating for her and her family while they tried to help her son heal, she made it quite clear that she did not want to "blame anyone for what happened." That said, in the following excerpt she did note that there were certain structural deficiencies in the way addicts are dealt with in Cartref.

Ben - So what can we do better as a community to rally and help, even if it is personal factors that influence addiction, what can we do as a community to help people? What are we missing? Lisa -1 think there needs to be more counselling. The doctors tend to be... I mean whenever my son went there they would give him another pill to help whatever, and an addict will abuse the pills. And just, any kind of anti-depressants, he would take one one day and skip three days. I think the verbal counselling and the detox. Being able to take your kid to a detox when they need it is just so crucial. And the doctors definitely could use some training.

Working with these strong and passionate people made me more determined than ever to produce a document which might help them to advocate for their goals. To see the pain etched on the faces and actions of parents who have lost children gave me the determination to do the very best work possible. Moreover, my commitment to GHA has made me seek to produce a document which was accessible to those without an anthropological background. If a document is unreadable by the general public it is possible for participants to suspect ethnographers of being evasive or elitist (Jacobs-Huey

2002: 798). I felt this would be especially true for the members of GHA, who were kind enough to take me in and help me obtain an internship credit when they were already pressed for time and resources.

Section 2 — Ethics and Preparing for 'the Field*

Any project involving human participants must meet the ethical guidelines set out by York

University and the Tri-Council. Thus, prior to conducting any interviews a great deal of thought was

28 put into how to carry out my research ethically. There were two ethical obligations in particular of which I was constantly conscious. The first is the respect for privacy and confidentiality. Certain aspects of achieving this were quite straightforward, such as ensuring anonymity by changing or concealing the names of all participants. I also asked participants not to reveal personal information while being recorded. The latter was difficult at times as several interviews were conducted with people, or parents of people, I knew personally. Consequently, open-ended discussion would sometimes elicit information I had to be wary not to record in my interview transcripts. The most difficult part of maintaining anonymity was trying to set up interviews with people through their secretaries without explaining what it was I was doing. It was also complicated when participants would tell their family members I had interviewed them. A peer might then approach me in a public place and want to discuss the interview, creating an awkward moment as I tried to change the subject without acknowledging an interview had been conducted. Finally, in the pursuit of anonymity I also chose to alter the name of the town - settling on the name Cartref - in which I conducted my research.

The second major ethical challenge I faced was the duty to balance the harms and benefits generated for research participants. It was decided early on that I would not seek out interviews with addicts. However, avoiding doing this was a surprisingly complex task. I was left wondering to what degree conversations with friends I know to have used could compromise me ethically. Should an informal conversation with a friend also be considered an interview and subsequently avoided? What about interviewing people now involved in Narcotics Anonymous who had not used in years, at what point could I safely interview them without putting them at some risk of a relapse or some kind of discomfort? There was also the concern that I could bring up unwanted and painful memories for people I interviewed who had never been drug addicts. For instance, I was wary to avoid causing harm when interviewing the mother of a child who had committed suicide after battling addiction for years.

29 Finally, I was also wary that I might publish an interview excerpt that could end up causing someone trouble in a professional capacity. Could something said in an interview, and repeated in this thesis, result in someone losing their job? Or more realistically, what if something said in an interview came back to cause social conflict between fellow employees or rival business owners? Ultimately, I had to grapple with these issues individually as they arose. Thus, the ethical duty to balance harm to participants - though complicated - was sought by anonymizing all my data. Consequently, the names and genders of all the informants have been falsified in order to protect their identities.

Informed consent forms were read aloud and signed before conducting every interview. Thus, full disclosure was employed in every instance. While I am confident that everybody I sat down and recorded an interview with was fully aware of what it was that I was doing, I did have some reservations in other contexts. For instance, while working with GHA I attended several of their meetings where members of the general public were invited to attend. Because I was taking mental notes - and field notes after leaving the meetings -1 was always sure to introduce myself to any people at the meeting who might not be aware of some of my motives for being involved with GHA. Another complicated instance came about when I helped to organize a parade and candle-light vigil for GHA. I took mental notes to record later in this instance as well. There were several people in attendance at the rally who might not have known this. However, while I did not feel comfortable formally addressing all participants and explaining that I might "study" them throughout the evening, I did make an attempt to mingle and explain what I was doing to people on an individual basis. Dewalt et al. make mention of the fact that of all field methods participant observation has the greatest ability to create ethical dilemmas for the researcher. They note that part of the richness of data produced out of participant observation is borne out of the fact that we want participants to forget, at least for a moment, that we are studying them (1998: 272-273). Similarly, while I did not want to conceal the fact that I was

30 conducting research, I did not want to address all the participants on the microphone and frame the parade solely as a research opportunity. There were much more important things taking place that night.

After all, the opportunity to observe an anti-drug rally had not even factored into my motives for helping to organize the parade.

Section 3 - 'The Field'

Entering 'The Field'

If an anthropologist can "write up" an ethnography based on data collected during doctoral fieldwork twenty or thirty years ago, why should it not be possible for "natives" to "write up" an ethnography based on their lives? In what sense might we think of one's "background" - growing up, as it were, in "the field" - as a kind of extended participant observation? (Gupta and Ferguson 1997: 32).

My parents moved to Cartref when I was only a year old. So, to a certain degree I have been engaged in some form of participant observation in Cartref for the past twenty-five years. Indeed,

Dewalt et al. note that children learn how to get by in their own cultures through participant observation (1998: 265-266). However, they do not argue that this is the exact same phenomenon as academically oriented participant observation. This they describe as "the explicit use in behavioural analysis and recording of information gained from participating and observing" (1998: 259). Thus, according to this more strict definition I can only say with certainty that I first 'entered the field' of my hometown as a participant observer in the spring of 2008. Though even this distinction is a little hazy as I have been interested in analysing behaviour - and have taken notes to this effect in a personal journal I have kept for nearly a decade - wherever I found myself since first reading the work of Erving

Goffman several years ago. However, the 'data' collected in this way is obviously of a very different nature than data gathered by a trained outsider doing participant observation.

31 I do not wish to overstate the significance of being an "insider" in my field site. It has afforded me certain insights and shaped certain features of my project. For example, what questions I was most determined to explore. However, this is not to say that I feel the research I have generated is privileged.

Instead, what I would argue is that it is distinct. Kirin Narayan grapples with this issue in her article

"How Native is a "Native" Anthropologist" (1993). Narayan points out that the features that determine when - and if - we will be accepted by the people we study are multiple, and moreover, constantly in motion (1993: 671). Indeed, personal characteristics of the ethnographer, such as gender, class, and race may determine the intimacy of the relationship between researcher and informant to a greater degree than supposedly sharing a cultural identity (1993: 672). This is compounded by the fact that as ethnographers we do not always posses the ability to choose which parts of our identities will influence how we are perceived in the field. Narayan observes that "which facet of our subjectivity we choose or are forced to accept as a defining identity can change, depending on the context and the prevailing vectors of power" (1993: 676). Consequently, when I speak of being from my field site I do not wish to overstate the power of my position as an "insider" in contrast to "outsiders." My interactions and insights may have in fact been limited by my background in some instances. For example, when participants knew things about my family and identity prior to interviews this may have influenced what information was made available to me. Furthermore, it is possible that my perceptions of "local culture" are potentially biased.

The point at which I most definitively "entered the field" was the day I got in contact with Jude.

She is one of the founding members of GHA. I instigated this meeting after I mentioned my project to my younger sister, whereby she encouraged me to look into working with GHA. My sister was aware of GHA because the mother of one of her peers played a part in founding the group. I subsequently got in contact with Jude and arranged to drive back from Toronto to meet her so that we could discuss my

32 project over coffee. Jude explained what activities GHA had been involved in, provided me with quite a few articles and newspaper clippings concerning local drug use, and informed me of future plans for the group. I in turn described my initial ideas for my thesis project and asked her to provide me with any input she could. We decided that she would consult the other members of GHA about what types of questions they might want answered and arranged for me to attend their next meeting. After attending the meeting and gathering the input of more GHA members it was decided that I would simply do what

I could to help the group meet some of their goals in writing my thesis. As one of GHA's primary goals is to raise awareness about local drug use they felt that even conducting the interviews for this project would be helpful to them.

Immersion in 'The Field'

Upon moving back to Cartref for the summer of 2008 I began to directly collect data for my thesis. Sometimes this was accomplished in mundane ways, such as taking notes on any of my experiences that I felt were relevant to understanding aspects of local drug use. I would even go so far as to take notes after witnessing physical altercations at the local bar. For instance, I felt that the slurs used and the motivations behind the fights could in some ways help me to understand local conceptualizations of masculinity. However, the bulk of my data was obtained through prearranged interviews. These interviews probably had a certain air of formality because they were almost always scheduled in the form of appointments. I tried to counteract this by being as open as possible during the actual interaction. Thus, I would usually have certain questions in mind before beginning the interview, but I always tried to allow the conversation to unfold as naturally as a recorded conversation can. Thus, even had I wanted to keep interviews to a predictable schedule - which I most certainly did not - it would have been difficult. The outcomes of these interviews were in no way uniform. Some lasted for

33 twenty minutes while others would unexpectedly continue for two hours. In total I interviewed nineteen different professionals. This group consisted of two police officers, a probation officer, a federal prosecutor, a judge, a children's aid worker, a pharmacist, a doctor, a mental health worker, two members of native mental health, a councillor from addiction outreach, two municipal politicians, two members of GHA, a priest, a local historian, and a grant writer. With this sample size I hoped to gain a qualitative understanding of professional attitudes concerning local oxycodone use. Finally, these interviews were generally conducted in the informants' place of work. It was relatively easy to facilitate anonymity in this way because most of these people already had private areas set up in the workspace for dealing with clients.

There was no unanimity in the ways types of professionals answered the interview questions I presented to them. Those with more biomedically situated backgrounds did seem to conceptualize addiction in a more scientific fashion, but what this entailed was not readily predictable. For instance, when I queried a registered nurse who worked at Native Mental Health about how she conceptualized addiction she stated:

I do lean probably towards the medical model because of my training and the environments I've worked in. But because we are patient oriented and centred we take an eclectic model and work with them the way they want to be worked with. There is also an element of me that believes that you heal the spirit and then growth and development can occur. But they're the drivers so it's kind of hard to impose your model on them.

Thus I would say that the ways in which most informants conceptualized and spoke about addiction tended to evade any facile classification. There were certainly cases where an informant's professional training would shine through in the things they said during an interview, for instance, whether they chose to analyze the issue of drug addiction using statistics or not. However, to say that all "x" adhered to the view of "y" would be inaccurate. Consequently, throughout this paper when I present a quote to demonstrate how a certain professional explained the ways they conceptualized of addiction, I do not

34 wish to imply that this quote is perfectly representative of their entire outlook. Instead, it should be viewed as merely an important ingredient in a complex whole.

There were some interviews that did not turn out to be relevant. Or rather, they were relevant in less direct ways. For instance, I interviewed a priest after trying to get in touch with several local religious leaders. I was curious to see what role these institutions might currently play in helping local people overcome addiction. One church ignored my calls completely. Another church told me they would be unable to speak with me for fear of breaching the confidentiality of their parishioners. Finally, one leader did agree to speak with me although he advised me that he might not have many insights on my topic. He was very kind and tried his best to answer my questions. This man has been leading church services for more than two decades. However, he could only recall a single instance where he had helped a client overcome addiction. In this instance he arranged an intervention for a parishioner who was attending Sunday services drunk. Thus, while this interview did not provide me with many current insights on how local religious leaders directly deal with addiction, it did highlight the fact that they may be having trouble maintaining relevance in the lives of local youth. While it is certainly not the case that religion no longer plays a role in how people conceptualize addiction (certain groups in

Alcoholics/Narcotics Anonymous have highly religious undertones) it did not seem to be an issue commonly dealt with by this priest at weekly church services. Therefore, valuable information was gained from every interview I conducted in some way or other. This was even true when the answers of some interviewees failed to address my questions directly.

Exiting 'The Field'

When I left 'the field' is equally as difficult to establish as when I entered 'the field.' I continued to conduct some interviews and follow up interviews right into the spring of 2009. However, if I must

35 draw a distinction I would say I left 'the field' in the fall of 2008 when I returned to Toronto to begin writing up my findings. At this point my internship with GHA was over and the bulk of my interviews were completed. At first I was tempted to find rides home in order to continue to attend monthly GHA meetings. I continued to feel a great deal of debt to GHA and wanted to continue on projects for them such as designing a website. However, before long my commitments in Toronto began to take precedence. That being said, I have remained in email contact with members of GHA as well as other actors who have provided me with insights on this project.

An Introduction to the Informants

I must emphasize that it was clear to me that all participants in this study were people that were genuinely motivated by a desire to help addicts. This was true regardless of their professional training.

While in a few instances later in the thesis I critique the conceptualizations of addiction that inform their practice, I must make it clear that I have never once questioned the motives of individual participants. As such, it is necessary to provide some information about a few of my key informant's in order to make this distinction as apparent as possible.

Dr. Juniper has been practising medicine in Cartref for 14 years. Dr. Juniper has a particular interest in treating addiction and helping addicts. This is evidenced by the fact that Dr. Juniper has taken extra training in treating addiction from the Centre for Addiction and Mental Health (C AMH) and the Betty Ford Clinic. He is also the only local doctor who is licensed to prescribe methadone. Dr.

Juniper is open to new and alternative treatments for health issues, as exemplified in the following interview excerpt:

Ben - As a front lines doctor, a health worker, would you feel that this is something [prescribing heroin to addicts] you wouldn't want to participate in if the government were to have a look at this model? Dr. Juniper - No not at all. I have a handful of patients who I prescribe medical marijuana to. Ben - And do you feel that this is a common sentiment among doctors? 36 Dr. Juniper - No, even in Cartref because I prescribe methadone I feel that some of my colleagues are a bit suspicious, they don't understand addiction. And I think that that is something as a small community, I think a better understanding that addiction is a problem in nice places with nice people is something that we could do as a small community. Ben - That's interesting it hadn't occurred to me that doctors might have a problem with prescribing methadone. Dr. Juniper - Ya, well I also run up against people because I do abortions as well. Ben - That interesting I didn't know that. Dr. Juniper - Ya I kind of have a sex, drugs, and rock and roll reputation as a doctor in this

town.

In a sense, Dr. Juniper is one of only a few local doctors trained and willing to help patients suffering from more stigmatic health problems and illnesses.

The pharmacist I interviewed has been practising since 1989 and has been working in Cartref for the past 14 years. It was also clear that she was genuinely committed to ameliorating the health and welfare of her clients. During our interview she recited the oath taken by pharmacists (similar to the well known Hippocratic Oath) upon graduating and went out of her way to forward it to me the days following the interview. She felt that new recruits to the profession were not taking this oath seriously enough, and choosing to pursue profit to too great a degree. She is also known within Cartref for being a professional who refuses to dispense opiates to anybody she suspects of diverting or abusing their prescription. Instead of blaming Purdue Pharma and other large drug companies, she had a tendency (as evidenced in our interview) to place the blame for prescription opiate abuse on doctors and pharmacists who make these drugs too easy to access.

The judge I interviewed has only been hearing cases in Cartref for 3 years. However, he stated that even in that short time he has begun to recognize the faces of a few locals who have appeared before him on more than one occasion. His passion and commitment to re-evaluating the way addiction is dealt with in Canada was evident. He was frustrated with the feeling that he was being encouraged to send people with health problems to prison stating that we were "criminalizing healthcare issues." He also implied that the way addicts are dealt with in prison is inadequate in the following exchange:

37 Ben - And do you know, in prison, are there counselling services, are there psychiatrists? Judge - Yes. I also know that we have to send them for a certain length of time before they are likely to get any type of uh... and they have to be very persistent because everybody puts their name in for it. And you have to be in there for 6-9 months to be able to access treatment and pre treatment that kind of stuff.

Both of my interviews with police officers were arranged on the spot with people I had never met before.3 Part of the reason I had never met these people stemmed from the Ontario Provincial

Police's (OPP) tendency to move officers in small towns around a lot in order to avoid unprofessional conduct and corruption.4 The first police officer I interviewed had been working for the OPP in various rural communities for the past 30 years. He was very much in favour of decriminalizing the possession of illegal drugs. Frankly, he seemed a bit burnt out from the job. He said he was tired of dealing with the same individuals over and over again, and that since arresting them was clearly not helping them, it was time we tried something else.

The other police officer I interviewed had different opinions than her colleague. At the time of the interview she had been a police officer in Cartref for less than a year, and a police officer on a different police force for four years prior. She felt that addictions were a contributing factor towards much of the crime committed locally. However, she felt that longer prison sentences for drug crimes were the best way to combat this problem.

The probation officer I spoke to had been working for the province of Ontario for almost 30 years. He was born and raised in the town of Cartref. He was very clearly critical of some of the structural factors that he felt led to recidivism. He felt that a lot of criminal and anti-social behaviour is learned or imparted upon children from marginalized and dysfunctional households. While he did seem to feel that addiction was a mental health issue, he felt the most efficient way to ensure that particularly

3 1 would go to the local police station and ask the secretary to inquire if there were any officers present who would be willing to participate in a study about drug use. On two occasions it just happened to work. 4 It is interesting to note that the Mayor was highly critical of this policy. He felt that it was a mistake to disband the local police force in the late 1980's, arguing that a police force that is known by the local population is integral to crime prevention.

38 recidivist addicts accessed treatment was through the penal system. This was made clear to me when he stated:

I think that the province needs to put more and better treatment options inside the institutions [prisons]. And sometimes with these guys hooked on the oxys, being in prison is the only way they are gonna get treatment. And 6 weeks doesn't sound like a long time, but to some of these people that's an eternity.

The probation officer did not view prison so much as a form of punishment, but rather as the most effective means to wean someone from an intense physical addiction. It was clear that he was still passionate about his job and helping his clients, even as he approached retirement.

I interviewed a local grant writer and lobbyist because he was highly involved with GHA's attempts to secure funding for a local detox facility. He is employed by the local hospital to help acquire government grants for various initiatives. However, his work with GHA was actually not done at the behest of the hospital, but rather, it was a result of him volunteering his time and expertise to a group that had reached out to him for help. He was a kind and approachable informant. Our conversation mostly focused on how to secure government funding for projects like building a detox centre, something he was clearly passionate about.

I interviewed three different mental health workers. The first was named Bia. She had been working to help drug addicts in Cartref for 3 years. She operated using what she termed a "cognitive behaviour model." She stated that this entailed trying to help addicts change their thought patterns and analyze how they relate to drugs. It was clear that she was passionate about helping people as made clear in this excerpt:

With people that I support, I give them non-judgemental support. Listening, is number one, just being there. Because people come in and they relapse and they come in and they relapse, and then they feel scrutinized and judged on the relapses. So I think number one is to be non-judgemental and to be there.

I also interviewed a mental health worker named Logan. At the time of the interview he had

39 been working as a mental health worker for a little over a year. He was passionate about helping his client's and highly concerned that prescription opiate abuse was a growing problem.

I also interviewed Logan's boss who was a registered nurse for twenty years prior to becoming a mental health worker. She has been coordinating the native mental health program in Cartref for the past 2 years. She was born on a reservation near Cartref, and as such, seemed to have a particularly strong commitment to helping "her people." Thus, she was one of the most energetic and enthusiastic informant's I had the privilege of interviewing. Given her training, she did state that she had a certain commitment to biomedical models of disease and addiction. That said, she seemed to take on some fairly holistic views on how to achieve healthy states of mind:

And we do as practitioners have to be on a path to wellness ourselves, to kind of save our souls. So every Saturday, and all the time, I do mindfulness activities and sort of meditate, and sort of listen to everything that is going on around me, and not sort of react to it.

Thus, this project is grounded in data obtained from interviews with an enthusiastic group of people from an array of professional and educational backgrounds. I learned something from every person I spoke to. Most importantly, I learned that those who work at eye level with addicts have views that render simplistic categorization impossible. It was clear that I was not alone in being critical of the system under which we dispense, conceptualize, and deal with prescription opiates. Everybody I interviewed was able to offer some sort of critique pertaining to how this was done. Thus, they were critical of the ways that we currently deal with addiction even though they were often bound to follow them.

Section 4 - Challenges and Limitations

I did not receive ethical clearance to interview addicts. I was comfortable with this decision because I had plenty of my own ethical reservations about conducting interviews with drug users.

40 Nonetheless, this fact did provide me with challenges. Some of my friends and contacts who have/do use oxycodone were eager to help me out and share their experiences. There were even times when they would seek me out in a generous attempt to provide me with insights. I found it to be extremely difficult to negotiate these occurrences. In the summer prior to attending York University I had actually been having many conversations such as this out of personal interest. When bumping into the same person a year later I would have to explain that I could no longer have conversations on this topic because I was doing research. This was sometimes confusing for both of us. In the end I had to distance myself from a childhood friend due to my professional obligations. This was because I knew it would not be possible to interact with him without discussing this topic. Consequently, the duty to balance harm challenged me insofar as it made navigating some social situations quite tricky. Moreover, 1 was not afforded the opportunity to seek out certain insights that may have been readily available. However, though these precautionary measures provided me with challenges and certain limits, I recognized that observing them was ultimately of great importance.

My interviews were also sometimes limited by skepticism on behalf of some of my informants.

In one instance, after the bulk of my interviews had already been conducted, I arranged an interview from Toronto a month in advance. I arrived and began setting up my recorder and asking questions when I realized I had forgotten to bring an informed consent form. An awkward exchange ensued and the participant questioned my identity. I provided the informant with my drivers license, explained who

I was, and explained that members of the informant's family knew me personally. I returned home and printed a copy of my informed consent form, but by this point the tone of interview was already spoiled to a certain degree. The tape recorder was left off and I took notes in shorthand. Prior to leaving I read my notes aloud to the informant in an attempt to demonstrate that his/her words would not be misrepresented or taken out of context. While this is an extreme example, it was true that many of the

41 professionals I interviewed were a little bit sceptical of the interview process.

Ana Ning has discussed the partiality of truth generated through ethnographic research. She noted that the staff working at the methadone clinic where she conducted research were initially sceptical of her methods. This was because many of Ning's interviews were carried out with clients who would hang around the clinic, and these clients were often viewed as the most problematic by staff. Consequently, some members of the clinic staff felt that the system's "failures" would be given too much weight when Ning wrote up her findings (Ning 1998: 84). Ning uses anecdotes such as this to demonstrate that much of what is seen as truth in relation to human experience is dependant upon one's position. She also makes note of the specificity of the knowledge she generated, observing that her research was an attempt to study treatment interventions rather than the entirety of a client's life experience (Ning 1998: 83-84). Like Ning, I must also note that any knowledge generated out of this research is both partial and specific. It is for this reason that I believe this research might be limited in it's applicability to different geographical and temporal contexts. This is not to say that this study should never be used to inform future research. However, no objective truths or laws about oxycodone abuse and rural North America have been uncovered here. Gupta and Ferguson have stated:

Rather than viewing anthropologists as possessing unique knowledge and insights that they can then share with or put to work for various "ordinary people," our approach insists that anthropological knowledge coexists with other forms of knowledge. We see the political task not as "sharing" knowledge with those who lack it but as forging links between different knowledges that are possible from different locations and tracing lines of possible alliance and common purpose between them (1997: 38-39).

It is in this regard that I have come to conceptualize of the knowledge generated in this study, not as an exercise in generating a single truth, but as a specific contribution from a particular location that might provide additional useful insights on an important topic. Even illuminating the complexity inherent to the ideologies of virtually every professional I spoke to - rather than providing sweeping

42 generalizations about their outlooks - is an important contribution.

43 Chapter III - A Medical Anthropological Perspective

This project is anthropological at its core. While numerous texts and concepts from within the discipline of anthropology (as well as material from disciplines outside of anthropology) have been consulted, this project is ultimately centred on work generated out of medical anthropology. As such, it is important to locate those ideas from within this subset of the discipline that have been most influential on the nature of this project. Thus, this chapter will explore some of the current trends within medical anthropology for thinking about biomedicine, health, disease, and addiction. Most medical anthropologists agree that biomedical models have a tendency to under privilege the equally important social origins of disease. Thus, the first section of this chapter will introduce a variety of different schools of thought from medical anthropology on biomedicine and health. Following this, the method of inquiry termed critical medical anthropology will be introduced. A great deal of emphasis is placed on exploring this method of thought as the tenets espoused by this method of doing medical anthropology have proven greatly influential in constructing this thesis.

Section 1 - Some Medical Anthropological Outlooks On Biomedicine

Within medical anthropology there seems to be a general consensus that culture informs the way people experience and conceptualize health, illness, and medicine. This realization has culminated in a diverse array of anthropological outlooks and orientations to biomedicine. Bennett and Cook, the authors of an article entitled AIcohol and Drug Studies (1996), have pointed to the need for culturally focused treatment and research. Whereby, planning for effective prevention, intervention, and treatment strategies for drug-addiction should be informed by cultural context. This can allow people their right to heal as they see fit (1996: 248). Thus, certain anthropologists argue that the concept of cultural relativism should be made central to anthropological health research as well. An outlook such as this

44 certainly does not privilege biomedicine. Instead, the job of the anthropologist would be to help construct health policies that reflect the desires of those who will be making use of them. Consequently, these recommendations may or may not involve the use of biomedical conceptualizations and health treatments depending on the group of people being interviewed.

Andrea Wiley and John Allen have advocated conducting medical anthropology using what they have termed a "biocultural perspective." To employ this approach an anthropologist must consider the social, ecological, and biological influences upon health issues (Wily and Allen 2009: 5-6). This approach is far less critical of the biomedical establishment. They state "although populations differ in the types of afflictions they suffer from, the way these maladies unfold physiologically is fairly consistent. In biocultural analysis, it is possible to make use of these regularities, which are well described in biomedical literature" (Wily and Allen 2009: 7). This should not imply that Wily and Allen are entirely uncritical of biomedical understandings of illness and treatment. For instance, they disapprove of the tendency within biomedicine to over-privilege the body as the most important

"environment" for understanding the nature of disease. That is, they are wary of biomedicine for presenting the maintenance of health as a primarily individual responsibility, whereby, the cause of disease is believed to be generated from personal behaviour instead of the larger contexts in which people exist (Wily and Allen 2009: 7). While I have not employed a biocultural approach in the present study (in some part because Wily and Allen did not address the issue of addiction in this monograph) this project has incorporated one of its tenets. That is, the ability of biomedical science to record and describe the physiological characteristics of illness and disease has not been written off outright in this study. In contrast, it has been recognized that in many circumstances the biomedical establishment can create effective treatments to help patients overcome disease. However, I am very wary of the tendency within biomedicine to privilege only particular types of treatments, and this is especially true in relation

45 to treatments that ignore - or worse, gloss over - the ability of exploitative social relations to culminate in illness.

In Doing Health Anthropology: Research Methods for Community Assessment and Change.

Christie Kiefer has advocated using what she terms a "social perspective" in medical anthropology. A social perspective on health entails a consideration of how social, cultural, economic, environmental, historical, and political processes influence the way humans live, including the ways they conceptualize and experience health (Kiefer 2007: 10). This approach is fairly hostile to understandings of health which are solely grounded in the biomedical disease model which focuses most on individual bodies.

Similar to Rose, Kiefer argues that the disease model is given unwarranted prescience because it has proven profitable for certain actors. She notes that adhering to the biomedical disease model entails the production and consumption of expensive equipment and drugs (Kiefer 2007: 12). Kiefer further notes that adopting a social perspective to explain disease is not more common because doing this has powerful political implications. Whereby, illuminating the structural factors that generate unhealthy situations focuses attention on social inequality, pollution, and the marketing of products that damage people's health (Kiefer 2007: 12). Kiefer goes on to argue that many aspects of health and illness can only be elucidated by considering the historical, cultural, and social surroundings of the people we study (Kiefer 2007: 13). Kiefer's "social perspective" has proven quite useful in informing the current project. However, though Kiefer fully acknowledges that economic interests play an important role in determining the way we think about and experience health care, she did not sufficiently address just how important a role it was. In order to find this I had to turn to the work of another group of medical anthropologists.

46 Section 2 - Critical Medical Anthropology and Biomedicine

Critical Medical Anthropology (CMA) is a theoretical outlook that critiques the influence of the market economy on biomedical truth and the social production of disease. Singer and Baer, two of the most outspoken proponents of CMA, are highly critical of anthropologists who fail to question the validity of biomedical knowledge. They argue that dominant social groups seek to resolve social conflict in their favour by attributing an increasing number of social conditions to individualized biological disease. Hence, anthropologists who are uncritical of the tendency for those in power to employ biomedical discourses in this way are felt to be unwittingly complicit in a system designed to exploit people (Singer and Baer 1995: 33). It is argued that "in adopting a supportive or subservient position vis-a-vis biomedicine... medical anthropology becomes not only an instrument for the medicalization of social life and culture, but also, like biomedicine, an unintended agent of capitalist hegemony and a tag-along handmaiden of global imperialism" (Singer and Baer 1995: 5). Singer and

Baer do not advocate avoiding relationships with health care professionals in order to disentangle medical anthropology from biomedicine. In contrast, they recognize the importance of collaborating with these people in order to generate meaningful alternative solutions (Singer and Baer 1995: 5-6).

However, in these engagements an anthropologist should always be willing to call biomedical truths into question. For instance, they argue that the anthropological tendency to engage only with the concept of "illness" - thus allowing biomedical authorities to define "disease" in any way they please - compromises the knowledge we generate in the favour of those with power. That is, a failure to engage with the concept of disease allows powerful interests to define these phenomena as purely biological. In doing this we fail to acknowledge that social conditions are also significant sources of disease (Baer,

Singer, and Susser 1997: 5-6).

Singer and Baer argue that biomedicine has become a globally dominant medical system not

47 only as a result of it's renown "curative efficacy." That is, the expansion of the "capitalist world economy" has also played an important role in the proliferation of Western biomedical concepts of health (Singer and Baer 1995: 68). As a consequence of this, CMA is largely interested in understanding health issues using a political economy approach. Thus, one of the core purposes of

CMA is to highlight "the importance of political and economic forces, including the exercise of power, in shaping health, disease, and illness experience, and health care" (Singer and Baer 1995: 5). Using this approach elucidates the understanding that health and disease are not merely chance biological phenomenon. Instead, they are conditions which are borne out of people's relations to production and consumption. That is, while the symptoms of a disease may only arise after exposure to a particular pathogen or toxin, the reality is that people are unequally exposed and compromised by these agents.

Malnutrition, poor housing, political powerlessness, and occupational risk - among many other factors

- play important roles in determining who will be exposed to what diseases and to what degree they will suffer (Baer, Singer, and Susser 1997: 6). Hence, to understand disease we must look for deeper explanations that are not generally forthcoming in biomedical conceptualizations of illness.

Current biomedical explanations of disease often have a tendency to overlook the social roots of disease precisely because they have been constructed to do so. Singer and Baer argue that reading the work of theorists like Marx and Gramsci can offer explanations of how and why this has been the case.

That is, in conceptualizing social relations, we can come to see that dominant institutions - biomedicine for instance - tend to proliferate understandings of reality which "legitimize, rationalize, and reproduce the dominant relations of society" (Singer and Baer 1995: 5). Thus, they assert that the current biomedical system is hegemonic in the Gramscian sense. In short, biomedicine is part of a process where a dominant class systematically exerts influence over the conceptions of other social groups without the use of direct coercion. Thus, particular values - which tend to reinforce established

48 power dynamics - are diffused within civil society through structural institutions such as education, popular culture, consumerism, and in this case, health care in the form of biomedicine (Baer, Singer, and Susser 1997: 14). As a result, Singer and Baer implore anthropologists who adhere to a critical medical anthropological approach to always consider what social group's interests are met through particular conceptualizations of disease and health (Singer and Baer 2007: 33).

Singer and Baer are explicit that CMA should be understood as "consciously emancipatory and partisan" (Singer and Baer 1995: 60). According to this view the project of anthropologists is not merely to study and understand culture. In addition to understanding culture we must seek to alter oppressive and exploitative social dynamics within biomedicine and society in general (Singer and

Baer 1995: 60). This is in keeping with the notion that one must be critical of larger social structures in order to bring about equitable health care. In the current biomedical system the interests of a small privileged social group are at the fore. While it would be inaccurate to say that the desires of the rest of society are always left completely unaddressed, a more universally effective health care system is possible. This would be a health care system structured in such a way that meeting the needs of the greatest number of people - instead of generating profit and masking inequality - was a first priority

(Baer, Singer, and Susser 1997: 33). In an effort to realize this goal critical medical anthropologists are encouraged to collaborate with labour unions, environmental groups, self-help movements, and any other initiatives formed to combat exploitation (Baer, Singer, and Susser 1997: 33). Thus, it is evident that CMA is indeed a "discipline in action."

It is important to note that challenging the biomedical status quo is not a denial of all scientific knowledge. CMA does not deny that diseases are biological in nature. It would obviously be fallacious to assert that the bacteria which cause tuberculosis are culturally constructed in an identical manner to more abstract cultural concepts such as nationalism. However, it is important to recognize that diseases

49 are not only biological in nature (Singer 2006: 33). Hence, it is possible to recognize that bacteria which cause symptoms of tuberculosis exist materially, but that social dynamics are at the root of the fact that these symptoms exist in greater proportion in particular segments of the population. Thus, a distinction needs to be made between "biology as a material fact (that is never knowable directly) and any particular cultural rendering of it (including the biomedical one)" (Singer and Baer 1995: 91). This insight should not be viewed as a rejection of science, but rather as an addition to science.

Acknowledging that the practice of science, as with any human activity, is culturally dependent will allow us to interpret material realities with greater precision. Consequently, it can be said that failure to recognize that science and biomedicine are imbued with the values of dominant ideologies impedes the quest to generate the best possible solutions to a given problem (Singer and Baer 1995: 49-50). CMA is therefore not the practice of "doctor bashing," as it is evident that the great majority of physicians are genuinely interested in helping people (Singer and Baer 1995: 36). Instead, CMA is an attempt to encourage doctors (or any health care workers) to consider how their beliefs, and consequently the treatments they offer, reflect their own positionality. In this way it is hoped that these actors might begin to search for new and even more effective solutions to pressing issues.

Conclusions

The CMA approach described above has played a role in informing the proceeding chapters. As such, it must be made abundantly clear that the critiques that follow are targeted at the larger biomedical system, rather than a personal attack on those who are trained and work within it. It was clear to me that everybody I interviewed was genuinely preoccupied with providing help to their clients. It would be hypocritical for me to note how the individual actions of addicts are justified and explainable through the system under which they survive without affording the professionals I

50 interviewed the same privilege. Nonetheless, it is true that the health professionals I spoke to are entangled in a system that is structured to meet the interests of the wrong actors, such as large pharmaceutical companies.5 However, I wish to avoid presenting these people as actors lacking any agency. Many interviewees demonstrated a desire to address unhealthy dynamics on scales larger than individual pathology. In fact, on several occasions interviewees were openly hostile to large and powerful interests. For instance, this can be observed in the following extract from an interview with

Dr. Juniper:

Dr. Juniper -1 think that the drug itself [OxyContin] has caused enough problems that 1 think it's formulation should be discontinued. Personally I think Purdue should change the formulation of this drug and if they don't do it willingly they should be forced to stop producing it, or else put something in it so it can't be abused. Ben - Do you know offhand how to force a drug company to stop producing something like this? Dr. Juniper - It would have to go through Health Canada, there would have to be a class action lawsuit, you could get the college of physicians involved. Narcotics have there time and place, but this drug obviously just has too many problems.

However, despite some of the interviewees' benevolent intentions, their ability to help their clients may at times be circumscribed by a powerful global system that may at times value profit and efficiency over all else. This is the subject to be examined in the Chapters that follow.

These entanglements are the primary subject of the chapters that follow.

51 Chapter IV - A Chemical Solution to a Discomforting Experience

In order to understand the local dynamics of oxycodone use it is necessary to consider my field site in its political, economic, and historical context. I will be especially concerned with investigating how the global restructuring of capital may have influenced local experiences with drug use. This approach is in keeping with the work of several anthropologists who have conducted research which is similar or relevant to this project. For instance, Bourgois has investigated how the changing dynamics of global capitalism have influenced drug use in the lives and behaviours of Puerto Rican immigrants to

New York City (1995b). Similarly, Leach has studied the effect of changing patterns of work amongst blue collared workers in rural Canadian contexts. While she engages in an extensive qualitative interview process, she is also careful to locate and consider her findings in historical and economic context. For example, in her recent work she states that she is specifically "interested in the layering of processes at local, national, and global levels, and the interface between these dimensions and across historical periods, as we attempt to understand what happens to ordinary people caught up in complex political and economic processes" (Winson and Leach 2002: 6). Thus, they consider how processes that begin on a global scale affect the lived and observable experiences taking place within the small towns in which they conduct their studies (Winson and Leach 2002: 15). Finally, Bonanno and Constance

(2003) make the argument that the quality of life for many people living in rural environments is increasingly influenced by socioeconomic events originating at the global level (2003: 241). Thus they argue that scholars interested in understanding rural issues should amend perspectives that view the local as a self contained unit. Consequently they state that we should qualitatively study the local/global interface in order to understand local rural phenomena (Bonanno and Constance 2003:

250).

52 Studying the rural issue of drug use in this way is particularly useful. In the book Something

Dangerous: Emergent and Changing Drug Use and Community Health Singer analyzes drug use according to what he terms "drug use dynamics." This he defines as the processes by which illicit drug use changes over time. Thus, the emergence of new (or rediscovery of old) types of drugs among certain demographics at certain times, the methods used to consume these commodities, and the way they are thought about are all drug use dynamics (Singer 2006: 10). Singer argues that drug treatment and prevention programs that may have been practical for helping users when initially developed can quickly become outdated. Thus, because drug use culture is such a dynamic process - with preferences, conceptions, and methods constantly in motion - programs and treatment philosophies sometimes remain in place long after they are still effective. To combat this problem Singer argues that critical medical anthropologists must constantly re-evaluate and determine the features of changing drug use dynamics (Singer 2006: 10). According to Singer "to fully understand particular drug use dynamics requires an examination of changes in the structure of political and social relations in society (at various levels); the organization, operation, and impact of changes in the economy on the daily lives of societal members; and further, transformations of society's political and economic relations globally"

(Singer 2006: 27). He argues that human bodies are everywhere affected by social history, thus using biology alone is not an effective way to understand drug use (Singer 2006: 26). I have also found this approach to be fruitful, it is for this reason that I have chosen to apply it in the present study. I will use the rest of this chapter to elaborate upon the economic and social history of Cartref in order to better understand the local drug use dynamics that have, and continue to, develop there. This will be accomplished through considering particular local historical features of Cartref, such as how the town came to be founded and how the local economy has adapted over time from being centred around resource extraction to a tourist based economy. However, larger macro process such as the general shift

53 towards service work - and the impact of this trend - within Western capitalist nations will also be considered. Finally, issues of masculine identity and how this relates to different types of work (and in particular tourism based service work) will also be considered in an attempt to explain how some of the drug use dynamics in place in Cartref and other similar locations are taking form.

Section 1 - Logging and the Early Years:

Cartref has been heavily influenced by global capital right from its inception in the 19th Century.

The town of Cartref was founded by two brothers (who I will refer to as the Stanleys) after they purchased a sawmill and timber rights to the land surrounding Cartref in the 1860's. The mill they purchased had been erected only five years before in the 1850's. The land they would found the town on was a portion of the 2,198 acres they purchased at the same time (McKean 1964: 169). Thus, it was global economics represented in international demand for timber that first brought about the construction of Cartref. That is, it was the need for large squared logs by the British empire (Macfie

2005: 85), and the demand for sawed lumber from the United States (Macfie 2005: 94) that helped bring the town of Cartref into existence. At the time the Stanley's purchased this land it was unsettled by Europeans. The land had not been surveyed and it was very isolated. This is partially due to the fact that at the time of this purchase there were no roads to Cartref. Thus, the only way to access the newly founded town was by boat (McMurray 2002[1871]: 140). Rick Stanley took over the family business in

Cartref by the end of 1863 and proceeded to build a town. At the time of the purchase the settlement consisted of a small saw mill, a small store, a boarding house, and about eight small shanties. In only a few years Stanley had constructed a general store, built roads, and purchased a steamship to bring supplies and people to town (McKean 1964: 172). He also built a road to Cartref commissioned by the government in 1865 so that people could start to access the town by land, though this access would

54 have been seasonal at best (Macfie 2004: 17). In 1868 the Government of Ontario opened up the districts around Cartref to European settlers by offering free grants of land. They started giving large swathes of land to people interested in farming the area under the Free Grant and Homestead Act. The rules surrounding this act dictated that any man or widow of eighteen years of age or older could receive a grant of land in the Cartref district provided that they reside upon the land for five years, build a house on the land, clear and cultivate at least two acres of land each year, and at least fifteen acres of land over five years. The people who were given this land were allowed to cut any timber that was required for building, fencing, and fuel. They were also allowed to clear land of trees in order to farm it, but they were not allowed to sell the timber. This was because men such as Stanley had already purchased concessions to the lumber on the land these settlers were to be granted (The Globe 1868: 2).

Thus, from 1868 onwards a steady stream of settlers were making their way to Cartref.

The way in which Rick Stanley reacted to these settlers demonstrates that his will to create a town shaped by his ideals was more important to him than an unchecked pursuit of profit. This is implied by the fact that unlike other lumber barons in this time Stanley not only tolerated - but on the contrary encouraged - farmers and settlers to move to the area and break the land. Most men making a profit off lumber discouraged this behaviour because it meant a drop in profits as farmers would often burn the trees on their land to clear it, meaning a loss of profit for those having the lumber concession over the land to be farmed (Macfie 2004: 16-17). Thus, for the most part communities that sprang up around lumber mills were temporary. When the lumber ran out the companies and their employees commonly deserted these settlements and moved to wherever the next big stand of unharvested trees could be found (Mawhiney, Neitzer, and Pitblado 1999: 11). In contrast, it is evident that Stanley actually wanted settlers to make their way to Cartref. For instance, he took out advertisements in the

Globe newspaper and used his steamship the Waubuno to transport settlers to the area (The Globe

55 1866:4).

Thus, Stanely created an outpost where a Protestant work ethic and value for temperance were valued by the populace. He would have had a certain ability to do this as he was obviously regarded as a leader by the people who lived there. This is implied by the fact that the residents gave Rick Stanley the purely honorary title of "Governor" (McKean 1964: 170). The lifestyle he and members of his

Church sought for the residents of Cartref was heavily influenced by their Methodist background. The local newspaper editor (and member of Stanley's Church) Thomas McMurray demonstrates this outlook in a book he published called Free Grant Lands of Canada. McMurray wrote this book in order to encourage settlers to move to the area. McMurray states:

I give it as my honest conviction that a man of limited means, with a large family of healthy children, cannot do better than by taking advantage of the Free Grant Lands so generously provided, and settling down in the bush; for while they have to work hard they are free from numerous temptations (McMurray 2002[1871]: 141).

It is evident that Stanley had a similar outlook to McMurray for several reasons. First, both Stanley and

McMurray attended the same Methodist Church that had been built and paid for by Stanley.

Moreover, the evangelical enthusiasm of Rick Stanley is also clear. When he first founded the town, there were no churches. Thus, for his first two years in Cartef, Stanley held his own services in the cookhouse of the mill he had purchased (McKean 1964: 178). However, by 1865, Stanley had paid for and built a church on land he donated for this purpose. In this new church Stanley conducted two sermons every Sunday and also took on the role of superintendent to the Sunday school (McMurray

2002[1871]: 148). Furthermore, when another larger Church was required to serve the growing population of Cartref in 1871, Stanley once again donated land and contributed a significant amount of money towards the expense of constructing it (McKean 1964: 179). Thus, through his efforts to finance the construction of Churches, and perhaps more importantly his enthusiasm for preaching within their

56 walls, it is evident that Rick Stanley was quite pious. His efforts to build a town that embraced his religious views seem to have been successful. The census of 1871 indicates that out of a total population of 1, 052 people, 77 were Roman Catholics, 218 were Presbyterian, 221 were members of the Church of England, and 438 were Methodists (Census of Canada 1871). Therefore, the overwhelming majority of the town was Protestant, and the majority of those Protestants attended the same church as Stanley.

However, Stanley was not satisfied by creating a town with a populace that merely attended church. He sought to create an environment and a culture that valued temperance by avoiding intoxication. In order to accomplish this, Stanley enacted what was referred to in local lore as the

Stanley-Covenant. This covenant made it law that even after a plot of land was sold by the Stanleys to a third party, alcohol could never be sold, bartered, or traded on this property, then and forever. Reading the town directory points to the fact that should this clause (which was written into all of the deeds to the land Stanley sold) ever be violated the property was to be forfeited by the holder to the seller

(1987[1898]: 27). Thus, because all of the land the original town was founded on was originally owned by the Stanley family enforcing temperance was a relatively easy task. However, after 75 years this sale condition was overturned through provincial legislation (Macfie 2005: 24). It might be argued this covenant is merely indicative of the determination of businessmen interested in preventing lost productivity due to intoxicated workers. However, this was obviously not Rick Stanley's only motive because even when the Stanley family sold their stake in the local lumber business by selling their mill to the Rathbun Company in 1871 he continued to take an interest in seeing the town grow and develop according to his vision. This is evidenced by the fact that upon selling his holdings in town he demanded that the Rathbun Company continue to enforce the covenant prohibiting the sale of alcohol on town lands. Furthermore, the deal also stipulated that lumber felled on the concession they sold was

57 to continue to be milled and processed locally (Macfie 2005: 141-142). Therefore it is evident that Rick

Stanley was attempting to ensure that the town remained economically viable. Furthermore, it is also clear that Stanley sought to ensure the town remained free of alcohol even when he would only have had religious motives for keeping the town dry.

It is clear that Stanley's attempt to found a town forever free of intoxication was doomed to failure. His temperance policies were resisted to a certain degree even from the start. For instance, resentment for the Methodist inspired prohibition of alcohol in Cartref is evidenced by a term developed in the area to refer to a two bladed (or two faced) axe used by lumber workers. This type of axe was commonly referred to as a Methodist axe in the bush because it had two faces like Methodists who preached temperance but were believed to partake in drinking themselves (Macfie 2005: 262).

Other ways in which the Stanley Covenant was resisted at the time of its inception are also readily available. Rick Stanley was not able to extend his covenant to all land in the town because the land he purchased ended on one bank of a river which divides the town today. Thus, the land to the left of the river was never purchased by the Stanley family and was thus not subject to the Stanley Covenant. For this reason a settlement - originally distinct from Cartref - referred to as Cartref Harbour quickly sprang up where hotels that sold alcohol existed. Indeed, a commonly heard nickname for Cartref today

(which I will not mention because it is well known outside Cartref as well) developed in reference to this settlement. It is said that when the lumber drivers would finish the dangerous task of pushing the lumber down the river to the mill in the spring they would descend on this side of town using this nickname as their rallying cry (Macfie 2004: 83). While Cartref Harbour remained a distinct settlement from Cartref proper for a time it was eventually incorporated into the town in 1887 (North Star 1887:

3). Thus, while the lumbermen for the most part obeyed the rules in camp and abstained from alcohol, this was certainly not the case once they returned to town from the bush. This attitude is demonstrated

58 in a quote by a man named Burley Harris who worked as a logger in Cartref in those days. In a conversation recorded by a local historian Harris stated:

Anyone that used to make a habit of follyin' the drive mostly drank, and just as quick as they got out in the spring they'd go right to the hotel and never come away. Maybe they'd have to borrow some money before they would get back to work. The Montgomery House and the Kipling on the harbour side [of Cartref] were the main places (Macfie 1987: 158).

Thus it is undeniable that Rick Stanley's best attempts to prevent drinking in Cartref were resisted right from the outset. To this day "the harbour" is still the part of town most associated with intoxication and vice. While the Beer Store, liquor store, and the town's bars are now located on the side of town that was formerly dry, the harbour is now associated with opposition to a new kind of prohibition.

Marijuana and other illegal substances can be purchased relatively easily on this side of town.

Furthermore, the harbour is home to low income housing and generally lacks any municipally sanctioned commercial space.

Finally, in order to shed light on currently held conceptualizations of work and masculinity in

Cartref, it is important to understand the nature of the work these early settlers undertook. The lumber business that the town was founded upon was subject to seasonal variations in the availability and compensation for work. Periods of time were spent in camp chopping wood and taking it onto frozen lakes where it would make a journey downstream once the melt set in. Once the landscape thawed and the logs had to be driven downstream the dynamics of work changed. The work became even more dangerous and for this reason everyone involved in the drive was better compensated for their efforts.

Those men who took the greatest risks drew the highest wages. Moreover, the men were also better compensated because at this time of year they had to work from dawn till dusk to drive the logs downstream before the force of the melt water dissipated (Macfie 2005: 244). Considering this, one might understand why these men were so boisterous upon finishing the drive and returning to town.

59 Furthermore, the nature of this labour, as well as the intense labour necessary to break land for farming on the Canadian shield, likely affect the way masculinity is conceptualized in Cartref to this day. This fact is evidenced by the popularity of events such as the annual logging festival celebrating Cartref s history by commemorating the hard working loggers that founded the town. It is widely understood that work is an important source of masculine identity (Laoire 2004: 287). For this reason the ways that changing forms of rural labour effect the conceptualization of masculinity has been studied by academics in other contexts (Laoire 2004). Moreover, understanding how local forms of masculinity are rooted historically is especially important for this project because, as explained to me by virtually every person I interviewed, it is young men who are most likely to use oxycodone in Cartref.

Therefore, it would seem possible that the intermittent, dangerous, and physically intensive nature of the labour associated with logging, in conjunction with the self-reliant, private, and physically intensive labour necessary to farm in the area have had lasting influences on masculinity in Cartref. This early history can partly explain how the local culture of machismo which in my lifelong experience has centred on being "real bushmen," unfettered by physical danger, subject to binge drinking after intense periods of work, and independence may have come to develop.

Therefore, the ways in which the first phase in Cartref s economic and social history might have influenced local culture are fairly straightforward. This was a town brought into existence by global capitalism insofar as it was the global demand for lumber that made this settlement economically viable in the first place. Thus, to a certain degree, the fate of Cartref has always been heavily influenced by powerful interests located well outside the town proper. However, this is also a town whose early social history - especially in relation to the use of intoxicants - was shaped in particular ways according to more local power structures, such as the personally held religious convictions of Rick Stanley.

Moreover, it is evident that opposition to powerful interests that attempt to regulate peoples'

60 relationships to intoxicants has always existed in Cartref to a certain degree. Finally, certain features of the way masculinity has come to be conceptualized locally are rooted in the historical forms of highly intense physical labour undertaken by early settlers to the area. However, this form of dangerous seasonal labour ceased to exist when the highly coveted pine trees started to run out. By 1910 most of the softwood from the region was gone and the Cartref Lumber Company tried in vain to sell its mill in town (Macfie 2005: 143). Thus new forms of labour, and consequently new influences on the lives, identities, and outlooks of local residents began to emerge.

Section 2 - Industrial Fordism Comes to Town

In the article "Who Benefits From Economic Restructuring? Lessons From the Past, Challenges for the Future," Falk and Lobao argue that in order to understand the uneven social effects of economic restructuring it is useful to identify three distinct stages of economic change that have occurred in

North America since the Second World War (Falk and Lobao 2003: 153). They refer to the first phase as the Postwar Fordist period. This period ran from 1945 into the 1970's and is characterized by industrialization and economic growth. The second stage is marked by what they term a Fordist decline. As economies begin to be restructured in this period a process of deindustrialization begins to become evident in many Western capitalist nations. This second phase took place roughly between

1970 and the early 1990's. Finally, they argue that the third stage which began in the early 1990's, and the one in which we presently find ourselves, is a period of transformation toward a new form of capitalism altogether (Falk and Lobao 2003: 153-154). Many academics have associated this final phase with decreases in the number of jobs in the manufacturing, agricultural, and resource extraction sectors and increases in jobs in an expanding service sector (Leach 2000; Winson and Leach 2002;

McDowell 2005; Dunk and Bartol 2005). Moreover, Falk and Lobao argue that while this process has

61 had profound effects on populations throughout Western capitalist countries, much more is known about how it has affected those who live in urban environments than rural ones (Falk and Lobao 2003:

154)\ The Fordist industrial economic phase first became evident in Cartref around World War One.

The second and third phases of deindustrialization and capitalist reinvention in Cartref though do seem to more closely correspond with the time periods Falk and Lobao attribute to the rest of North America.

After the local lumber industry collapsed in the early 1900's, the population of Cartref was left searching for new sources of income. This came to them in the form of factory work during the First and Second World Wars. A company called the Canadian Explosives Limited built factories in town to supply the allied war effort with a variety of ordinance. Production of these wares began just outside

Cartref late in 1915 (Macfie 2005: 312). Thus began the industrialization of Cartref s rural landscape.

The principal product manufactured in these factories was cordite. This was a type of propellant used by the British military instead of gunpowder because it was less volatile (Macfie 2005: 298). When the

First World War ended, demand for cordite dropped and the locals were left scrounging for wage-based work once again. However, with the start of the Second World War another economic boom began in

Cartref. At their height these factories employed 2000 workers, which is quite considerable when one accounts for the fact that only five-thousand people lived in Cartref at the time (Macfie 2005: 299).

Moreover, during both wars locals were able to capitalize on this surge in available work in ways other than labouring at the factories. Local entrepreneurs offered rooms for rent to transients who moved to town in search of employment. Furthermore, movie theatres, radio stations and even bootleggers and brothels also began to spring up in town (Macfie 2005: 313-314). However, in the decades after the end of the war the plants began to close once again. Some jobs were saved for a period of time but

6 I would argue that this is especially true in relation to economic restructuring and drug-abuse. For instance, Philippe Bourgois' much read ethnography In Search of Respect examines how moving light industry such as textile manufacturing offshore has affected the drug use patterns of marginal populations in New York City (1995a). However, until now very little (if anything) has been written on how the restructuring of rural economies has influenced rural drug use patterns.

62 eventually the factories were abandoned, closed and fenced off (Macfie 2005: 299). Moreover, like other parts of Northern Ontario previously centred around resource extraction (Dunk and Bartol 2005:

34), the town of Cartref capitalized on the post war boom in becoming a transportation hub for resources. Looking at any photo of Cartref taken in the 1960's demonstrates that this was an industrial harbour where goods where shipped in and out. The town's location in a deep naturally sheltered harbour off a Great Lake along two national railway lines made it an ideal way-point for many goods and resources.

Interviews that I conducted with long time residents of Cartref indicated that the period of economic stability, driven by the two world wars, entailed much different drug use dynamics than we see on the ground in Cartref today. For instance, this possibility is attested to by the following extract from an interview with the Mayor of Cartref. He is an older gentleman who has been involved in local politics for four decades, and a resident of Cartref for even longer. Having been born and raised locally he has lived in the town of Cartref considerably longer than anybody else I interviewed (with the exception of a local historian who repeated the same sentiment). This is due in part to the fact that many of the other people that I interviewed were professionals. Consequently, most of them had moved to Cartref in search of jobs after being born and educated outside of town. Thus, in speaking to the

Mayor I gained current political insights on my topic as he is deeply concerned with what he sees as a growing local problem with drug use. Furthermore, in speaking to him I also gained historical/economic insights, such as the following:

Ben - So you've been in this town as it went through different phases, from back in the day when it would have been primarily manufacturing I guess, and now it's more tourism. Would you say that in your experience, was it always kind of a drinking town, like back in the day? Mayor - Well, like every town it had it's characters. But by in large back then these folks were harmless cause it was just alcohol. And not to say that alcohol is harmless, but back then it was just alcohol and there weren't really other drugs around to my knowledge. But back in my day, very little drinking with teenagers, the drinking age was 21, and pretty

63 well followed. You've also gotta remember that the economy was such back then that people didn't have a lot of money. And even parents, they would only get a case of beer on a special occasion, none of this continuous drinking like you see today. I can't tell you when drugs became an issue in the community, but probably in the 1970's, as I remember [a nearby city's] drug squad coming here, and back in those days it was LSD and all sorts of things. Ben -1 always had some sort of vision of the history of Cartref with the loggers, that we have an age old drinking culture. Mayor - Well, they certainly did drink, but that was more of a party and on the one side of town, it was different.

It is interesting to note that the time period in which the mayor identifies a transformation of drug use dynamics in Cartref is exactly around the same time the town of Cartref began to de-industrialize.

Cartref has not remained an industrially based economy to the present day. The deindustrialization of Cartref s economy began in the late 1960's and early 1970's. Academics such as

Winson and Leach have noted that evidence exemplifying the deindustrialization of Canada is relatively difficult to find on the whole (Winson and Leach 2002: 27). Thus, finding numbers specific to Cartref is an extremely difficult task. However, Cartref was at least equally subject to the same general trend of deindustrialization that most of Canada experienced between roughly 1970 and 1990.

That is, where agricultural, mining, fishing, and manufacturing accounted for 40 percent of Canadian jobs in 1967, these types of jobs represented only 29 percent of jobs in Canada by 1988 (Winson and

Leach 2002: 27). The changes to the harbour (the centre of Cartref to this day) between 1967 and the current moment make it obvious that this town was not an exception to the labour trends which gripped the rest of Canada during this period.

This restructuring of economies towards the service economy has significant implications for the populations of Western capitalist economies. Economic restructuring has largely resulted in a gradual erosion of the middle class in Canada and Western capitalist nations more generally. For instance, there has been a decline in numbers of middle stratum income earners in Canada, whereby

64 three fifths of the lost middle stratum jobs have been replaced with lower paying jobs (Winson and

Leach 2002: 28). Thus, where manufacturing and goods producing work has declined it has been replaced with lower-wage service sector work (Falk and Lobao 2003: 157). This trend has even more significant implications for rural areas. In urban areas the lost blue collar jobs have been at least partially replaced with higher end service sector jobs in industries such as law, insurance, and banking.

However, rural areas tend to attract a much greater proportion of lower paid service jobs in fast food restaurants, gas stations, and grocery stores (Leach 2000: 211; Falk and Lobao 2003: 153; McDowell

2005: 22). Moreover, the few secure blue collar jobs that remain are harder to secure than ever. For instance, in one of their ethnographic examples, Winson and Leach note that all of the young people they interviewed currently working at a lumber mill in the small town of Iroquois Falls had post secondary education. This is in contrast to the people working there a generation ago who could be assured a well-remunerated position at the mill without so much as a high school diploma (Winson and

Leach 2002: 115). Thus securing one of the few reasonably paid jobs that remain is more competitive than ever, and those that expect the same quality of life as their parents after obtaining similar levels of education are left sorely disappointed.

The implications of this shift on the quality and type of work available are also important points of consideration. Governments and economists spend a lot of time analyzing unemployment rates. Job creation statistics are produced and analyzed in order to asses the stability of the economy and populace of a country. However, in these equations not enough attention is given to analyzing the types of jobs that are being lost, and what types of jobs they are being replaced with (Winson and Leach 2002: 101).

Some academics have argued that this is a very flawed approach for understanding the condition of a workforce, and that the quality of the jobs being produced is of central importance (Winson and Leach

2002: 101). Leach's anthropological data has shown that rural Canadian workers who lose access to

65 stable full-time employment with benefits are often forced to seek work in the new economy that places them in jobs that are casual, flexible, and part-time (Winson and Leach 2002: 104). Thus, it is because of changes to the structure and nature of work that patterns of class inequality are becoming even more polarized in Western capitalist nations (McDowell 2005: 29). This is a fact that has broad ramifications.

The consequences are particularly evident outside of the world's "global cities," in rural and semi-rural locations where the resulting polarization of classes is even more pronounced (McDowell 2005: 22). It could be argued that this process has even greater significance in rural economies reliant on tourist dollars. This is because the newly created service class is subjected to catering to people who have presumably fared much better than themselves in the new economy. Thus, in their work they are constantly reminded of their own status and class position in relation to the people they serve.

There are several reasons why these changes to the economic and work structure in Western capitalist nations has resulted in intensified class polarization. As Dunk and Bartol observed in a small town in North Western Ontario, the jobs being lost in the manufacturing and resource extraction industries used to be unionized. The new service sector jobs they are being replaced with are non- unionized and consequently more unstable (2005: 41). Moreover, as if to add insult to injury, simultaneous to the transition where old forms of stable well remunerated work are being lost, the

Canadian and Ontario governments have been busy slashing funding for social programs. Thus, across the country - and in rural areas in particular - stable jobs are more difficult to obtain than ever before

(Dunk and Bartol 2005: 41) and forms of social welfare for those most disenfranchised by the structure of the new economy has rapidly begun to dry up (Winson and Leach 2002: 137). Finally, even when a certain number of particular jobs are replaced with an equal number of new jobs of equal pay (which is rarely the case) in a different sector of the economy we must investigate how the quality of the new work will affect the individuals employed in these jobs. For instance, we must ask what forms of

66 opposition to authority are available in the new work environment? Does this new work have an impact on the ways in which workers (and their family and friends) are able to conceptualize of themselves?

And, do these new jobs leave workers feeling dignified and secure?

Section 3 - The Customer is Always Right: Service Work, Tourism, and Cartref

In this section I will focus on the ways in which the replacement of better paid and more stable forms of work with service based jobs in the tourist industry have resulted in a reduction in the quality of life for local residents. This is true in relation to the material quality of life. For instance, in the stability and compensation for work, and dwindling access to land which used to be available to local residents for hunting and fishing. However, the quality of life of local residents has also been impacted insofar as living and working in a tourist based economy has dire implications on the sense of independence and dignity of local residents. This portion of my argument is informed by the work of

Philippe Bourgois, as he has made similar arguments relating to drug use and Puerto Rican immigrants to New York City (1995a; 1995b). Bourgois argues that the findings he has generated from this context can be relevantly applied to a great deal of very different contexts when he states:

On a subtle theoretical level, the "caricatural" responses to poverty and marginalization that the dealers and addicts represent provide privileged insight into processes that may be experienced in one form or another by major sectors of any vulnerable working-class population experiencing rapid structural change anywhere in the world and at any point in history (Bourgois 1995b: 127).

Therefore, I am arguing that much like Bourgois observed through his fieldwork in East Harlem, drug use dynamics may have been changing rapidly in Cartref because drug use is employed as a coping strategy for the fear associated with changing class positions. Essentially, Bourgois argues that young men in East Harlem have had a particularly difficult time finding work in the new service economy.

This is in contrast to Puerto Rican immigrants during the post-war boom who had little difficulty

67 finding work in the light manufacturing industry, where embodying inaccessible cultural characteristics and ways of being was less critical to maintaining employment. However, when these jobs moved off­ shore the new jobs that were created were not suited to second and third generation Puerto Ricans living in East Harlem. Thus, this generation (and in particular young men) often lacked the cultural capital to succeed as service workers in New York's Finance, Insurance, and Real Estate (FIRE) sector.

Moreover, in much the same way that tourist based work is experienced by young men in Cartref,

Bourgois argues that the servile nature of these jobs conflicted with the historically rooted notions of jibaro masculinity embodied by some of his informants (1995a; 1995b).

It seems possible that the transition from the more secure post-war work structure to a more unstable and potentially degrading tourist economy has affected the residents of Cartref in a similar manner. It has been argued that tourism has been one of the most significant influences on rural areas since around the 1970s (Butler 1998: 211). Generally, as tourism and recreation industries are developed in communities they have a pattern of moving from a supplementary role in local economies to a role of domination (Butler 1998: 223). There are several consequences for communities that become economically dependent upon tourism. First, tourism based jobs are among the worst paying jobs in the already poorly remunerated service sector of the economy. In conjunction with low pay, these jobs tend to be even more casual, flexible, part-time, and insecure than the rest of the service sector which is already infamous for these things (Krannich and Petzelka 2003: 192). Another significant drawback to tourism based work is that it often leaves employees with little room for career advancement. It is easy to imagine this would leave many employees feeling under-utilized and bored.

Moreover, the seasonally induced fluctuations of tourism result in a frequency and scale of economic upswings and downturns that are actually more significant than those experienced in traditional resource extraction economies (Krannich and Petzelka 2003: 192). Finally, being dependant upon

68 factors outside the control of a community in order to obtain a living produces a constant sense of anxiety. In Cartref, bad tourist seasons have often resulted in business owners going bankrupt and jobs being lost. Uncontrollable factors such as general economic decline, bad weather, or even things like the outbreak of S ARS can all take serious tolls on how many tourists visit Cartref in a given summer.

Seasonal tourism has played a role in the economy of Cartref almost from the outset. Tourism took on importance for the area as early as 1881. This is evidenced by an article in The Globe entitled

Summer Resorts (1881:5). However, at that time the town of Cartref was certainly not dependant on tourist dollars for its existence. In contrast to then, today the economy of Cartref is largely reliant on tourism for survival. From a local cruise ship that often takes over 1000 passengers a day out to see the islands in and around Cartref, to the cottage industry where many local men earn their living constructing cottages. The result is that currently almost forty percent of the jobs held by people in

Cartref are directly dependant on the existence of the tourist industry. That is, twenty-one percent of jobs are provided by restaurants, hotels, or companies that provide "amusement, recreation, and gambling." Moreover, almost eighteen percent of jobs are held by people who work in the construction of buildings, selling building materials, or in the trades more generally (Labour Market Group 2009:

15). To place these numbers in context, Cartref has more than twice as many people employed in the construction trades, and nearly twice as many employed to manage retail food and accommodation services than the rest of Ontario on average (LMG 2009: 23). Alarmingly, while Cartref relies on tourism for most of its economic activity, the jobs created through industry seem to be decreasing.

Between 2001 and 2006 there was a nineteen percent decline in employment in the retail trade sector and a 14 percent decline in the accommodation and food services trades (LMG 2009: 41). Furthermore, in keeping with the general trend for tourism service work many of the jobs generated through tourism in Cartref are part-time, flexible, and seasonal. For instance, several restaurants downtown are only

69 open for business in the summer months. Also, indicative of the seasonal intensity of tourism is the fact that road traffic during the winter is reduced by at least half on most of the roads surrounding Cartref, with traffic on Cartref Drive being reduced to a third of the volume seen in the summer (PSCBD 2009:

7). Finally, as expected, the seasonal employment that provides the bulk of the drive for Cartref s economy also pays less than jobs available elsewhere in Ontario as a whole. Thus, the average household income in Cartref stands at 53, 104 dollars per annum while the provincial average is considerably higher at 69, 156 dollars per annum (Statistics Canada 2006). The new economic structure thus creates a situation where local residents spend their summer months helping wealthier outsiders enjoy their vacations. When they finally do get time off work it is during the winter when it is more difficult to find outdoor activities to partake in.

Drug use habits seem to be more destructive among certain demographics. While my informants have told me that there are many demographics represented among people who use oxycodone recreationally in Cartref, most of them have stated that this practice is most prevalent among young men. For instance, a probation officer that I interviewed stated that:

We're talking about a real high percentage of younger folks here. My case load is for the most part men, twenty-eight and under, though that gap is narrowing. A high percentage of those folks [who never receive another court order to see the probation officer] would be having some substance abuse problems at the time, sometimes oxys, sometimes other substances, but they may not have gotten to the point where they are chemically dependant. So, they binge drink, out and wired for sound on a Friday night and got into a fight, that kind of thing. Of the guys at the other end, virtually all have had, are having, and may again have substance abuse issues. You know it goes into, there are periods of sobriety and going straight, but its always a factor.7

This is not surprising as it seems to coincide with data on oxycodone abuse produced in other contexts

7 It is important to note that I recognize that the uncertainty and indignity associated with the emerging economic structure has led to higher than average rates of drug-abuse in Cartref for many substances in addition to oxycodone. However, 1 have chosen to exclusively address the impact of the changing economy on oxycodone use rates because this drug is the primary focus of the current study as a whole.

70 with similar drug use dynamics. For instance, in rural and semi-rural areas where oxycodone abuse has been studied quantitatively it has been found that users are more likely to be young and male than the population as a whole (Grau et al. 2007; Havens et al. 2007). This pattern represents a further indication that this type of drug use is linked in some way to the process of economic restructuring in

North America. This observation can be supported by the fact that most of the growth in Canadian jobs at the bottom tier of the earnings distribution have resulted from declining relative wages among young people. This holds true across all sectors of the Canadian economy (Winson and Leach 2002: 28-29).

Moreover, it is young men in particular who have experienced the greatest decline in relative wages, a trend that began in the 1980s (Winson and Leach 2002: 29).

The way tourist based service work conflicts with certain locally held forms of masculine identity may also influence drug use dynamics among the demographic of young males. The formation of masculine identity is a subject that has been under theorized until relatively recently (Horshelmann and Van Hoven 2005: 5). This is particularly true in relation to rural Ontario. Belinda Leach has noted that there have been very few anthropological analyses of gender ideology in rural Ontario contexts.

Moreover, the few studies that do exist are concerned with studying the gender dynamics within farm families, and hence not extremely relevant to masculine identity in Cartref (Leach 2000: 220). Thus, in order to analyze how historically rooted masculine identities present in Cartref interact with changing labour relations (and influence drug use dynamics) I have consulted literature from outside of discipline of anthropology, and outside North America. One article that proved extremely useful in this analysis is entitled "The Men and the Boys: Bankers, Burger Makers, and Barmen" (McDowell 2005) which draws on some of the insights of Philippe Bourgois. McDowell utilizes his arguments to produce an analysis of how the masculine identities of young working class men in England have been influenced by the declining availability of traditional middle-class work. This article is extremely relevant to my

71 own arguments about Cartref because it very specifically grapples with the issue of masculinity in relation to service work. McDowell argues that young working-class men in England are finding it increasingly difficult to find work that will allow them to take on the traditional breadwinner role

(2005: 19). A similar situation has likely also arisen in Cartref, where being a primary earner in a household may have traditionally held importance in the formation of masculine identity. Young men in

Cartref are now having difficulty finding jobs that will allow them access to the same masculine identity as their fathers. This is because they are increasingly forced to seek work in the poorly remunerated service industry. However, McDowell further argues that finding stable work in the service industry can be even more difficult for men than women. She notes that in the low wage service economy woman are often preferred as employees because of the social skills and bodily performances they are engendered with from a young age. That is, in contrast to girls, boys are seen as messy, more likely to become distracted and play, and also less likely to defer to rude and abusive customers who must at all times be treated with respect (McDowell 2005: 26). In much the same way young men in

Cartref are not only having difficulty accessing historically-rooted masculine identities because of declining wages, but also because of declining opportunities to find employment at all.

Furthermore, even when service work becomes available to men many will refuse it as a source of income. Some men in rural Ontario find service work to be degrading because it is inconsistent with the masculinities that have formed in relation to traditional rural occupations like logging, mining, or agriculture (Krannich and Petrzelka 2003: 192-193). Moreover, these kinds of work can be especially humiliating for employees who have knowledge or skills that are not being put to adequate use, and this is often the case. It is common to find people working within the retail, personal, and consumer services sectors that are not using their education, skills, and training (Lowe 2000: 65). This frustration is compounded as these employees are often asked to answer questions or perform work for tourists

72 that make the wealthy visitors appear to lack common sense. In the following quotation Dunk and

Bartol have argued that it is extremely difficult for residents of rural areas in Ontario to respect better educated metropolites:

The metropolites may have a better formal education, but for the local working-class men this is no reason to respect them. To the contrary, their lack of 'commonsense' and practical skill is perceived to be one of the reasons why those from outside the region who have such influence over its affairs seem to frequently make decisions which harm local interests (2005: 37).

Thus, to be forced to serve people who appear undeserving of their wealth represents an extremely humiliating dynamic for many people employed in Cartref s tourist industry. Finally, being an employee of the service industry entails conforming to certain modes of dress, style, and behaviour that seem unnatural to much of the middle-class, and especially men (McDowell 2005: 26). To add insult to injury, employees (especially in the lowest paid jobs such as fast food) are often treated by customers as worthless, expendable, and stupid. McDowell has noted that many of the abuses suffered while working at these jobs would almost certainly provoke a fight outside the workplace, but this rage must be internalized by anybody who wants to remain employed (McDowell 2005: 28).

Another frustration borne out of service work is that the nature of the work saps the ability of employees to feel a sense of empowerment. That is, to perform well at these jobs it is necessary for employees to always treat their bosses with respect (Bourgois 1995b: 134). The humiliation of this fact is compounded in the tourist industry where the customers are outsiders that appear to lack common sense. After all, this is an industry where the mantra is essentially "the customer is always right."

Consequently, employees are forced to comply with customers even when they disagree with them.

This is in contrast to more traditional middle-class jobs where employees were better able to develop a sense of self-empowerment while following orders by scowling and taking more time to complete a task than was necessary. In the service industry these are terminable offences that run in direct

73 contradiction to the "technological" requirement of enthusiasm (Bourgois 1995b: 133). I can attest that this fact also holds true for young men in Cartref. In fact, one of my friends who became an oxycodone user first lost his job and became unemployed after he punched someone in the face for flirting with his girlfriend at work. This reality is compounded further in the tourist based service industry where employees are under constant supervision by customers as well as bosses. This makes even minute acts of defiance all the more difficult to carry out without detection and penalization. Furthermore, in jobs more commonly available prior to the shift to service based work it was acceptable to enact a certain degree of opposition towards your boss. Bourgois states that in factory or shop settings a certain degree of verbal conflict with the foreman was expected and considered to be a normal expression of masculinity (1995b: 129). This outlet for exploited workers frustration is also quaffed in the tourist based service economy where there is no tolerance for verbal conflict with customers. Finally, organized forms of empowerment such as the ability for workers to unionize have also been eroded in the new service economy (Winson and Leach 2002: 27; Bourgois 1995b: 130). The most obvious result of this has been a real decline in wages and benefits for employees. However, the tactics used to prevent workers from unionizing, such as hiring employees on a contingent or part-time basis and denying workers a regular shift together, can also result in a declining sense of shared identity among workers (Winson and Leach 2002: 31). Denying workers a common identity in this way leaves workers feeling isolated and individually exploited. For all of these reasons workers in the new service economy

- and in particular in the tourist industry - are denied almost any sense of empowerment on the actual job site. At a later date I would like to further explore how stifling rural workers ability to enact their masculinity by asserting independence at work might result in a desire to symbolically save face by resisting authority through drug use in their personal time. Moreover, I would like to investigate whether the fact that the tourists who they work for are also perceived as being in control of political

74 policy (and consequently drug laws) makes drug use feel even more like an effective form of opposition to authority. However, using my current data for the time being I can only conclude that these things are a possibility.

Finally, restructuring the local economy around tourism might lead to drug use in Cartref even more directly. This is because when a community's economy becomes dominated by tourism there are also more direct material effects on the local population. For instance, increasing tourism entails the creation of new land use patterns. First, it has been shown that many new (especially ex-urban) residents in rural areas are more prone to deny people access to their land. This has created a situation in North America where it is becoming more difficult for people living in rural spaces to engage in outdoor activities and hobbies. For example, ex-urban residents are considerably more likely than locals to view activities such as hunting and fishing with contempt (Butler 1998: 222). Moreover, access to some of the nicest lakes becomes impossible as cottages have started to ring entire shorelines.

While the water in the centre of these developments remains public property, accessing it becomes a increasingly difficult (Butler 1998: 222). In the past decade there was also a unique transformation of public land in Cartref. This was the act of creating a huge Provincial Park next to the town. This park was established on 130 square kilometres of what was formerly crown land. This land used to be very accessible to town residents, and was therefore commonly used for hunting and fishing. Moreover, before this park was established many of the inland lakes were rarely visited by anybody from outside of town. After the park was opened these campsites started to be in use almost every night of the summer. Even though hunting and fishing remain legal in the park these activities often conflict with the ways camping enthusiasts might desire the land to be used. Many of the professionals I interviewed felt that a major contributing factor towards drug-use in Cartref was boredom. It is not surprising that people might become bored in a town where access to formerly public spaces is increasingly difficult to

75 come by.

Therefore, it is evident that the emergence of a new economic structure, based around service work and the tourist industry, might be partially responsible for the emergence of new drug use dynamics (which have recently changed through inclusion of substances such as oxycodone) in Cartref.

There are two primary reasons that the tourist industry may have generated this result. First, substance use may have become a tool employed by certain segments of the population to counteract the degradation and humiliation engendered through employment in service work. This possibility, which is still in need of further investigation, is in keeping with the findings of other anthropologists who have been making similar connections between service work and drug use for quite some time. For example, Bourgois has noted that drug use and involvement in the underground drug economy can become attractive when people "resist exploitation from positions of subordination" (Bourgois 1995b:

133). He also notes that there is a growing body of literature at the intersection between anthropology and education that delineates how complicated forms of resistance can lead to self-destructive behaviour and negatively effect public health (Bourgois 1995b: 140). This should not imply that I (or most people who make this argument) feel that class and relationships to capital are solely influential over how people use drugs. The ways in which numerous other powerful actors and processes - as well as the ways different forms of individual agency are enacted - affect drug-use dynamics have also been given their due attention later in this paper. However, central to the theoretical perspective of Critical

Medical Anthropology is the notion that drug use should be understood as partially resulting from deeper structural dilemmas (Singer 2006: 28). Merrill Singer summarizes this point best when he states that people may use drugs as "a chemical solution to a discomforting experience - whether that experience be the misery of domestic violence, the assault on one's dignity borne of prolonged unemployment, the internalized rage of... racial discrimination, or the bland boredom of teen life in

76 suburbia" (Singer 2006: 32). In summary, this chapter seeks to trace how structural, political, historical, and economic factors may have created discomforting experiences for certain segments of Cartref s population. It seems quite possible that economic reliance on tourism has played a hand bringing about some fairly destructive drug use dynamics in Cartref.

77 Chapter V - Biomedicine and the Production of Truth

Foucault has argued that society is underpinned by multiple relations of power, and that these various powers are premised on the ability to produce and circulate discourse (1980b: 93). This outlook is exemplified in his statement that "we are subjected to the production of truth through power and we cannot exercise power except through the production of truth" (Foucault 1980b: 93). If power defines truth, then all knowledge is socially constructed. As a consequence, truth and knowledge often reflect existing social and class divisions. That said, while these truths are hegemonic, they are not monolithic

(Greenlee 1991: 80). This is because knowledge is always subject to contestation. After exploring the notion of truth it is hoped that readers will be in a greater position to critically engage with biomedical truth as they encounter it in their day-to-day lives. This is in keeping with Foucault's observation that

"the main objective of these struggles is to attack not so much such-or-such institution of power, or group, or elite, or class but, rather, a technique, a form of power" (1982: 331).

Currently, a lot of knowledge pertaining to addiction is circulated and produced using the powerful language of biomedicine. Thus, biomedical truth as it pertains to drug use and drug addiction is a subject in need of exploration. As such, this will be the subject of this chapter. In Tactical

Biopolitics Philip and da Costa state that they "believe it remains crucial to investigate, critique, and create forms of collective production, distribution, and deployment of knowledge that engages with history and culture, academia and the public, technoscience and everyday life" (Philip and da Costa

2008: xviii). As such, in order to understand oxycodone abuse it is necessary to critically engage with

Western models of biomedicine.

It would be inaccurate to portray biomedicine as a singular all encompassing entity. What is entailed by the term "biomedicine" in some ways depends on who is using it. This concept will be

78 examined in much greater detail as the chapter progresses. However, there are a few undercurrents to biomedicine - applications, power dynamics, ways of presenting knowledge - that can be found quite consistently throughout the biomedical community. It is these commonalities, and more particularly a critique of what this entails, that will be explored in the present chapter. This is necessary because prescription drug use is intertwined with a larger biomedical system and philosophy in almost every aspect. Large multi-national corporations such as Purdue Pharma invent and market these drugs.

Doctors are trained to prescribe them. Pharmacists own businesses that sell them. Mental health workers are trained to help people cope with their addiction to them. Finally, doctors are called upon once again to prescribe new drugs to these "patients" in order to bring them back "under control" according to biomedical tenets. Biomedical language is employed throughout all of these processes to legitimize health policies that are shaped in part by a larger system centred around economic growth.

Thus, science based knowledge - presented as incontestable objective truth - is often times employed to obfuscate some of the motives that inform its construction. Those biomedical professionals who work within the system (as well as anybody who seeks treatment within it) are positioned in such a way that they must buy into the philosophies extolled by biomedicine in order to subsist. This is therefore not an act of collusion on behalf of health professionals, but rather a sometimes successful attempt on behalf of powerful interests to shape accepted truth discourses. However, as will be demonstrated throughout this chapter, power cannot construct human action exactly as it pleases, and consequently, a certain degree of opposition is evidenced by the people I have interviewed.

Section 1 — Biomedical Definitions of Disease, Drug-use, and Addiction

Rabinow and Rose have noted that Foucault used history "to diagnose some of the fault lines ingrained within it. These works did this by mapped [sic] the contingent pathways along which the

79 taken-for-granted possibilities and limits of our present have come into existence" (Rabinow and Rose

2003: 8). As such, it is important to identify the historical contexts in which particular biomedical truths have come to be conceptualized today.

Drug-use and addiction began to be conceptualized as a biomedical health issue in the U.S. at least as early as the 1850's. What is reported to be the first rehab clinic in the world was built in Boston,

Massachusetts in 1845 (American Association for the Study and Cure of Inebriety 1893: 22).8 From the description it would seem as if this place, Washington Home, would probably be characterized today as a prison specialized to meet the particular needs of addicts in withdrawal. However, the people who were committed to this institution are described as suffering from the "physical disabilities of inebriates," and hence, there was clearly a biomedical distinction made between these people and other types of prisoners of this era (American Association for the Study and Cure of Inebriety 1893: 22).

While the language and science used to explain addiction in the 1890's is markedly different from what one might encounter today, it is clearly biomedical in nature. For instance, predisposition to addiction as a genetic condition is explained in the following manner by the American Association for the Study and Cure of Inebriety:

First will appear the direct heredities. Those inebriates whose parents and grandparents used spirits to excess. The line of the inheritance will be from father to daughter, and mother to son; that is, if the father is a drinking man, the daughter will inherit his disease more frequently than the son. While the daughter may not, from absence of some special exciting causes, be an inebriate, her sons will in a large proportion of cases fall from the most insignificant exciting causes (1893: 145).

The study of genetics was very new to science at the time that this quote was published. Thus, it is probable that a contemporary biomedical researcher would be quick to dismiss these findings.

However, what is important to note is that - regardless of how these explanations differ from current biomedical conceptualizations - the language of biomedicine has been employed in the West to

8 Described here as "the first embrio asylum of the world"

80 conceptualize addiction for over a century.

During the twentieth-century biomedical sources increasingly defined addiction as a disease or mental disorder. It was argued with greater frequency that addicts needed to be treated as patients instead of criminals. For instance, Marie Nyswander wrote an important book in 1956 entitled "The

Drug Addict As Patient" that made precisely this argument. In it Nyswander explains that many physicians were frustrated by the fact that they had no legal recourse if they chose to offer treatment to patients suffering from addiction (1956: 101). Nyswander also argued that addiction was similar to any other disease. This was insofar as addiction was conceptualized to be a condition beyond the control of a patient which would cause them physical harm (1956: 1). Similar arguments were made in a study published a year later by the World Health Organization. Here it was stated that "the Study Group wished to emphasize very strongly that the treatment of drug addicts is a medical problem and that drug addicts are patients" (World Health Organization 1957: 4). Another seminal work in establishing this view of addiction was written by E. M. Jellinek. This monograph was titled "The Disease Concept of

Alcoholism" (1960). This book was one of the first to precisely describe alcoholism as a disease and outline several of the symptoms and stages of alcoholism - many of which are still employed in biomedical discourse today. Jellinek sought to establish working definitions for words commonly used in different regards to refer to aspects of drug-use and addiction. Thus, in the book he grapples with the meaning of words such as tolerance, craving, habituation, sensitivity, compulsion, "habit forming drug," withdrawal symptoms, and "loss of control" (Jellinek 1960: 12). Jellinek also attempted to address the fact that the word "alcoholism" can mean different things in different cultural contexts.

Thus, an attempt to create a definition for alcoholism which was universally applicable is made when

Jellinek states "we have termed as alcoholism any use of alcoholic beverages that causes any damage to the individual or society or both" (Jellinek 1960: 35).

81 In recent times it has become common practice within the biomedical community to conceptualize certain practices of substance-use as illness. The American Psychiatric Association

(ASA) publishes and updates a monograph entitled the Diagnostic and Statistical Manual of Mental

Disorders (DSM). The DSM serves as a primary reference and diagnostic tool for Western biomedical professionals when assessing a patient's mental health (Ning 1999: 98). In the most recent edition of the

DSM over one hundred pages are devoted to explaining and describing "substance related disorders."

This demonstrates that substance abuse is considered a significant form of illness once one accounts for the fact that less than fifty pages are devoted to exploring schizophrenia. The substances of abuse covered in the DSM are grouped into eleven categories as follows "alcohol; amphetamine or similarly acting sympathomimetics; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opioids; phencyclidine (PCP) or similarly acting arylcyclohexylamines; and sedatives, hypnotics, or anxiolytics" (ASA 2000: 191). However, the concept of "addiction" is left unaddressed in the DSM.

Instead, problematic substance use patterns are broken down into two separate categories. The first is referred to as substance-dependence. This condition can be diagnosed if the patient indicates three of the following seven symptoms:

Tolerance (Criterion 1)... the need for greatly increased amounts of the substance to achieve intoxication... Withdrawal (Criterion 2a) is a maladaptive behavioural change, with physiological and cognitive concomitants, that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. The individual may take the substance in larger amounts or over a longer period than was originally intended... (Criterion 3). The individual may express a persistent desire to cut down or regulate substance use... (Criterion 4). The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects (Criterion 5). In some instances... important social, occupational, or recreational activities may be given up or reduced because of substance use (Criterion 6). The individual may withdraw from family activities and hobbies... (Criterion 7) (ASA 2000: 192-195).

If an individual does not meet the criteria to be diagnosed with substance-dependance than they might instead be categorized as substance-abusers. The DSM defines substance-abuse as:

82 a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home... (2) recurrent substance use in situations in which it is physically hazardous... (3) recurrent substance-related legal problems... (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (ASA 2000: 199).

It is interesting to note that some biomedical sources have called into question the decision of the ASA to use the wording "substance-dependence" instead of "addiction." Some have lobbied for the replacement of the word "dependence" with the word "addiction" in the upcoming edition of the DSM slated to be published in 2012. This is because it is feared that the distinction between addiction ("i.e., the compulsive use of a substance or thoughts about a substance assuming great importance to the detriment of other activities") and physiological-dependence (" i.e., tolerance and withdrawal as normal pharmacologic responses to repeated administration of certain drugs") - a differentiation that some might find nebulous to say the least - might be confused (Stewart 2009: 82). Some consider it important to distinguish between these two conditions in order to avoid scenarios where a physician might end up "underprescribing opiate medication for a chronic pain patient., due to his/her misinterpretation of "physical dependence" as "addiction"" (Stewart 2009: 82). The United States Food and Drug Administration (FDA) is also careful to shape biomedical understandings of addiction in such a way that opiates can be prescribed without physicians or patients worrying about creating addictions.

For instance, the following excerpt can be found on an FDA webpage set up to answer Frequently

Asked Questions about the oxycodone based prescription drug OxyContin:

Will I become addicted to OxyContin if I take it every day? OxyContin is only intended for moderate to severe pain that is present on a daily basis and that requires a very strong pain reliever. Patients with this type of severe pain condition require daily pain treatment. Taking OxyContin daily can result in physical dependence, a condition in which the body shows signs of narcotic withdrawal if the OxyContin is stopped suddenly. This is not the same thing as addiction, which represents a situation in which people obtain and take narcotics because of a psychological need, and not just to

83 treat a legitimate painful condition. Concerns of addiction should not prevent patients with appropriate pain conditions from using OxyContin or other narcotics for pain relief (U.S. Food and Drug Administration 2008).

Thus, even though it is common for biomedical sources to present the diagnosis and definitions of drug-use behaviour as emanating from objective scientific fact, the reality is that these definitions have been shaped and contested over time. Moreover, the ways in which these conditions are defined and diagnosed - and this is true in relation to many other human illnesses - will continue to be updated into the future.

After these definitions are produced through biomedical research or established within the manuals used by health practitioners they can be observed in the professional and popular imagination.

A good example of this is demonstrated by the way biomedical experts conceptualize the link between genetics and addiction. For instance, some biomedical experts claim that approximately fifty percent of all addicts have genetic markers that predispose them to addictive behaviour (Martin, Weinberg, and

Bealer 2007: 5-6). As a consequence of this it is not uncommon to come across articles discussing the genetics of addiction in the media (for instance: Ogilvie 2007; BBC News 2004). This way of conceptualizing the links between drug-use and genetics was also evidenced in some of my interviews with health practitioners in Cartref. For example, when I was interviewing Dr. Juniper he responded to my question regarding addiction in the following manner:

Ben - So you don't feel that there is necessarily a greater proportion of depression or anxiety in these people before they get addicted? Dr. Juniper - No, probably not. I would say that from my point of view they probably have a genetic predisposition to addiction. And that they have the same sort of list of psychiatric or emotional issues that other people do.

He links the root cause of addiction here to the genes an individual possesses instead of their social histories. Later on during the same interview Dr. Juniper did note that many of the patients he treats for addiction did have histories of sexual abuse. However, his biomedical training has led him to

84 conceptualize of addiction as a primarily genetic condition even when his practical experience may have taught him otherwise.

This is in keeping with Coleman's observation that powerful interests who play a part in constructing scientific discourse do not get to do so exactly as they please. In her work on "psychiatric survivors" Coleman notes that current psychiatric practices have evolved partially in response to the demands of patients themselves. Thus, biomedical models that explain stigmatic medical conditions through brain chemistry have been taken up partially "because it provided a pronounced pledge: a moral alibi that could free human persons from certain forms of responsibility, and thus, it was said, from stigma" (Coleman 2008: 349). As such, conceptualizing addiction as being premised on genetic factors meets the needs of another powerful and interested group of people. That is, the patients themselves and the professionals who are their advocates.

Section 2 - Nikolas Rose on the Construction of Biomedical Truth

Many academics have weighed in on the debate about why and how biomedicine constructs truth. Rose has observed that one reason many national and local governments have privileged Western biomedicine is that the "need" for economic growth holds a lot of political clout. Investments in bioscience, biotechnology, and biomedicine are seen as important methods for creating a robust and modern economy. Rose states "politicians, both national and local, come to believe that in some way or another, the future prosperity of their countries, their region, or their city depends upon its occupying a leading place within the new market for biotech'" (Rose 2007a: 142). As a consequence of this governments are likely to encourage the proliferation of a biomedical system that operates according to a particular view of what counts as knowledge. Moreover, returns are expected because this relationship is in many ways seen as an investment on behalf of government. These returns can come in

85 the form of the creation of high paying jobs or increased tax revenue. As a result of this relationship governments become invested in encouraging companies to seek out profit in the act of constructing biomedical truths.

Therefore, the pursuit of profit is one part of what shapes the nature of the truth that is constructed within Western biomedical frameworks. Rose argues that this does not result in the manufacture of outright falsehoods. However, the knowledge that is generated is every where affected by the fact that it must result in a profit for those who fund it. This means that the way research is organized, the types of questions that are asked, and the solutions that are provided are constructed according to demands for a financial return (Rose 2007b: 32). For instance, Rose points out that in the past, mental disorders were imagined to have a negative impact on a nation's economy. Whereas, in the current moment as biomedicine becomes an increasingly important source of national income, mental disorders are seen as important opportunities to generate profit for the pharmaceutical industry. It is according to this rubric that what counts as a mental disorder - and the list is increasing - comes to be defined (Rose 2007b: 209). As a consequence of this Rose states "our vitality has been opened up as never before for economic exploitation and the extraction of biovalue" (Rose 2007b: 8). Biomedical knowledge concerning what the appropriate form of medical intervention might be in a given situation is not always "wrong." However, this knowledge is generated from a particular position and favours answers that culminate in particular outcomes. Rose observes that "the pathway of medical truth seems to be shaped by the possibilities of generating products that can sell in the market" (Rose 2007a: 149).

Thus, equally as these solutions are not necessarily "wrong" they are also not necessarily "right."

Moreover, they are almost certainly not the only logical solutions that could be generated to deal with health issues.

What makes this situation troubling is that the companies who offer these solutions utilize the

86 objective language of science to present their situated knowledge as the only kind that is rational or even possible. However, it is culturally based value judgements that inform the types of medical intervention that are seen as desirable, possible, or necessary. Indeed, some of these value judgements have been rendered almost invisible by how widely accepted they have become. For instance, Rose points out that the application of pharmaceutical drugs to alleviate pain or anxiety implies in itself that one way of living is better than another (Rose 2007b: 50). It is easy to take for granted that all people do - or more importantly should - desire to be chemically relieved of their pain. This, however, is not actually a universal human sentiment, there are a variety of reasons why an individual might prefer to experience unadulterated pain. In any event, the position that chemical intervention (and in particular the use opiate based drugs) is the most rational solution for treating chronic pain is a particularly subjective one. Some might argue the equally valid positions that the potential for powerful opiates to be diverted and cause harm must make us vigilant to only prescribe these drugs in very specific circumstances, that altering one's consciousness in any way is undesirable, or that the best way to relieve pain is to physically (rather than chemically) address the root of the pain.

Rose uses the term "ethopolitics" to refer to these attempts to shape what we deem appropriate health interventions. Ethopolitics being the arena where attempts to shape human behaviours are made by influencing our "sentiments, beliefs, and values - in short, by acting on ethics" (Rose 2007b: 27).

Ethopolitics can be used to explain the ways in which the desire to create biovalue have begun to shape accepted biomedical discourses. In essence, ethopolitics are employed to shape, proliferate, naturalize, and render rational a particular set of values that inform the way we think about health care.

Furthermore, the pursuit of profit can be seen as the primary motive for constructing these sentiments in this way. That is, attempts are made to shape the way people think so that those medical solutions which are profitable for a company or government are seen as the most rational. Finally, it must be

87 noted that in order to accomplish this dynamic, the powerful language of biomedicine - that of objectivity and rationality - has been co-opted by those with the power to do so, such as large pharmaceutical companies.

In my interview with Dr. Juniper I came across an interesting example that might be used to elucidate this process. He stated:

I think the thing that I am most interested in, and what my patients are telling me, is you detox, you go away you do your yoga and that kind of thing, but then you come back and you have to deal with the same situation and people you were around before. So with the suboxone9 you stay at home, you don't lose your job and you start dealing with the day to day realities of overcoming addiction.

This quote implies that Dr. Juniper recognizes that there are important local structural factors in motion that make opiate addiction difficult to overcome. However, the solution that comes to his mind is a chemical one which is profitable for the company that makes suboxone. In contrast, Dr. Juniper could seek to address why living in this social environment might compel a person to abuse drugs in the first place. Dr. Juniper personally stands to gain nothing by opting to use this medication to treat addiction.

That is to say, his income is not dependent upon how many drugs he prescribes. Nonetheless, powerful ethopolitics have created a system whereby solutions that generate profit are more likely to be favoured by doctors, and moreover, more likely to be requested by patients.

Section 3 - The Profit Motive in Relation to Addiction and Pharmaceutical Drugs

The "medicalization" of society is a term used by academics who study biomedicine to refer to the process by which more and more aspects of our lives become defined as medical problems (Burri and Dumit 2007: 4). Obviously the pursuit of profit is not the only powerful interest that informs biomedicine and the medicalization of society. In following chapters, and the next chapter "Governing

9 Suboxone is a drug that can be prescribed instead of methadone. It is used to prevent opiate withdrawal while acting as an opiate antagonist (by blocking the certain opiate receptors in the human brain).

88 Drug Use" in specific, I will explore some of the other avenues of power through which modern biomedicine is informed. However, here I will detail how the process of medicalization is used by powerful actors to generate profit. Rose's arguments presented above dealt with how a profit motive might influence biomedical models on a larger scale. In this section the topic of investigation is the profit motive specifically in relation to pharmaceutical opioids.

Baer, Singer, and Susser have noted that a major factor driving medicalization is that there is a lot of money to be made in discovering new diseases that require treatment (Baer, Singer, and Susser

1997: 14). This is in keeping with Joan Paluzzi's observation that "successfully marketing drugs to essentially healthy people requires more than convincing people to choose one brand over another; it often first requires convincing them that they may not be as healthy as they assume they are" (2009:

256). Thus, in order to drive up profits through medicalization it is often necessary for powerful interests to co-opt biomedical language to influence the way patients as well as medical practitioners conceptualize illness. Consequently, it is increasingly common for patients to request that physicians prescribe medication for conditions that they might not normally be inclined to prescribe for (Paluzzi

2009: 265). Indeed, Dr. Juniper made it clear to me that she felt this was a significant contributing factor for why some local doctors prescribed oxycodone based drugs to the extent that they do. All of these observations support Nikolas Rose's argument that:

If one has a path-dependant theory of truth, as I do, then it becomes clear that some of the basic truths articulated in the biomedical sciences are being shaped, in part at least, by research and development directed by the search for biovalue, by beliefs and expectations about the potential for the extraction of value - economic, moral, professional, political - from the very vital character of human life itself (2007a: 142).

It is difficult to establish the degree to which major pharmaceutical companies might be willing to shape biomedical truth in order to encourage increased sales through prescription drug-abuse. Merrill

Singer has cited sources that indicate as much as thirty percent of the drugs illegally consumed in the

89 United States are pharmaceutical in origin (2006: 91). It seems fair to assume that this statistic might be relevantly applied to the practices of illicit drug consumption in Canada as well. This is given that a publication produced for CAMH recently noted that "while the rates of heroin related admissions remained low and stable, the OxyContin-related admissions increased substantially (i.e., 3.8%, 8.3%,

20.8%, 30.6%, and 55.4% of the total opioid admissions, 2000 to 2004 respectively)" (Sproule and

Brands 2008: 1). What is most controversial is the degree to which this sort of behaviour is facilitated by the pharmaceutical companies that profit through the sale of these drugs. Singer has argued that the pharmaceutical industry is currently operating in a similar manner to the tobacco and alcohol industries. This is insofar as they are using their enormous profits to override efforts to place restrictions on their abilities to continue to realize profits on current scales. This is regardless of the health implications involved in realizing these profits (Singer 2008: 21). Indeed, Singer has stated that one can observe "an enduring and unambiguous pattern within the industry of inflicting harm if it serves the cause of making a profit... it is within this context that the pharmaceutical companies aggressively produce adequate quantities of drugs to meet both legal and illegal demand" (2008: 264).

During my interview with a Cartref pharmacist another avenue by which seeking profit might fuel prescription drug use was revealed to me. This is the pursuit of profit on behalf of pharmacists who own the drug stores in which prescriptions are filled. I was told the following by this pharmacist/pharmacy owner:

I personally suspect that three of the five pharmacies in town might dispense these drugs even when they might have doubts because of the financial benefits. Not to say they are filling prescriptions that don't exist, but perhaps they are willing to fill prescriptions early because of excuses like "I'm going out of town to a funeral." We need to be dispensing these drugs by the book, remaining absolutely vigilant. If there is any potential that the drug is being diverted, if there is even a slight indication that the drug is being diverted, mother gets a prescription, then the father gets one, after a while they get prescriptions for their kids, if you see that pattern start up, if you make it more difficult for the diverting individual to get that prescription you will squash that really quickly, it is a lot better than just doing nothing and filling it to make a sale.

90 Thus, the current structure through which pharmaceutical drugs are dispensed - whereby pharmacies are often owned and operated by a professional who earns their livelihood based upon sales volume - is also conducive to the abuse and diversion of prescription opiates.

It is possible that large pharmaceutical companies would continue to manufacture and market drugs known to cause health problems. Many would argue that because this sort of behaviour has been observed in the past it is quite possible for it to happen again. That is, it is estimated that between 88

000 and 138 000 people may have died because of being prescribed a pharmaceutical drug named

Vioxx (Singer 2008: 155). There is debate as to how long the company that produced Vioxx knew the drug carried this risk prior to "wilfully" withdrawing it from the market in 2004. It is possible that drugs could continue to be marketed in spite of evidence that they are unsafe because of the strategies used by the pharmaceutical industry to control biomedical truth in relation to drugs. Singer has argued the strategies that pharmaceutical companies have employed to do this include "1) making successful claims of efficacy; 2) influencing strategic elites; 3) courting biomedicine; 4) suppressing contrary findings; 5) silencing critics; 6) buying science; and 7) intimidating the FDA" (2008: 148). In doing this it is possible that rogue pharmaceutical companies could manufacture biomedical knowledge in such a way that detrimental drugs remain on the market even when it is not in the best interest of the general public.

I will now examine some of the biomedical literature produced by pharmaceutical companies on opiate use and addiction. This is done in an attempt to demonstrate that biomedical discourses might have been used to encourage elevated prescribing practices for oxycodone based drugs. In the early

1990's a study was conducted which "demonstrated" that oxycodone was of low risk for abuse because out of 12 000 people administered the drug during the study, only 4 became addicted (Lockwood 2007:

91 14). It was based upon this research that Purdue Pharma, the company that manufactures a powerful oxycodone based drug named OxyContin, began to make assertions such as "concerns about abuse, addiction, and diversion should not prevent the proper management of pain" in documents produced to advise doctors on how to prescribe their products (Purdue Pharma L.P.: 11)'°. Moreover, later in the same document it is stated that:

Patients should be advised that if they have been receiving treatment with OxyContin for more than a few weeks and cessation of therapy is indicated, it may be appropriate to taper the OxyContin dose, rather than abruptly discontinue it, due to the risk of precipitating withdrawal symptoms. Their Physician can provide a dose schedule to accomplish a gradual discontinuation of the medication (Purdue Pharma L.P. 2007: 15).

This is as close as Purdue Pharma comes in this document to instructing doctors to warn their patients that they may become addicted to OxyContin even if it is taken as instructed by a physician. Indeed, it would seem that Purdue Pharma deliberately attempts to make a distinction between the experience of

"addiction" and "physical dependence" when they state "abuse and addiction are separate and distinct from physical dependence and tolerance" (Purdue Pharma L.P. 2007: 11). These biomedical truths concerning physical dependence and addiction sharply contrast with some of the experiences of patients recounted to me by health professionals I interviewed. For instance, this might be evidenced in the following exchange that I had with a mental health worker I interviewed named Logan:

Logan - Umm... I have a few clients that have addictions to drugs, yes, alcohol and prescription drugs. Actually the one client that I do have is prescribed OxyContin, and umm... he takes it, he takes it as it is prescribed. He has been upping the dosages, Ben - and he's taking it for pain Logan - he's taking it for his chronic pain, and I do think he is genuine, the problem is, he does not want to be taking it. Ben - He's physiologically addicted to it Logan - ya, and he's tried to stop, but its too painful with his pain in the first place, and then the pain coming off it.

There is a final example which might be used to elaborate upon how it could be possible Purdue

This was printed in the "information for doctors" section of a document about OxyContin published by Purdue Pharma

92 Pharma has employed biomedicine to meet their business imperative to sell pharmaceutical drugs. In

this instance Purdue Pharma provided funding for the publication of a biomedical document on Urine

Drug Testing (UDT). This document was given to me by Dr. Juniper. One of the reasons for using

UDT's put forward in this document was that:

Drug abuse or concurrent addiction does not rule out a pain problem, but requires careful evaluation and use of a treatment plan. Appropriate use of medical management techniques (eg, treatment agreements, pain scales, UDTs) may improve adherence monitoring by physicians, and offer greater protection from drug abuse/addiction and diversion. This will help overcome a major barrier to effective pain relief- physician fear of iatrogenic addiction or relapse of previously addicted patients (Gourlay, Heit, and Caplan 2006: 5).

Thus, it is being argued that UDT's might be useful for physicians insofar as they might allow for

increased prescribing rates for addictive drugs. The authors of this report later note that:

Clinical urine drug testing, like any other medical test, is performed to improve patient care. Inappropriate interpretation of results, as with any other diagnostic test, may adversely affect patient care; for example, discharge of patients from care when prescribed drugs are not detected (compliance testing) (Gourlay, Heit, and Caplan 2006: 11).

This is also a major theme throughout the rest of the document. The importance of not misreading a

UDT that was negative for prescription drugs such as oxycodone - and consequently resulting in a

physician ceasing to prescribe the drug to the patient - is stressed several times throughout the

document (Gourlay, Heit, and Caplan 2006: 3, 9, 11, 15, 19).

Conclusions

By this point it is hoped that some of the means by which power can influence truth claims have

been drawn out. In mapping the historical development of biomedical conceptions of addiction the reader should be in a better position to critically engage with such concepts when they encounter them.

Philip and da Costa have stated that a goal of analysis' such as these is to coordinate with "larger

93 strategy based movements of resistance to hegemonic forces" (2008: xviii). It is in keeping with this philosophy that this chapter was written. Another primary focus of this chapter was an exploration of the ways in which a desire for profit can inform biomedical truth. This need not imply that profit is solely (or even primarily) determinative of biomedical models. Rabinow and Rose have stated that "in the discourses regulated by the norms of truth... it is a matter of investigating the conditions that establish, at any one time, the relation between true and false which is, on the one hand, intrinsic to the sciences and their history, and, on the other, essential to the ways in which human beings have come to govern themselves and others" (Rabinow and Rose 2003: 7). Thus, profit is only one important part of a larger system that designs truth with government of the human body in mind.

Finally, the people that I interviewed in Cartref were not in the business of producing truth.

Rather, they had a "professional obligation" to proliferate and enforce biomedical truth. That said, they were often willing to call these truths into question on their own. Thus, it is hoped that making this document available to them will intensify their urge to question biomedical truth when appropriate.

94 Chapter VI - Governing Drug Use

It is the population itself on which government will act either directly through large-scale campaigns, or indirectly through techniques that will make possible, without the full awareness of the people, the stimulation of birth rates, the directing of the flow of population into certain regions or activities, etc. (Foucault 1978: 100).

*

To govern a state will therefore mean to apply economy, to set up an economy at the level of the entire state, which means exercising towards its inhabitants, and the wealth and behaviour of each and all, a form of surveillance and control as attentive as that of the head of a family over his household and his goods (Foucault 1978: 92).

This chapter will explore the ways in which drugs, and conceptualizations of drugs, can be used as tactics of government. In order to accomplish this task, Foucault's concept of governmentality is introduced and explained in the first section of this chapter. Following this, some of the more apparent ways in which addictions can be used for the purpose of government are explored. Thus, the ways in which substances like caffeine and nicotine have been used to influence human behaviour will be analyzed. Proceeding this, the ways in which drugs such as methadone can be used to influence the behaviours of addicts, as well as the underlying logic for doing so, will be analyzed. The final two sections will examine the ways in which drugs can be used to influence the behaviours of those who do not ingest them. The first will explore the ways in which social morality and fear of the addict/other can be generated and employed as a tactic of government by those in power. The second will investigate the ways biomedical tendencies towards the medicalization of society can obfuscate the social realities that underpin suffering, and consequently, undermine social unrest. Thus, ultimately, this chapter is an exploration of the ways that drugs and their conceptualizations can be used to facilitate the government of populations.

Government need not only refer to the state. There are rules in place that dictate the ways that

95 we can and should use drugs. Some of these rules come in the form of laws upheld by the state that designate particular drugs as legal or illegal. It would be fallacious to assume that these are the only - or even most important - methods by which our interactions with psychoactive substances are governed.

Social rules, which are not always explicit, also play an important role in guiding drug use behaviour.

Hence, our conceptualizations of drugs change over time as culture and structures of power shift. The ways we think about and consume drugs can reflect the values of a particular social group, serve the interests of powerful actors, or result out of the messy interactions between multiple sources of power which operate simultaneously. This chapter seeks to explore the nature of the complex sets of power relations that influence the ways in which we conceptualize and consume drugs. It is tempting to privilege the state as the most important avenue through which our interactions with drugs are decided.

However, this would be an oversimplification of the complex intertwining of historically rooted relationships of power that influence our relationship with psychoactive substances. That is, to analyze only the most visible manifestations of power would lead to the development of a critique with limited ability to instigate effective reforms. As Michel Foucault has observed:

there is a second way of overvaluing the problem of the state, one which is paradoxical because apparently reductionist: it is the form of analysis that consists in reducing the state to a certain number of functions, such as the development of productive forces and the reproduction of relations of production, and yet this reductionist vision of the relative importance of the state's role nevertheless invariably renders it absolutely essential as a target needing to be attacked and a privileged position needing to be occupied. But the state, no more probably today than at any other time in its history, does not have this unity, this individuality, this rigorous functionality, nor, to speak frankly, this importance (1978: 103).

This chapter is an attempt at providing a critical analysis of the ways in which Canadian drug-use patterns have come to be shaped, not only by the state, but by multiple actors with diverse interests.

96 Section 1 — The Art of Government

Foucault can provide us with important insights for understanding the development of the methods by which populations have been governed. Foucault argues that new justifications for leading government needed to be established once "divine will" was no longer accepted as a reason for leaders to hold power. Consequently, the right to govern began to be legitimated by establishing as the task of government the augmentation of the condition of a population. Thus, those who governed increasingly began to concern themselves with ameliorating the health, wealth, longevity, and happiness of citizens

(Foucault 1978: 100). As a consequence, those who governed increasingly began to try to shape the characteristics of territory and population. This was not always done in an overt manner. That is, techniques began to be employed to stimulate birth rates, encourage settlement of a given area, or make certain types of professions more attractive to a person without the full awareness of a population

(Foucault 1978: 100).

The question of precisely who wields power and governs society became increasingly complex as well. Foucault has stated that "it is certain that, in contemporary societies, the state is not simply one of the forms of specific situations of the exercise of power - even if it is the most important - but that, in a certain way, all other forms of power relation must refer to it" (1982: 345). However, even given this we must avoid reifying the power of the state. This is because the power that governs us is located both within and outside the state simultaneously. Thus, in this view, all power "governs" whether or not it is currently defined as part of "government." That is, the ways we come to understand what is within the realm of state power - what is private, what is public - results from the larger process of being governed (Foucault 1978: 103). Hence, a critical examination of the contexts within which drug use occurs must include an analysis of power that includes the state while looking beyond it.

In order to understand the ways our relationships to drugs have been constructed, we must view

97 power as a relational phenomenon between actors, operating differently according to changing contexts of social interactions (Samuelsen and Steffen 2004: 3). Thus, the nature of power employed to control populations began to change as the purpose of government and structures of society became reconceptualized. Violence and coercion were not eliminated as tactics of governance with the institution of subtler forms of power. Instead, disciplinary power remained and worked in tandem with softer power to achieve an art of government. Foucault explains how we might best understand this transformation when he states:

Accordingly, we need to see things not in terms of the replacement of a society of sovereignty by a disciplinary society and the subsequent replacement of a disciplinary society by a society of government; in reality one has a triangle, sovereignty-discipline- government, which has as its primary target the population and as its essential mechanism the apparatuses of security (1978: 102).

Brute force ceased to be the primary means by which people's behaviours were governed, but it was still required to render the new tactics of government effective. Foucault explains how power has come to operate by explaining that power "is a set of actions on possible actions; it incites, it induces, it seduces, it makes easier or more difficult; it releases or contrives, makes more probable or less; in the extreme, it constrains or forbids absolutely, but it is always a way of acting upon one or more acting subjects by virtue of their acting or being capable of action. A set of actions upon other actions" (1982:

341).

Evidently the operation of power is no longer - if it ever was - based in the ability to physically force a person to do or not to do a given thing. Indeed, Foucault observes that it would not be nearly so effective if it was. Instead, power works on the level of knowledge and desire, framing truth and action in such a way that human behaviours are likely to fulfil particular interests (Foucault 1980: 59). Doing this can even be experienced as desirable, or perhaps the only rational action, but this is because people have been constructed to experience life in this way, not because it is objectively so.

98 This theoretical outlook of power is quite useful for analyzing the purposes underlying the methods used in Canadian society to govern drug-use. Our relations to drugs have been altered over time in accordance with changing power structures. However, the tactics described above have been used to influence our drug-use on an increasingly global scale for quite some time. This is evidenced in a policy document written for the World Health Organization in 1957. In describing how best to offer treatment to a drug addict it was stated that "although it will frequently be necessary to resort to coercion before the patient can be made to undergo treatment, as far as possible he should be allowed to make, or to feel he has made, a free decision, so that from the beginning some degree of co-operation may be obtained and treatment may be based on a sense of trust" (WHO 1957: 7).

Foucault has argued that it is ineffective to oppose only specific institutions, groups, or classes that are understood to wield power. Instead, we must identify and critique the overarching forms and techniques of power. Hence, as in the Soviet example, it has been shown historically that occupying the state or removing a given institution of power does not create a more egalitarian society. For this reason, we must ascertain the ways this non-localized system of power interactions acts on us as individuals by operating through us in shaping our desires, our knowledges, and consequently our experiences (Foucault 1982: 331). If power relations are understood to be enacted not only politically, but "rooted in the whole network of the social," we can only hope to alter them by demystifying their subtleties (Foucault 1982: 345). Bourgois has noted that Foucault's understanding that power permeates truth, knowledge, and even resistance can overwhelm and incapacitate the ability and willingness of academics to take political positions on reconceptualizing reality. However, Bourgois also notes that the practice of ethnography is well suited to realizing the purposes for which Foucault himself sought to describe power and governance. Thus, in a similar way to the work on drug use carried out by

Bourgois, this chapter is an attempt to fulfil the role of a "specific intellectual" taking political

99 positions on the "technoscientific" practices that govern drug-use (Bourgois 2000: 188).

Power is contestable precisely because it operates through knowledge. This view of power is in keeping with observations generated from within critical medical anthropology. Power is not infinite, it cannot shape people exactly as it likes. Hence, people - ill or not - are influenced by power but they are also fully capable of contesting and reshaping it to meet their own needs (Singer and Baer 1995: 63;

Singer and Baer 2007: 34; Singer 2006: 26; Greenlee 1991: 80). This chapter is thus an attempt to analyze power precisely so it can be contested.

Section 2 —Addiction As Power

Addictions can be employed as a source of power. An addiction can be manipulated to ensure repeat business, encourage brand loyalty, or heighten productivity. Physical addictions can lead to unequal power distributions between actors. Several examples of naked power realized through addiction come to mind. One of my friends from Cartref who was addicted to prescription painkillers once explained to me how his drug dealer used his opiate addiction to manipulate him into performing physical labour. That is, he might sometimes clean his dealer's house, chop his wood, or shovel his driveway in exchange for a slight discount on pills. Bourgois has noted how shopkeepers in San

Francisco employ the power of addiction over heroin users in a similar way. That is, it was common for store owners to pay their favourite homeless addict the price of a dose of heroin to perform labour for them. In this way they could be sure that they were supplied with cheap labour to carry out chores at precisely the same time every morning (Bourgois and Schonberg 2007: 15). On a larger level one might also note that many commodities we purchase contain chemicals that are physically addictive. They are sometimes put there, rendered palatable11, or intensified in order to retain power over consumers. For

1' For instance, cocoa is mixed with large amounts of sugar to make it more pleasurable for people and children to consume.

100 instance, cigarettes, chocolate, coffee, and cola flavoured pop all contain addictive chemicals. The filtered cigarette was invented so that a smoker might ingest more of the addictive substance in a given day than was previously possible. The power of addiction ensures both brand loyalty and that customers will return and purchase a product they might not have been inclined to purchase in the absence of addictive chemicals.

The process by which certain addictive drugs come to be classified as appropriate or legal for actors to employ to shape behaviour is complex. Particular historical circumstances and properties of certain drugs have led to a situation where distributing some substances is legal while others are not.

This is framed, and indeed commonly conceptualized, as resulting from the inherent nature of a drug.

Thus one substance may be imagined as innately healthy and another inherently dangerous for reasons that are related to power dynamics as well as biology. Nonetheless, the hypocrisy of these distinctions is often visible to the people who enforce the laws that surround their consumption. For instance, when speaking to a probation officer, he noted "I think we are kind of hypocritical in a way, that tobacco is almost outlawed but we still skim millions of dollars in taxes. You know, alcohol is, you know people talk about pot and hash being gateway drugs but you know alcohol would probably fall into the same sort of path, same category." Sidney Mintz has argued that substances such as tobacco and alcohol were historically approved for mass consumption because they provide the user with a break from reality and mask the desire to eat. Moreover, the use of coffee, tea, and chocolate were encouraged because they provide stimulus to production without having to allow workers time to eat. Sugar also became important for sweetening these substances, thus making these bitter stimulants palatable to the masses

(Mintz 1986: 186).

In keeping with the complexity of this theory of power there are often several reasons a given substance is classified in a particular way. Singer observes that when tobacco was first introduced to

101 England, measures were enacted to reduce its consumption. However, by the end of the seventeenth

century it was realized that tobacco could be used to generate considerable tax revenue and the

substance became legal throughout Europe (Singer 2006: 39). Furthermore, Paul Gootenberg notes that

the mass consumption of drug commodities helped to establish territorial states (2009: 17). Thus, the

consumption of substances grown in the new European colonies (tobacco, sugar, coco, coffee, tea,

among others) was promoted in order to make settling these areas economically viable. Thus, for a

given substance a variety of different stakeholders might simultaneously promote or overlook its use if

it meets their interest.

More recently, the consumption of tobacco became much less actively promoted after it was

exposed that ingesting this substance could lead to a variety of fatal conditions. However, this should

not imply that public health considerations always dictate what substances we are influenced to

consume. Indeed, a recent Canadian study found that across the globe one in twenty-five deaths could

be attributed to the consumption of alcohol. In Europe this number is even more significant, where

alcohol is involved in the deaths of fully one tenth of the population (Ubelacker 2009). In spite of this

fact powerful interests still push for the consumption of alcohol. As in the tobacco example, people are

obviously able to influence the way these drugs are marketed in their capacity as consumers and voters.

The process by which the public comes to differentiate so differently between two highly unhealthy

substances such as alcohol and nicotine is messy to say the least. Why people continue to allow

corporations to advertise alcohol to anybody - and specifically to children - could be the subject of an

entire project in itself.

Section 3 - Governing With Methadone

It is important to examine the process - and underlying power dynamics - by which distinctions

102 between illegal opiate use and methadone use have come to be established. This is because these substances can be imagined differently depending on the contexts in which they are used. Dependant on factors such as time, location, and who you ask, one substance might be described as medicine while the other is viewed as a poison. For instance, Lovell has observed some of the ways in which opiates that are used to treat addicts can become entirely reconceptualized as they cross markets and borders

(2006: 137). Consequently, examining the motives that might have played a part in generating and disseminating these distinctions is of relevance for understanding use patterns.

The current treatment paradigm for opiate addicts in North America generally dictates that they should be prescribed drugs such as methadone to "overcome" their addiction. Once ingested, methadone can prevent the physical symptoms of opiate withdrawal by binding to similar receptors in a person's brain. However, methadone does not provide the pleasurable euphoria (one no longer gets

"high" so to speak) common to many other opiates if it is administered consistently at a measured dose

(Jamieson 2002: 7). Moreover, once ingested methadone prevents other opiates from acting on these portions of a user's brain. In this way methadone mitigates opiate withdrawal without getting the user high while simultaneously preventing the user from getting high by ingesting any additional opiates

(Jamieson 2002: 7).12 The reason that methadone can have this effect on users is because - ironically - it is much more physically addictive than many opiates commonly used on the street (Bourgois 2000:

170). Thus, addicts are "cured" by generating a new more powerful opiate addiction within the chemistry of their brains. Whether or not this should be defined as an "addiction" depends on the positionality of the person providing the definition. Some would argue that an individual is "addicted" to a substance whenever withdrawal symptoms are produced after failing to ingest said substance according to an established routine. However, it would seem no single definition of addition is

12 As a consequence many methadone patients overdose and die while trying to attain a high by self-administering large doses of illicit opiates (Corkery et al. 2004: 569 and 572).

103 universally accepted. This is evidenced by the following quote from a pamphlet on methadone use produced by the Centre for Addiction and Mental Health (CAMH):

Is methadone addictive? Modern definitions of "addiction" look at many factors in assessing a person's drug use. Some people say that methadone is just as "addictive" as heroin. People in methadone treatment do become tolerant to the effects of the drug, and will experience withdrawal if they do not take their regular dose. But methadone fails to meet a full definition of "addictive" when we look at how and why the drug is used (CAMH 2003).

Consequently, it is important to analyze the process by which addiction to a more physically addictive substance becomes a prerequisite for the treatment of many addicts suffering from "addiction."

There are two primary reasons used to justify the biomedical distinction between physical addictions to licit and illicit opiates. First, when opiate use is administered by a health professional many of the negative side-effects common to illicit opiate use can be eliminated. This is demonstrated in the following excerpt from the same pamphlet on methadone treatment produced by CAMH: "an important benefit of methadone treatment is that it reduces heroin use. The dangers of heroin use include death by overdose, and becoming infected, through needle sharing, with viruses such as HIV and hepatitis C" (2003). It would be difficult to dispute the fact that addicts who remain in methadone treatment do realize these benefits to their lives. However, as will be shown, this effect can be realized to a similar degree when doctors prescribe and administer opiates other than methadone to treat opiate addiction. Eliminating the ability of a drug user to feel euphoria becomes the second reason that biomedical professionals favour methadone addiction to other types of opiate addiction. For instance, when I asked the doctor I interviewed why the biomedical community preferred to prescribe methadone to treat addiction (rather than morphine) he stated:

Dr. Juniper - Well I think people are more likely to get themselves in trouble while high. Ben - Neglect their children, that kind of thing? Dr. Juniper - Well not only that, but get in car accidents, engage in high risk sexual behaviour, that kind of thing.

104 Once again, this observation seems plausible enough as the effectiveness of methadone maintenance in reducing high risk behaviour is "well documented" (Belding 1998: 485). However, this is not the only reason why opiates with less pronounced psychoactive effects are preferred for the treatment of opiate addiction in North America.

An additional reason methadone is preferred over other opiates is that it helps the state to govern addicts according to dominant logic and hegemonic values. Several scholars have noted the ways in which methadone can be employed in order to govern the behaviour of addicts (Bourgois 2000;

Bergschmidt 2004; Ning 2004; Dahl 2007). Bourgois has employed Foucault's framework to argue this point. He states that methadone is indicative of "the state's attempt to inculcate moral discipline into the hearts, minds, and bodies of deviants who reject sobriety and economic productivity" (2000: 167).

Thus, he argues that addiction to methadone is used to force addicts to behave in ways that the state - and larger public - conceive of as appropriate. Sobriety is imagined to be intricately tied to productivity. Hence, methadone is used to ensure that a patient does not experience drug-induced euphoria. Moreover, the fact that methadone is even more physically addictive than heroin siphons power from the user and places it in the hands of professionals who are influenced by the interests of the state. The coercive nature of these power dynamics are shielded behind the technocratic language of biomedicine. Thus, high doses of methadone are presented uncritically in scientific literature as the most effective method to ensure abstinence from illicit drug-use (Bourgois 2000: 182). The logic being that high dosages are best able to help addicts to resist the temptations of addiction. In contrast,

Bourgois notes that the correlation between patient compliance and high dosage might better be explained by the observation that it becomes too painful for an addict to act out once they are physically addicted to this drug (2000: 183). Bourgois ethnographically documents this through

105 conversations with informants who are addicted to methadone. His informants' doses were at times lowered (which entailed the onset of mild symptoms of withdrawal) or upped (sending them into a

"drooling oblivion") to ensure compliance with dominant biomedical logic on illicit drug use. During this process the underlying power dynamics are obscured in biomedical language that describes this process as a quest to discover the individually appropriate dosage of the drug (Bourgois 2000: 183).

Ning has also made note of what she terms the "social management" function of methadone treatment. In reflecting upon an interview she conducted with an employee of a methadone clinic Ning notes that "by stating that methadone treatment programs are not completely "altruistic," he allows for the possibility that the actual goals of the treatment program are not necessarily those of therapy but, rather, those of social management - preventing an "unhealthy" other/addict from "contaminating" the wider "healthy" public" (Ning 2005: 360).

The utilization of methadone to allow professionals a position of power to influence the behaviour of opiate addicts was also acknowledged during one of my interviews. In this instance the form of coercion was significantly less brutal. That is, in this example power was not achieved by altering a patient's methadone dosage. Instead, control was achieved through manipulating the desires of addicts. In my interview with Dr. Juniper, he stated:

Dr. Juniper- You can't just give a patient a methadone prescription and assume they're gonna be fine. You need to take a multifaceted approach that is medical, social, and underpinned with community support. Ben - And how do you ensure that your patients take part in this multifaceted approach? Dr. Juniper - Well, I tend to take a more positive reinforcement approach. If you show up for your appointment and you've got crack in your urine I'm not going to say okay you're cut off, I'm not giving you your methadone anymore. The reason I do drug screens on people is its an early warning sign that somebody is relapsing. For me the big carrot is that if you are consistently clean and you're showing up for your appointments, and your doing well, I will give you some carries [doses of methadone] to take home with you. It's also a financial incentive. There is a twelve dollar dispensing fee associated with your methadone, whereas your price of methadone is only two dollars, having to go in there and get it from them means you will have to pay twelve dollars. So twelve dollars times seven versus twelve dollars once a week.

106 The ability of physicians to decide which addicts can avoid the onset of withdrawal without visiting a pharmacy gives the doctor a great amount of power to influence the behaviour of a patient. This power can be used by medical practitioners in order to force addicts to behave according to the dominant logic that privileges addiction to certain types of opiates over others.

Dahl noted the existence of a power dynamic similar to above in studying methadone treatment in Denmark. He notes that a recent development in methadone treatment in his fieldsite has been to allow addicts to remain in treatment even after they provide "dirty" urine samples (Dahl 2007: 109).

Dahl observed that the doctors he studied would reward compliant patients with take-home methadone doses in order to reward them for good behaviour. This was done instead of withholding drugs to punish bad behaviour (Dahl 2007: 110). In this way, addicts undergoing methadone treatment in

Denmark were also governed to engage in particular kinds of behaviours by controlling access to take- home dosages of methadone.

Moreover, the cost of dispensing individual doses of methadone is not the only basis for this power. Another element of this power dynamic is that it is very difficult for a patient to lead a "normal" life while having to visit a pharmacy everyday to avoid painful withdrawal symptoms. For instance, in my conversation with a probation officer he made the following observation about his clients:

Probation Officer - Well you know, methadone is a better option than most, than many, but it's uh, an imperfect solution, it's a very controlling regiment. Ben - Government control kind of? Probation Officer - That, and you know, the involvement with doctors and pharmacists. It's very difficult to be at work or live a normal lifestyle when you gotta go to the pharmacy every day during business hours, which are usually the same as working hours, and you gotta go to [a nearby city] or some place else at least weekly, and it's a very difficult life to sort of get into that rhythm and have a family or employer who is supportive enough to have you doing that. And that's not a quick turn around, that's a pretty long term ordeal to do that.

107 Biomedical control of addicts in "recovery" is thus secured by a dynamic whereby health professionals can reward a patient for relating to drugs in ways deemed inappropriate by the dominant logic of the biomedicine and the state. This can be accomplished by making relief from withdrawal easier to access and afford if the patient is willing (or able) to abide by hegemonic social values which tend to focus on the idea of regaining "self-control" (Ning 1999: 96).

The reasons that the state prefers addiction to opiates like methadone instead of heroin are complex. As stated earlier, exposure to certain pathogens and death due to accidental overdose can be better regulated when opiates are prescribed by biomedical professionals. But these outcomes can be realized by prescribing opiates that are equally psychoactive to illicit ones. The biomedical tendency to prescribe non-psychoactive opiates to addicts is thus justified because impaired states of consciousness are thought to be more dangerous to users and society. However, the motive for prescribing opiates that deny the addict pleasure are also grounded in our cultural values pertaining to sobriety. I was repeatedly told by my informants that either they personally, or the public at large, would never support the use of tax dollars for the prescription of heroin. This is evidenced in the following exchange I had with the second police officer I interviewed:

Ben - How do you feel about the needle exchanges in Vancouver? Police Officer #2-1 think that's good, there are always going to be people who have addictions. We can at least avoid spreading diseases and that kind of thing Ben - How about [long explanation of Swiss study that found heroin addicts were more likely to stay in treatment, maintain jobs, and avoid illness when prescribed heroin instead of just methadone] where the addicts are actually given heroin on the weekend? Police Officer #2-1 think it would be complicated, I know its not black and white issue. I don't know if I personally would support that, personally I wouldn't be thrilled to see my tax dollars go to heroin.

Evidenced here is the commonly held conception that it is legally and morally acceptable for the

Canadian medical system to provide people with addictive opiates only so long as sobriety is not compromised. This is true even if the goals of realizing greater health and productivity for addicts is

108 better achieved when potentially intoxicating opiates are prescribed.

This outlook may be the result of a hegemonic cultural notion that getting high on opiates is a dangerous, unproductive, and immoral act. The Swiss experiment which I referenced in many of my interviews studied the effects of prescribing either methadone, heroin, or morphine (with the option for some addicts to supplement their prescription with another opiate of their choosing) to a large group of addicts. It was demonstrated that those addicts who were prescribed heroin were most likely to become functional according to classical criminal and biomedical logics. That is, they were less likely to be hospitalized, killed, report psychological distress, commit crimes, consume street drugs, and more likely to find and maintain employment than those prescribed methadone by itself (Rehm et al. 2001:

1418-1420; Bourgois 2000: 186). Those participants who were allowed to supplement their prescription with a drug of their choice were most likely to choose methadone. Moreover, out of the entire group it was these patients who demonstrated the greatest ability to enter the legal workforce and maintain employment (Rehm et al. 2001: 1418-1420; Bourgois 2000: 187). A similar experiment was repeated in

Germany which generated nearly identical findings (Wylie 2006). In light of this evidence sixty-nine percent of the Swiss public approved of the prescription of heroin to treat opiate addiction in a referendum held in the fall of 2008 (BBC News 2008).

Despite experiences and studies such as these, the Canadian treatment paradigm for opiate addiction does not include the prescription of heroin. That said, many of the informants I spoke to recognized that the practice of prescribing opiates most effective for keeping addicts in treatment (and hence, reducing the transmission of disease while enabling an addict to maintain a job) might be beneficial regardless of psychoactive effect. For instance, the judge I spoke to stated:

Judge Avery -1 saw this Swiss thing, but I also saw the British experience which was just as powerful. And we take a lot of our legal sort of heritage from them. They did the same thing. With national health of course it makes a lot sense because you can control the health aspects of it as well. Incarcerating them too, provincially we know what the costs

109 are for that. And so this is costing tonnes of money when a lot of the time the root cause isn't really criminal it's health or social. It's a health issue. But of course the Excited States of America doesn't approve of anything like that so it makes it a bit more difficult for them to do what they need to do.

Section 4 — Social Morality, Fear of Addiction, and Power

Drugs can also be used to govern people who do not use them. This has been accomplished by inciting the public to fear certain substances and the people perceived to use them. For instance, Singer has argued that many of our current drug-policies stem from attempts to exclude particular ethnic groups from fully participating in North American society. Opium was first outlawed in the U.S. after an economic depression in the 1870's that redefined Chinese immigrants (imagined to be opiate addicts) as responsible (Singer 2007: 46). Similarly, marijuana was commonly prescribed and used in the U.S. until it became associated with surplus Mexican labour in the depression of the 1920's (Singer

2007: 50). It was also feared that cocaine would give the long repressed black populations of the U.S. superhuman strength culminating in an unstoppable uprising (Singer 2007: 51). This fear is best expressed in a quote from a doctor taken around the time cocaine first became illegal in the U.S.:

Perhaps the most interesting feature of the effects of cocainism, at least from a medical standpoint, is the fact that the drug renders the user immune to shock to an astonishing degree... In the language of the police officer, 'the cocaine nigger is sure hard to kill' - a fact that has been demonstrated so often that many of these officers in the South have increased the caliber of their guns for the express purpose of'stopping' the cocaine fiend when he runs amuck.... Needless to say this immunity to shock, together with the fearlessness, hallucinations, and homicidal tendencies that cocaine engenders, makes the 'fiend' an object of special dread (As quoted in Cohen 2006: 73).

Entrenched racism could thus be more easily justified through reference to particular substances and the qualities they supposedly instilled in their users. It seems plausible that conceptualizations of drugs are still exploited to target particular segments of society. For instance, this might be evidenced by the

110 fact that seventeen percent of federal prisoners in Canada are Aboriginal, despite the fact that

Aboriginal people only constitute three percent of Canada's total population (Siegel and McCormick

2003: 65).

Fear of the drug addict may also be stoked in the U.S. in order to soften the political influence of the poor and people of colour. That is, some have argued that American drug policies exist in their current form because powerful interests use drug policy to further repress structurally marginalized people. Those charged with drug offences overwhelming come from backgrounds of poverty.

Criminalizing drug-use and declaring a war on drugs is thus not an act of fighting a war against substances, but instead, an act of fighting a war against those structurally positioned to use and distribute them (Singer 2004: 288). This is therefore an effective means by which powerful interests can deny marginalized groups political power. This is because many states in the U.S. do not allow a person who has been convicted of a criminal charge the right to vote. Thus the drug war can be used to structurally deny poor people and people of colour a democratic ability to speak out against policies which repress them (Gootenberg 2009: 27). Another similar use of drug-policy to further marginalize exploited peoples in the U.S. can be observed in the newly emerging practice of denying welfare aid to clients who use illegal substances. That is, it was recently reported in the Seattle Times that eight U.S. states are considering adopting a policy of denying state assistance to anybody caught with concentrations of unapproved drugs in their urine (Breen 2009). It is in these ways that current conceptualizations of drug-use can be used to exploit marginalized people in an absolutely ruthless manner. Poor people are denied their right to vote and policies are enacted to deny them any assistance to aid them in overcoming their exploitative social positions. While drug policies in Canada may not be enacted for these purposes, they are constructed at least partially in reference to them, even if only to ensure our borders remain as open as possible to trade.

Ill Finally, a fear of drug use and addiction to illicit substances is also elicited among the public for powerful geopolitical reasons. Prior to the "War On Terror" it was difficult to obtain carte blanche from both the public and the international community to invade sovereign states to "develop" their resources.

Thus, it was partially with this purpose in mind that President Ronald Reagan first conceived of the

"War On Drugs." Consequently several sources have noted the past involvement of clandestine factions of the U.S. government in fostering the production and distribution of illicit drugs (Singer 2004: 295;

Singer 2006: 179; Gootenberg 2009: 26). Gootenberg also notes that because many drug-distributors operating out of periphery states during the Cold War tended to have anti-communist affiliations they received clandestine aid in distributing their product (Gootenberg 2009: 26). The practice of criminalizing drug-use by the U.S. Government for geopolitical ends has a long history. For instance the U.S. convened a global anti-drug conference in 1912 in order to place international restrictions on the trade of opium. Historians have since noted that a primary motive for this action was not a concern for the health of the Chinese. In contrast, this action was taken to gain an economic advantage over the

British empire who were greatly profiting in selling opium to China (Singer 2006: 57).

Section 5 - Biomedicine, Drug Use, Addiction, and Social Control

The Western biomedical system is also tailored in part to serve as a mechanism of social control. Singer and Baer state:

according to the reductionist model of disease in which physicians assign the source of disease to pathogenic or related factors, personal stress emanating from social structural factors such as poverty, unemployment, racism, and sexism is secluded from the potentially disruptive political arena and secured within the safer medical world of individualized treatment (Baer, Singer, and Susser 1997: 32).

The process by which this is accomplished is referred to as reification. This is a concept that was originally developed by Karl Marx to describe the way products of social relations come to be

112 conceived of as facts of nature. That is, Marx noted that through capitalism, people came to think of commodities as "objective expressions of human labour on nature" (Singer and Baer 1995: 76). By conceptualizing objects in this way the exploitative social dynamics by which commodities are created are rendered less visible. Thus, the value assigned to a given workers labour, a unit of a particular resource, and hence, the final price of a commodity at market, are imagined to originate out of a natural order of things rather than an exploitive economic system. The term reification is applied in CMA to describe the way biomedicine is utilized to obscure the role played by social relations in producing illness (Singer and Baer 1995: 76). Thus, reification occurs when a disease is explained by biomedicine as primarily a manifestation of a biological reality. This process was made apparent to me when Dr.

Juniper explained that "the rewards of the drug [OxyContin] are greater for people with a greater genetic predisposition for addiction than for others." In this way addiction can be accounted for in a manner that is less disruptive to currently established power dynamics. That is, doctors and other health professionals are trained to think of addiction in this way in order to depoliticize issues which are at least partially political in nature. It is not that biomedicine or biomedical professionals are incapable of identifying the ways social relations affect health. Indeed, it was not at all uncommon for Dr. Juniper and other health professionals I interviewed to attribute elevated rates of drug-abuse to local social dynamics. For instance, in my interview with an Aboriginal mental health worker named Logan he stated:

I think that [drug use] stems from trauma, which is just a cycle in those communities. Whether it was due to the, just how they were treated in the last few hundred years, and also the trauma of residential schools, and how it cycled down through the generations. And people escape their trouble through addiction, pain killers, marijuana, alcohol, whatever.

However, the current biomedical treatment framework is constructed to address disease primarily after the onset of symptoms. In this way, a great deal of money is spent on treating or masking symptoms of

113 disease without having to address the sometimes exploitative social dynamics that also significantly contribute to the spread of disease.

Another good example of a way biomedicine is used to reify disease solely as a natural biological process was brought to my attention when I interviewed a mental health worker named Bia.

She is a health professional who only works with addicts who have what are termed "concurrent disorders." That is, it is her job as a health practitioner to offer support to addicts who also have underlying mental-health issues. These mental-disorders are thought to have arisen either as a result of addiction or may have led to an addiction in the first place. Regardless, Bia used an assessment form that can be found on page 34 of the DSM in order to diagnose her patients with mental health disorders

(ASA 2000). This assessment form is called the Global Assessment of Functioning Scale (GAS).

Patients are assigned a score between one and one hundred, with the higher scores indicating better mental-health. Interestingly, the lower scores, which indicate the presence of mental disorders, are heavily invested with ideologies of productivity. For instance, if a patient has a score between 51-60 they are likely to demonstrate "moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with co-workers)." Those patients that score between 41-50 are likely to exhibit behaviour like "frequent shoplifting" and can be marked by "any serious impairment in social occupational, or school functioning, (e.g., no friends, unable to keep a job)" (ASA 2000: 34). I would argue that these assessments are loaded with the values of those who economically dominate society.

What is seen as "insane" behaviour - things such as shoplifting, disinterest in education, or having conflicts at work - are as much issues of social inequality as they are indicators of a pathological personality. Thus, instead of systematically trying to address those social structures that can lead members of particular social groups to conduct themselves in these ways, the problem is conceptualized as an individual manifestation of a mental health condition that needs to be medicated.n

13 It must be noted that Bia does not base her treatment solely on biomedical frameworks such as these. Indeed, she noted

114 Moreover, it has been argued that the way we think about drug-use has enabled those in positions of power to disguise the causes of social inequality. Thus, the public comes to believe that particular groups of people are suffering as a result of their own moral failing instead of structural disadvantage. For instance, Singer argues that inner cities in the U.S. were left to rot when blue collar manufacturing jobs were moved offshore by companies in search of cheaper sources of labour. One might identify this as a cause for the decay and poverty experienced by those who were marginalized when this shift occurred. Instead, the inability to abstain from illicit drug-use is the commonly offered explanation for why people in inner-cities suffer and experience disproportionate levels of poverty

(Singer 2004: 295-296). As a consequence of the individualization of suffering, the American consumer can continue to buy into this exploitive system, buying many of their goods from offshore, without acknowledging its devastating effects.

This is all part of a larger process of biomedical social control, whereby, disease is individualized in order to develop biomedical treatments and conceptions of illness that can avoid addressing the social dynamics which contribute to disease. As a consequence of this the "proper" maintenance of one's health has increasingly come to be viewed as a personal moral responsibility

(Burri and Dumit 2007: 4). For instance, when a disease such as lung cancer is diagnosed it is relatively common to hear people blame the patient instead of the companies that advertise and sell these products. An individual's personal lack of will power can thus be blamed instead of holding large tobacco companies responsible for encouraging people to construct their identities in relation to the consumption of these addictive and deadly products (Singer and Baer 1995: 79). Singer and Baer refer to this biomedical process as "privatization." In this way a form of social control which Singer and

Baer refer to as a "depoliticization of social issues" is achieved (1995: 77). Claudia Chaufan has

to me that "there are different theories that the addiction comes first then the [mental] disorder, or that the disorder comes first then the addiction. Its quite a challenge so you never know what to treat first."

115 demonstrated how this process has unfolded in relation to the endemic of diabetes in Western culture.

She notes that many people lobbying government on behalf of diabetics demand funds to address this health issue through research that will develop a "cure" (2004: 267). This quest to uncover a "cure" is a perfect manifestation of the biomedical tendency to privatize illness. What might seem to be some of the most practical methods available to address elevated rates of diabetes (for example, making it illegal to advertise unhealthy food, barring the sale of junk food in schools, raising tax rates on unhealthy food, and generally questioning our culture of over consumption that has led to high rates of childhood obesity) is overlooked in favour of the development of an individual "cure." Privatizing diseases leads people to conclude that the maintenance of health is primarily an individual responsibility. Those people who succumb to the powerful social structures encouraging them to consume things in potentially unhealthy manners - people who eat junk food, smoke cigarettes, accidentally become addicted to painkillers prescribed by their doctor - are consequently blamed for lacking self-control. As a result health issues become depoliticized. In this way companies are given an infrequently contested ability to generate profit while significantly contributing to the creation of illness.

A couple of examples of the ways in which addiction as a health issue can be individualized were produced during my interactions with biomedically trained professionals. One of these instances was during an interview with Dr. Juniper when he stated:

I am quite honest with my patients, like you're an addict, you have a problem, you're always going to be an addict, you're going to mess up occasionally, its not about perfection but its about trying to make the best of this situation and reduce the harm to you. You have to know that you're not going to be abandoned the minute you screw up.

Here addiction is conceptualized as an unchangeable individual reality. If addiction was instead viewed as resultant at least in part from the patient's social experiences, addiction might be viewed as a

116 reversible outcome borne out of particular social circumstances. However, social marginalization can be accepted (instead of unaddressed) when biomedical language is used to train doctors to imagine addiction as a predetermined biological disease. Another example of this sort of privatization of disease occurred during my interview with Bia, the concurrent disorders specialists. She stated:

I think most change needs to come from the individual. We need to help people through their problems. When someone relapses and says I need to start from day one, I say no, you've learned something from this and try to get them to think about what works and what doesn't.

This is another example where addiction is conceptualized as an individual health issue. The privatization of illness has different undertones in this instance. This conceptualization is in keeping with the view that locates the responsibility for the maintenance of health as an individual moral responsibility. However, this privatization of illness similarly serves to distract both the patient and health worker from identifying the social structural influences on addiction.

Biomedicine is also employed as a social control mechanism in ways that are more overtly coercive. Thus, one of the responsibilities bestowed upon health care practitioners is the role of medical gatekeeper. Consequently, it is a duty of biomedical professionals to monitor and determine who can legitimately access the "sick role." Social power apparatuses are set up in such a way that these people become charged with the responsibility of differentiating between conditions that are conceptualized as legitimate organic disease and those behaviours which count only as malingering (Singer and Baer

1995: 86). In this way it can be determined which people can be excused from work without sanction

(Baer, Singer, and Susser 1997: 31). If one accepts the anthropological position that much of disease is culturally relative than it is clear these distinctions are a part of a process that privileges certain social positions over others. Moreover, these distinctions are arbitrary to a certain degree. An example can be found in a pamphlet used to advise doctors on how and when to use urine drug testing with patients.

117 Within a section of the pamphlet written to address the question of "why doctors should conduct urine tests," the reason given was that of patient advocacy. Thus it was stated that "with accurate record­ keeping and due care, practitioners can use UDTs [Urine Drug Tests] to advocate for patients in family, workplace, and contested situations as documentation of compliance with the agreed upon medical plan" (Gourlay, Heit, and Caplan 2006: 5). If doctors employ urine testing in this way significant social control functions are met. That is, preference is given to opiate addicted patients who use drugs according to the preferred biomedical framework using drugs such as methadone or suboxone.

Consequently, the patients who are socially positioned in such a way that accessing medical care is possible, or for that matter, understood as a priority (patients who come from less marginalized backgrounds; methadone treatment in Cartref costs a patient twelve dollars a day and the pharmacy where it is dispensed is difficult to access without a car) are allowed access to the sick role. Thus, addicts from preferred social backgrounds are distinguished as genuinely ill patients who are under control. This process differentiates these people from those addicts who might display different behaviours which can sometimes be explained as culminating out of their social positioning.

Conclusions

Bourgois has argued that we need to de-exoticize the way we think about drugs (2000: 190).

Most concretely we need to be thinking about the ways we can make all people's relationships to drugs the most beneficial - or least harmful - possible. What this entails should always be contested. An important starting point is to realize that criminalizing the choice to use certain types of drugs is in nobody's best interest. Instead, we must offer addicts the help of their own choosing while simultaneously trying to eliminate forms of structural exploitation that can lead to self-destructive behaviour. This will mean making it illegal to advertise any potentially destructive activities be it

118 nicotine, provincially sponsored gambling, or alcohol. Moreover, it will mean identifying and trying to reverse power dynamics that leave people feeling powerless and desperate. Many of those people charged with the responsibility of enforcing the criminalization of drug-use have similar outlooks and are currently screaming for a reconfiguration of state drug-policy. This was evidenced in the following exchange I had with a Federal Judge:

Ben - So then basically your recommendations would be mostly on a political level that is greater than our community right? Judge Avery- Yes, i think we need to look someplace else other than to the South of us, where they have the highest - but for a few - they have the highest amongst the developed countries incarceration rate to the point where I think its almost one in a hundred adults, to the point where they're spending more on the prison system than they do on their healthcare. In California which pioneered the three strike rules, they don't do it anymore, they removed it from the books for a lot of very good reasons. One of which is the cost of housing prisoners for life. They had the hidden cost of people fleeing when they were on their third strike. They were hurting innocent people, they were shooting at police officers because they were gonna go to jail forever, not because they particularly had any hate or dislike for the police. So they've retracted from that and we're moving towards it, go figure. We never learn anything from what other people do.

However, these potentially destructive drug-policies cannot be politically addressed until the majority of the Canadian public, not just those who work with addicts, come to realize the status quo will not suffice.

In the words of the first police officer I interviewed: "we gotta take that 10 billion we spend on incarcerating people and spend it on better housing, better education, freer university, whatever." In spite of views such as this Canadian political policy seems to be running in the opposite direction at the current moment. While those states that have decriminalized drug use - which is hardly the same thing as promoting it - are realizing great benefits, we continue to engage in policies proven not to work.14

For instance, Singer highlights a widely cited 1994 RAND study which discovered that drug treatment is twenty three times more cost-effective than attacking drug-production abroad, ten times more cost

14 For instance, in Holland they are actually looking to rent prison spaces to neighbouring European nations because prison populations have declined so significantly since the 1990's (NRC Handelsblad 2009).

119 effective than programs designed to stop drugs at the U.S. border, and seven times more cost-effective than enforcing the criminalization of drug use (2004: 298). The current Canadian parliament can thus be seen to be promoting drug-policies that are in nobody's best interest. Thus, we must recognize these policies for what they are, even while the Prime Minister of the country states that he is making policies that work for ordinary Canadians instead of those who "work in ivory towers" (Whittington

2008). This view should be contrasted with the opinion of a federal judge I interviewed:

Ben - Yeah, I'm reading about [our local MP] begging for harsher penalties all the time right now. Judge Avery - Oh I know, you see the stupid things he's saying, it just makes you sick. A guy who never comes in the courts, he has no idea what these people are up to. Ben - I'm not even sure the Conservatives actually believe in this stuff, they just know it wins votes in these ridings. Judge Avery - Absolutely, it's just pure bullshit. The statistics do not support them in any reasonable fashion. Violent crime rate country wide is down, gun crime country wide is down.

At this point it should be evident that we need to use our power to renegotiate our current drug-policies in order to make them work both for addicts and taxpayers.

120 Chapter VII - Conclusion

To begin, I must admit that some of the conclusions drawn in this project have - to a certain extent - suffered for want of data. That is, some of the theoretical conceptions of power in the previous chapters would have been more compelling had they been more firmly rooted in data. That said, this state of affairs did not come about because of negligence. This was a project of such a large scope that executing it perfectly was somewhat of an impossibility. It is hoped that future research following in this vein can make note of the need for more data and expand upon some of the work done here.

Regardless, the goal of this project was to critically engage with the relationship between the town of Cartref and oxycodone. At first blush, it is hoped that even the process of identifying oxycodone use as an issue of concern in Cartref might encourage a rethinking of the way this drug is prescribed. Moreover, it is hoped that providing insights generated out of critical medical anthropology will allow readers to critically engage with the conceptualization of oxycodone use in Cartref.

In particular, it is hoped that in locating this problem in its historic, economic, and political context more can be done to alleviate this problem. Moreover, it has been a goal of this project to call biomedical truth discourses into question. This is particularly true for truth discourses that relate to drug use. In demonstrating the ways in which knowledge can be produced and disseminated, as well as the ways in which truth can be contested and rebuilt, it is hoped that professionals and their patients can be empowered to provide the best possible service to their patients.

Finally, it is hoped that in identifying some of the tactics of government (as utilized by various actors from the state to corporate pharmaceutical companies) that underlie the way we consume and conceptualize drugs, more positive realignments to drugs can begin. In doing this, it is hoped that the social origins of disease will be more readily identified, and consequently, addressed. Rather than

121 placing the sole blame for addictions on the users themselves, it is hoped that readers will begin to identify the complex processes outside the individual that play a role in addiction to oxycodone.

Among these are players such as the pharmaceutical companies that market these drugs, a culture that demands instant relief from pain, and a decline in the availability of blue collared work in rural

Ontario.

The understanding that drug induced suffering results from social relations was not overlooked by very many of the professionals I interviewed. For instance, the three following excerpts demonstrate exactly this understanding:

Police Officer # 1 - Nah, I don't think any of them [addiction treatment models] work unless you get them out of the environment that causes them to be that way in the first place. We all make choices, and if we make a bad choice, we learn from it. The problem with the drugs is, that they have no alternative. So if, you're depressed all day and someone offers you a pill that would remove that, it's gonna be hard to resist it. So socially, they need to change the system, how they're gonna do that I dunno.

*

Ben - And so you feel that drug addiction is a serious problem towards social dysfunction in this community generally? Logan - Um, definitely in the native community, because I think that it stems from trauma, which is just a cycle in those communities, whether it was due to the, just how they were treated in the last few hundred years, and also the trauma of residential schools and how it cycled down through the generations, and people escape their trouble through addiction, pain killers, marijuana, alcohol, whatever.

*

Probation Officer -1 don't want to get into class or religion or anything like that. Children who come from pretty privileged backgrounds come through here. Children of doctors and lawyers, lawyers themselves. But the biggest majority are kids who come from homes with limited support often times with parents and grandparents who are familiar to me. Kids who are raised in households where social assistance is the norm. So it is kind of a learned behaviour. They don't know to get up have a shower and brush your teeth and go to school.

Despite possessing the above insights, professionals such as these do not have free reign to develop drug treatment programs exactly as they might wish. Many of the structural problems that have the

122 potential to contribute to self-destructive behaviour are well outside the purview of their control.

Moreover, these people are trained and equipped with resources to provide individual solutions.

Thus, a public understanding that drug policies can be employed to transfer blame onto those who are casualties of rapid social change is an important first step towards creating meaningful drug treatment policies. It is hoped that in sharing these professional insights, generated out of long careers of working with addicts, the public, who will never be afforded these experiences, might be able to accept the same conclusions. Thus, gaining access to this sort of knowledge allows us to contest power by addressing (rather than ignoring) structural inequality.

123 Appendix A - Interview Schedule

Typical Questions Asked of Interviewees 1) How long have you been working in this capacity in the community of Cartref?

2) Have you seen any rise in the number of people coming through your door with issues relating to oxycodone use?

3) How do you conceptualize addiction?

4) Do you support the idea of having a local detox centre in Cartref?

5) What do you feel causes or contributes to addiction, and in particular, the recent rise in prescription drug abuse in Cartref?

6) What is the best approach to take to help people heal or cease using drugs once they have become addicted to them?

7) What is your training for working with addicts? Has this influenced the way you think about addiction?

8) How long have you lived in the community of Cartref?

9) Is there anything we can do to raise awareness about issues pertaining to oxycodone use?

10) How do people tend to ingest these drugs?

11) How do your patients (or the people you interact with) describe the feelings and habits of those who use opiates?

12) Have you been personally affected in any way by this form of drug use?

13) What can we do to prevent people from getting addicted to these drugs in the first place?

14) How much of your work day is spent dealing with people with addictions?

15) Is there any literature or issue that you think I really need to consult or read over to fully understand issues pertaining to oxycodone use?

16) How can I try to make this document useful to you in your professional capacity?

124 Works Cited Ackerman, Nance. 2006. Cottonland. 54 min. NFB. Montreal.

Addiction Services. 2006. Building a System. A report compiled by Deane Consulting for Cartref Addiction Services.

Agar, M., and H.S. Reisigner. 2002. A Tale of Two Policies: The French Connection, Methadone and Heroin Epidemics. Culture Medicine and Psychiatry. 26:371-396.

Agriculture Canada. 1986 [1871]. 1871 Census: District 086 (Cartref), Sub-District A (The Sound). National Archives of Canada.

American Association for the Study and Cure of Inebriety. 1893. The Disease of Inebriety from Alcohol, Opium and Other Narcotic Drugs: Its Etiology, Pathology, Treatment and Medico-Legal Relations. New York: E. B. Treat.

American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition, text revision. American Psychiatric Association.

Aulakh, Raveena 2009. Tori Case Casts Light On Woodstock's Drug Habit: City residents say abuse of OxyContin is pervasive and deadly. The Toronto Star, May 23, 2009. http://www.thestar.com/article/639199 (accessed May 23, 2009).

Baer, Hans A., Merrill Singer, and Ida Susser. 1997. Medical Anthropology and the World System: A Critical Perspective. Westport, Connecticut: Bergin & Garvey.

BBC News. 2004. DNA Test To Help Smokers Quit. The BBC News Online, Dec 2, 2004. http://news.bbc.co.Uk/2/hi/health/4061137.stm (accessed Jan 17, 2008).

2008. Swiss Approve Prescription Heroin. The BBC News Online, Nov 30, 2008. http://news.bbc.co.Uk/2/hi/europe/7757050.stm (accessed Jan 17, 2008).

Belding, Mark A., Thomas McLellan, David A. Anis, and Ray Incmikoski. 1998. Characterizing "Nonresponsive" Methadone Patients. Journal of Substance Abuse Treatment. 15(6). Pp. 485-492.

125 Bennett, Linda A. and Paul W Cook, Jr. 1996. Alcohol and Drug Studies. In Medical Anthropology: Contemporary Theory and Method. Carolyn F. Sargent and Thomas M. Johnson, Eds. pp. 235-251. London: Praeger.

Bergschmidt, Viktoria B. 2004. Pleasure, power and dangerous substances: applying Foucault to the study of 'heroin dependence' in Germany.'Anthropology & Medicine. 11(1). Pp. 59-73.

Blatchford, Andy. 2008. Clement Slammed for Safe Injection Remarks. The Toronto Star, Aug 18, 2008. http://www.thestar.com/News/Canada/article/480744 (accessed Aug 18, 2008).

Bonanno, Alessandro and Douglas H. Constance. 2003. The Global/Local Interface. In Challenges for Rural America in the Twenty-First Century. David L. Brown and Louis E. Swanson, Eds. Pp. 241-251. University Park: The Pennsylvania State University Press.

Bourgois, Philippe. 1995a. In Search of Respect: Selling Crack in El Barrio. Cambridge University Press.

1995b. From Jibaro to Crack Dealer: Confronting the Restructuring of Capitalism in El Barrio. In Articulating Hidden Histories: Exploring the Influence of Eric R. Wolf. Jane Schneider and Rayna Rapp, Eds. Pp. 125-141. Berkeley: University of California Press.

2000. Disciplining Addictions: The Biopolitics of Methadone and Heroin in the United States. Culture, Medicine and Psychiatry. 24:165-195.

Bourgois, Philippe and Jeff Schonberg 2007. Intimate Apartheid: Ethnic dimensions of habitus among homeless heroin injectors. Ethnography. 8(1):7-31.

Breen, Tom. 2009. States Consider Drug Tests for Welfare Recipients. The Seattle Times, March 26, 2009. http://seattletimes.nwsource.com/html/businesstechnology/2008925679_apstateswelfarewiths trings.Html (accessed March 26, 2009).

Burri, Regula Valerie and Joseph Dumit. 2007. Introduction. In Biomedicine as Culture: Instrumental Practices, Technoscientific Knowledge, and New Modes of Life. Regula Valerie Burri and Joseph Dumit, Eds. Pp. 1-14. New York: Routledge.

Butler, Richard. 1998. Rural Recreation and Tourism. In The Geography of Rural Change. Brian Ilbery, Ed. Pp. 211-232. Edinburgh Gate: Longman.

Cartref Directory, 1898-1899.

126 1987. Cartref: Local Architectural Conservation Advisor Committee.

Cicero, Theodore J., Richard C. Dart, James A. Inciardi, George E. Woody, Sidney Schnoll, and Alvaro Munoz. 2007. The Development of a Comprehensive Risk-Management Program for Prescription Opioid Analgesics: Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS). American Academy of Pain Medicine. 8(2): 157-170.

Canadian Broadcasting Association (CBC). 2009. Canada's Climbing Tuition Fees. The Canadian Broadcasting Corporation, Sept 2, 2009. http://www.cbc.ca/news/interactives/map-tuition-fees/ (accessed Sept 3, 2009)

Canadian Pharmacists Association 2006. Compendium of Pharmaceuticals and Specialties: The Canadian Drug Reference for Health Professionals. Ottawa: Canadian Pharmacists Association.

Centre for Addiction and Mental Health (CAMH). 2003. Opioids: Do You Know. Brochure.

Chaufan, Claudia. 2004. Sugar Blues: A Social Anatomy of the Diabetes Epidemic in the United States. In Unhealthy Health Policy: A Critical Anthropological Examination. Arachu Castro and Merrill Singer, Eds. Pp. 257-274. Walnut Creek, CA: Altamira Press.

Cicero, Theodore J., Hames A. Inciardi, and Alvaro Munoz. 2005. Trends in Abuse of Oxycontin and Other Opioid Analgesics in the United States: 2002- 2004. The Journal of Pain. 6(10):662-672.

Cohen, Michael M. 2006. Jim Crow's Drug War: Race, Coca Cola, and the Southern Origins of Drug Prohibition. Southern Culture: 12(3). Pp. 55-79.

Coleman, Gabriella E. 2008. The Politics of Rationality: Psychiatric Survivors' Challenge to Psychiatry. In Tactical Biopolitics: Art, Activism, and Technoscience. Philip, Kavita and Beatriz da Costa, Eds. Pp. 341-364. Cambridge, MA: The MIT Press.

Corkery, John M., Fabrizio Schifano, Hamid Ghodse, and Adenkan Oyefeso. 2004. The Effects of Methadone and its Role in Fatalities. Human Psychopharmacology. 19(1). Pp. 565-576.

Critical Art Ensemble. 2008. Bioparanoia and the Culture of Control. In Tactical Biopolitics: Art, Activism, and Technoscience. Philip, Kavita and Beatriz da Costa, Eds. Pp. 413-428. Cambridge, MA: The MIT Press.

127 Dahl, Helle Vibeke 2007. The Methadone Game: Control Strategies and Responses. In Drugs in Society: European Perspectives. Fountain, Jane and Dirk Korf, Eds. Pp. 102-115. Oxon: Radcliffe Publishing Ltd.

Dewalt, Kathleen M., Billie R. Dewalt, and Coral B. Wayland 1998. Participant Observation In Handbook of Methods in Cultural Anthropology. Russel 1 Bernard, Ed. Pp. 259-300. Walnut Creek, California: AltaMira Press.

Dunk, Thomas and David Bartol. 2005. The Logic and Limitations of Male Working-Class Culture in a Resource Hinterland. In Spaces of Masculinities. Bettina van Hoven and Kathrin Horschelmarm, Eds. Pp. 31-44. London: Routledge.

Dyck, Noel. 2000. Home Field Advantage? Exploring the Social Construction of Children's Sports In Constructing the Field: Ethnographic Fieldwork in the Contemporary World. Vered Amit, Ed. Pp. 32-53. London: Routledge.

Enterprise, The. 2007. What's Killing Our Children. Four Part Series. The Enterprise Newspaper, March 25- 28, 2007. http://www.enterprisenews.com/homepage/special_reports/x355028946 (accessed Jan 15, 2008).

Falk, William W. and Linda M. Lobao. 2003. Who Benefits from Economic Restructuring? Lessons from the Past, Challenges for the Future. In Challenges for Rural America in the Twenty-First Century. David L. Brown and Louis E. Swanson, Eds. Pp. 152-165. University Park: The Pennsylvania State University Press.

Foucault, Michel. 1978. Governmentality. In Studies in Governmentality with Two Lectures by and an Interview with Michel Foucault. Burchell, Graham, Colon Gordon, and Peter Miller, eds. pp. 87-104. Chicago: University of Chicago Press.

1980. Body/Power. In Power/Knowledge: Selected Interviews and Other Writings 1972-1977. Gordon, Colin ed. pp. 55-62. New York: Pantheon Books.

1980b. Two Lectures. In Power/knowledge: selected interviews and other writings, 1972- 1977. Gordon, Colin Ed. Pp. 78-108. New York: Pantheon Books.

1982. The Subject and Power. In Essential Works of Foucault: 1954-1984. Paul Rabinow and James Faubion, eds. pp. 327-348. New York: The New Press.

Geertz, Clifford. 1973 a. Thick Description: Toward an Interpretive Theory of Culture. In The Interpretation of

128 Cultures. Clifford Geertz, Ed. Pp. 3-32. New York: Basic Books Inc.

1973b. Deep Play: Notes on the Balinese Cockfight. In The Interpretation of Cultures. Clifford Geertz, Ed. Pp. 412-453. New York: Basic Books Inc.

Globe, The. 1866. Advertisement. The Globe, May 26: p. 4.

1868. The Free Grants. The Globe, April 22: p. 2.

1881. Summer Resorts: The Cartref Districts: The Village of Cartref and it's Environs. The Globe, June 30: p. 5.

Gootenberg, Paul. 2009. Talking About The Flow: Drugs, Borders, and the Discourse of Drug Control. Cultural Critique. 71. Pp. 13-46.

Gourlay, Douglas, Howard A. Heit, and Yale H. Caplan. 2006. Urine Drug Testing in Primary Care: Dispelling the Myths & Designing Strategies. California Academy of Family Physicians. Pp. 1-24.

Government of Newfoundland and Labrador. 2004. Oxycontin Taskforce: Final Report. Submitted to Minister of Health & Community Services, Minister of the Department of Education, Minister of the Department of Justice. St. John's, Newfoundland.

Gramsci, Antonio. 1971. Selections from the Prison Notebooks. Quintin Hoare and Geoffrey Nowell Smith, Eds. New York: International Publishers.

Grau, Lauretta E., Alison Phinney Harvey, Kevin Irwin, Anthony Givens, Mark L. Kinzly and Robert Helmer. 2007. Illicit Use of Opioids: Is Oxycontin a "Gateway Drug"?. The American Journal on Addictions. 16: 166-173.

Greenlee, Edwin J. 1991. Discourse, Foucault, and Critical Medical Anthropology. Central Issues in Anthropology. 9(1). Pp. 79-82.

Gupta, Akhil and James Ferguson. 1997. Discipline and Practice: "The Field" as Site, Method, and Location in Anthropology In Anthropological Locations: Boundaries and Grounds of a Field Science. Akhil Gupta and James Ferguson, Eds. Pp. 1-46. Berkeley: University of California Press.

Havens, Jennifer R., Robert Walker, and Carl G. Leukefeld. 2006. Prevalence of Opioid Analgesic Injection Among Rural Nonmedical Opioid Analgesic

129 Users. Drug and Alcohol Dependence. 87:98-102.

Havens, Jennifer R., Carrie B. Oser, Carl G. Leukefeld, J. Matthew Webster, Steven S. Martin, Daniel O'Connell, Hilary L. Surratt, and James A. Inciardi. 2007. Differences in Prevalence of Prescription Opiate Misuse Among Rural and Urban Probationers. The American Journal of Drug and Alcohol Abuse. 33:309-317.

Horshelmann, Kathrin and Bettina van Hoven. 2005. Introduction: From Geographies of Men to Geographies of Women and Back Again?. In Spaces of Masculinities. Bettina van Hoven and Kathrin Horschelmann, Eds. Pp. 1-16. London: Routledge.

IMS Canada. 2009. Data Released Upon Special Request.

Jacobs-Huey, Lanita. 2002. Exchange across Difference: The Production of Ethnographic Knowledge: The Natives Are Gazing and Talking Back: Reviewing the Problematics of Positionality, Voice, and Accountability among "Native" Anthropologists. In American Anthropologist. 104(3), Pp. 791-804.

Jamieson, Beals. 2002. Best Practices: Methadone Maintenance Treatment. Ottawa: Health Canada.

Kalso, Eija. 2005. Proceedings of the Symposium "Updates of the Clinical Pharmacology of Opioids with Special Attention to Long Acting Drugs": Oxycodone. Journal of Pain and Symptom Management. 29(15):S47-S56

Kedia, Satish and John van Willigen. 2005. Applied Anthropology: Context For Domains of Application. In Applied Anthropology: Domains of Application. Satish Kedia and John van Willigen, Eds. Pp. 1-32. London: Praeger.

Kiefer, Christie W 2007. Doing Health Anthropology: Research Methods for Community Assessment and Change. New York: Springer Publishing Company.

Krannich, Richard S. and Peggy Petrzelka. 2003. Tourism and Natural Amenity Development: Real Opportunities? In Challenges for Rural America in the Twenty-First Century. David L. Brown and Louis E. Swanson, Eds. Pp. 190-199. University Park: The Pennsylvania State University Press.

Laoire, Caitriona Ni. 2004. Winners and Losers? Rural Restructuring, Economic Status and Masculine Identities among Young Farmers in South-West Ireland. In Geographies of Rural Cultures and

130 Societies. Lewis Holloway and Moya Kneafsey, Eds. Pp. 283-301. Aldershot: Ashgate.

Leach, Belinda. 2000. Transforming Rural Livelihoods: Gender, Work, and Restructuring in Three Ontario Communities. In Restructuring Caring Labour: Discourse, State Practice, and Everyday Life. Sheila M. Neysmith, Ed. Pp. 209-225. Oxford: Oxford University Press.

Lockwood, Brad. 2007. Oxycontin: From Pain Relief to Addiction. New York: Rosen Publishing Group.

Lovell, Anne M. 2006. Addiction Markets: The Case of High-Dose Buprenorphine in France. In Global Pharmaceuticals: Ethics, Markets, Practices. Adriana Petryna, Andrew Lakoff, and Arthur Kelinman, eds. Pp. 136-170. Durham: Duke University Press.

Lowe, Graham S. 2000. The Quality of Work: A People-Centred Agenda. Toronto: Oxford University Press.

Macfie, John 1987. Cartref Logging Days. Erin, Ont: Boston Mills Press.

2004. Up the Great North Road: The Story of an Ontario Colonization Road. Erin, Ont: Boston Mills Press.

2005. Lots More... Cartref Stories: Essays on Cartref district History. Cartref, Ont: The Hay Press.

Mahood, Jonathan. 2008. Fined for Doctoring Prescription. The North Star, June 19: p. 3.

Martin, Peter R., Bennett Alan Weinberg, and Bonnie K. Bealer. 2007. Healing Addiction: An Integrated Pharmacopsychosocial Approach to Treatment. Hoboken, NJ: John Wiley & Sons.

Mawhiney, A., Neitzert, M., and Jane Pitblado. 1999. Introduction. In Boom Town Blues: Elliot Lake Collapse and Revival in a Single Industry Community. Anne-Marie Mawhiney and Jane Pitblado, Eds. Pp 11-18. Toronto: Dundurn Press.

McDowell, Linda. 2005. The Men and the Boys: Bankers, Burger Makers, and Barmen. In Spaces of Masculinities. Bettina van Hoven and Kathrin Horschelmann, Eds. Pp. 19-30. London: Routledge.

McKean, Fleetwood. 1964. Early Cartref and the Beatty Family. Ontario History. 56(3): 167-184.

131 McMurray, Thomas. 2002[1871]. Free Grant Lands of Canada: From Practical Experience of Bush Farming in the Free Grant Districts of Cartref. Huntsville: Fow Meadow Creations.

Mintz, Sidney W. 1986. Sweetness and Power: The Place of Sugar in Modern History. New York: Elisabeth Sifton Books.

Narayan, Kirin. 1993. How Native is a "Native" Anthropologist? In American Anthropologist. 95(3). Pp. 671 - 686.

Ning, Ana M. 1999. Embodying the Myth of Healthiness: Conformity, Resistance, and Complicity in Narratives of Addiction and Recovery. PHD Dissertation, York University.

2005. Games of Truth: Rethinking Conformity and Resistance in Narratives of Heroin Recovery. Medical Anthropology. 24(4):349-382.

North Star, The. 1887. Incorporation. The North Star, January 28: p. 3.

NRC Handelsblad Newsdesk. 2009. Netherlands To Close Prisons For Lack Of Criminals. NRC Handelsblad, May 19,2009. http://www.nrc.nl/international/article2246821.ece/Netherlands_to_close_prisons_for_lack_o fcriminals (accessed May 20, 2009).

Nyswander, Marie. 1956. The Drug Addict as a Patient. New York: Grune & Stratton.

Ogilvie, Megan. 2007. Can A Drug Cure An Addict? Researchers are working on a vaccine that could neuter the effects of narcotics like cocaine. Some experts warn this magic bullet could backfire. The Toronto Star, Dec 22, 2007. http://www.thestar.com/news/ideas/article/287513 (accessed Dec 22, 2007).

Paluzzi, Joan. 2009. Selling Sickness/Creating Demand: Direct-to-Consumer Advertising of Prescription Drugs. In Killer Commodities: Public Health and the Corporate Production of Harm. Merrill Singer and Hans Baer, eds. Pp. 255-282. New York: Altamira Press.

Pinsky, Drew, Marvin D. Seppala, Robert J. Meyers, John Gardin, William White, and Stephanie Brown. 2004. When Painkillers Become Dangerous: What Everyone Needs to Know About OxyContin and Other Prescription Drugs. Center City, Min: Hazelden.

132 Philip, Kavita and Beatriz da Costa. 2008. Introduction. In Tactial Biopolitics: Art, Activism, and Technoscience. Philip, Kavita and Beatriz da Costa, Eds. Pp. xviii-xxii. Cambridge, MA: The MIT Press.

Popova, Svetlana, Jayadeep Patra, Satya Mohapatra, Benedikt Fischer, and Jiirgen Rehm. 2009. How Many People in Canada Use Prescription Opioids Non-medically in General and Street Drug Using Populations? The Canadian Journal of Public Health. 100(2): 104-8.

Purdue Pharma L.P. 2007. Oxycontin: Package Insert. Pp. 1-30. Stamford, CT: Purdue Pharma.

Rabinow, Paul and Nikolas Rose. 2003. Foucault Today. In The Essential Foucault: Introduction. Rabinow, Paul and Nikolas Rose, Eds. Pp. 1-30. New York: New Press.

Rehm, Jiirgen, Patrick Gschwend, Thomas Steffen, Felix Gutzwiller, Anja Dobler-Mikola, and Ambros Uchtenhagen 2001. Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study. The Lancet. 358. Pp 1417-1420.

Rosaldo, Renato. 1989. Culture and Truth: The Remaking of Social Analysis. Boston: Beacon Press.

Rose, Nikolas.

1999. Powers of Freedom: Reframing Political Thought. Cambridge: Cambridge University Press.

2007a. Genomic Susceptibility as an Emergent Form of Life? Genetic Testing, Identity, and the Remit of Medicine. In Biomedicine as Culture: Instrumental Practices, Technoscientific Knowledge, and New Modes of Life. Regula Valerie Burri and Joseph Dumit, Eds. Pp. 141- 150. New York: Routledge.

2007b. The Politics of Life Itself: Biomedicine, Power, and Subjectivity in the Twenty-First Century. Princeton, NJ: Princeton University Press.

Samuelsen, Helle and Vibeke Steffen. 2004. The Relevance of Foucault and Bourdieu for Medical Anthropology: Exploring New Sites. Anthropology and Medicine. 11(1). Pp. 3-10.

Siegel, Larry J., and Chris McCormick. 2003. Criminology in Canada: Theories, Patterns, and Typologies. 2nd Ed. Toronto: Thompson Nelson.

Sigmon, Stacey C.

133 2006. Characterizing the Emerging Population of Prescription Opioid Abusers. The American Journal of Addictions. 15:208-212.

Singer, Merrill.

2004. Why is it Easier to Get Drugs than Drug Treatment in the United States?. In Unhealthy Health Policy: A Critical Anthropological Examination. Arachu Castro and Merrill Singer, Eds. Pp. 287-301. Walnut Creek, CA: Altamira Press.

2006. Something Dangerous: Emergent and Changing Drug Use and Community Health. Long Grove, IL: Waveland Press.

2008. Drugging the Poor: Legal and Illegal Drugs and Social Inequality. Long Grove, 111: Waveland Press.

Singer, Merrill and Hans Baer. 1995. Critical Medical Anthropology. New York: Bay wood Publishing Company.

2007. Introducing Medical Anthropology: A Discipline in Action. New York: Alta Mira Press.

2009. Introduction: Hidden Harm the Complex World of Killer Commodities. In Killer Commodities: Public Health and the Corporate Production of Harm. Merrill Singer and Hans Baer, eds. Pp. 1-32. New York: Altamira Press.

Sobo, Elisa J. 2009. Culture & Meaning In Health Services Research. Walnut Creek, California: Left Coast Press.

Sproule, Beth and Bruna Brands. 2008. The Changing Face of Opioid Addiction. Methadone News (CAMH). 26:4.

Stewart, Scott H. 2009. Dependence and Diagnosis. In Evidence-Based Addiction Treatment. Peter M. Miller, Ed., Pp. 77-88. Burlington, MA: Elsevier.

Trotter, Robert T. and Jean J. Schensul. 1998. Methods in Applied Anthropology. In Handbook of Methods in Cultural Anthropology. Russell Bernard, Ed. Pp. 691-736. Walnut Creek, California: AltaMira Press.

Ubelacker, Sheryl. 2009. 1 in 25 deaths linked to alcohol, study finds. The Toronto Star, June 25, 2009. http://www.healthzone.ca/health/article/656893 (accessed June 25, 2009).

United States Department of Justice. 2004. Intelligence Bulletin: OxyContin Diversion, Availability, and Abuse. National Drug Intelligence Center.

134 Vivian, J., H. Saleheen, M. Singer, J. Navarro, and G. Mirhej. 2005. Under the Counter: The Diffusion of Narcotic Analgesics to the Inner City Street. In New Drugs on the Street. Merril Singer, Ed. Pp. 97-114.

Weekes, John 2006. Oxycontin (Oxycodone Hydrochloride). Prepared for Canadian Centre on Substance Abuse Pp. 1-4. ISBN 1-896323-79-0.

Whittington, Les. 2008. Harper Rejects 'Ivory Tower' Criticism of Crime Proposals: Says sociologists, criminologists who criticize his tough-on-crime approach have been soft on crime for years. The Toronto Star, Sept 23, 2008. http://www.thestar.com/article/504317 (accessed Sept 23, 2008).

Wylie, Bob. 2006. Experts Hail Heroin Clinic Trial. The BBC News Online, June 4, 2006. http://news.bbc.co.Uk/2/hi/uk_news/scotland/5043766.stm (accessed Jan 17, 2008).

Wiley, Andrea S. and John S. Allen. 2009. Medical Anthropology: A Biocultural Approach. New York: Oxford University Press.

Winson, Anthony and Belinda Leach. 2002. Contingent Work, Disrupted Lives: Labour and Community in the New Rural Economy. Toronto: University of Toronto Press.

World Health Organization. 1957. Treatment and Care of Drug Addicts: Report of a Study Group. World Health Organization Technical Report Series, No. 131. Geneva: World Health Organization.

135