|The production of stigma by the disease model of addiction: why drug user activists must oppose it|
|Articles - Addiction|
|Written by Eliot Albers|
|Wednesday, 14 April 2010 00:00|
Presented at the 20th International Conference on the Reduction of Drug Related Harm, Liverpool, April 2010
We have seen a recent resurgence of the disease model of addiction, underlined emphatically by the 2007 passage through the US Senate of the ‘Recognizing Addiction as a Disease Act’, one of the consequences of which was that the National Institute on Drug Abuse (NIDA) changed its name to the National Institute on Diseases of Addiction. Interestingly this was couched specifically in terms of reducing the stigma implied by the term ‘abuse’ in the original name. As a press release noted "It also represents an important step in reducing the stigma associated with addictive disorders, and correctly renames the Institute to recognize that addiction is in fact a disease."
My paper argues contrarily that the description of addiction as a disease is both scientifically groundless and that contrary to the intentions of the framers of the act such a designation, far from reducing, exacerbates stigma. In spite of what the ‘addiction as disease’ theorists and practitioners insist, they do not treat addiction like any other disease. This stems from the fact that addiction is seen as an insult, a breakdown of certain fundamental elements of what it is to be human, namely self-control. I will argue that addiction is not a universal feature of human existence but is rather an artifact of modernity and a limited notion of the self-contained autonomous individual. This conception leads to the assumption that the addict is someone who does not know what is best for them but who may need treatment, or rational management and control imposed upon them.
I will show that reconceptualising what we call addiction as another example of the wide plethora of human bonding is more helpful and far less stigmatizing, as it restores will power and rational choice to people who use drugs in what is called an addictive way.
"So the true option is not vice as opposed to law and order, the real choice is between irrational consumption of adulterated products or an informed use of pure drugs. Demonizing them has only made us more helpless, more cruel towards our fellows, and more "idiotic" in the original sense of the word, for "idiotes" in classical Greek means a person who blindly delegates the things of his own to the public care of others. Not only our well-being, but the well-being of our sons and grandsons depends on disseminating patterns of "sobriae ebrietas" (sober inebriation), which reconsider the use of psychedelic drugs as a moral and aesthetic challenge, essentially related to the adventures of knowledge, and as palliatives for difficult parts of our lives, and for very bitter lives. In other words, we should dignify what is now being debased in order to cope with the generalized delusion and abuse created by the prohibitionist experiment." Inebriation as Experience of the Spirit (Antonio Escohotado, 1996)
This presentation has three principal objectives: the first is to outline the nature of the discursive formation that is the addiction-as-disease theory, and to attempt to understand why it has risen to such prominence and almost universal acceptance amongst both progressives and liberals engaged in the drug policy debate, amongst drug users as well as ‘treatment’ professionals, drug war hawks and drug policy reformers. I will examine how the complementary aims of the judicial and medical professions - where they intersect on the plain of the debate about the nature of so called addictive drug use converge in their propagation of the addiction-as-disease theory. Subsequent to this I will examine the functions this theoretical complex has for drug users. Second, I will seek to show why it is of the utmost importance that, in particular, drug user activists adopt a non-disease conception of drug use and resist with utmost fortitude the pathologisation of a lifestyle that follows from the disease conception. Third, I will attempt to sketch out the beginnings of a viable alternative theory to account for the phenomena that are taken to be constitutive of and proof of the validity of the addiction-as-disease theory.
Following Davies I will contend that theoretical and discursive formations are, prior to being adequate descriptions of an objective reality, above all functional; that is to say their deployment in a given situation serves certain purposes or functions, they perform a given role. What is the functionality of the addiction-as-disease theory for its various exponents? The principal function that the addiction-as-disease theory serves is to make it possible to re-classify certain behaviours, which are voluntary in ‘normal’ people as non-voluntary or disease symptoms in ‘addicts’. This is driven by two key closely allied concepts a) craving and b) withdrawal symptoms. The supposition that those afflicted by the disease of addiction have their rational capacities stripped from them so that they cannot resist their desires is a metaphysical or religious construction akin to earlier notions of mental illness that attributed it to demonic possession, and indeed drugs said to possess the innate capacity to enslave their users are frequently spoken of in the language of demonology or possession. In this respect addiction is best seen as a secularised, rationalised form of earlier ideas about possession in which an individual’s will is usurped by an external and malign force or demon (it is worth recalling that the early Temperance movement often spoke of the ‘demon drink, and later drug prohibitionists described users of heroin as the walking dead, or as zombies).
This leads us to a third driver of the addiction-as-disease theory, namely the Western view of the self-possessed, autonomous individual, which came to prominence during the Reformation. A by-product of this ideal individual is the possessed individual, no longer in command of his/her will, but under the malign direction of an external, all powerful force which commands them to do things that they would otherwise not do. The addiction-as-disease theory attempts to describe these behaviours and attribute them to a single etiology. This theory has now become so all encompassing as to include the administration of drugs for purposes other than the strictly medical (that is to say, outside of the direction of a State sanctioned technologist, ie a doctor), compulsive gambling, or an overweening need for sex and love. Addiction has started to include behaviours well beyond the ingestion of certain organic or synthetic preparations. It is quite clear that people gamble, have sex, and indeed use drugs without losing their self-control. This observation must make us question the two suppositions upon which the addiction-as-disease theory relies, namely that certain substances and personalities are intrinsically addictive. Where then does the seat of addiction lie? The most recent science to stake claim to being the ultimate explicator of addictive behaviours are the neurosciences and their related technologies which claim to locate the seat of addiction in changes or damage to certain pathways in the brain, and seek to demonstrate this by such methods as MRI, coloured images supposedly showing the afflicted brain.
The most recent imprimatur given to the addiction-as-disease theory was the passage through the US Senate in 2007 of the ‘Recognizing Addiction as a Disease Act’, one of the consequences of which was that the National Institute on Drug Abuse (NIDA) changed its name to the National Institute on Diseases of Addiction. Interestingly this was couched specifically in terms of reducing the stigma implied by the term ‘abuse’ in the original name. As a press release noted "It also represents an important step in reducing the stigma associated with addictive disorders, and correctly renames the Institute to recognize that addiction is in fact a disease."
That this is couched in the language of reducing stigma is interesting and something that I will spend some time on unraveling. The enthronement of addiction-as-disease seems to be all things to all people. For some liberals and drug user activists, this step is a positive boon, for instead of older moralistic condemnations of the afflicted addict as other, as a helpless victim of a predatory drug, by being defined as the bearer of a disease, the drug user is absolved of responsibility for their actions and welcomed into the arms of treatment to cure them of their illness.
In spite of what the ‘addiction as disease’ theorists insist, they do not treat addiction like any other disease. This stems from the fact that addiction is seen as an insult to, a breakdown of certain fundamental elements of what it is to be human - namely self-control. I will argue that addiction is not a universal feature of human existence but is rather an artifact of modernity and a corollary of its limited notion of the self-contained autonomous individual. This conception leads to the assumption that the addict is someone who does not know what is best for them but who may need treatment, or rational management and control imposed upon them. However this is an illness like no other, for once one has been found to be suffering from it treatment can become compulsory, and failure to comply can be met with criminal sanctions, despite the fact that it is not contagious, rhetoric to the contrary notwithstanding. The methadone clinics therefore operate between two mutually contradictory discourses: a “criminalizing morality versus a medicalizing model of addiction-as-a-brain-disease”[i]. Someone so diagnosed is henceforth powerless to manage their own life (this notion of powerlessness is repeated in the 12-step programmes, which also promulgate a disease theory of addiction, but here mysteriously they posit a disease that can be cured by talking about it – by exorcising it) but is instead placed under the strictures of a treatment regime that is frequently highly intrusive, and often backed up by judicial strictures. It is also noteworthy that the 12-step programme is in essence a fully developed and sophisticated religious system or cult that employs the full range of what one might call ‘emotional technologies’ (confession, submission of self, testimony, identification with the community of the saved, adoption of meta-narrative, etc. in combination with soteriology, teleology etc.) to effect a fundamental change in the emotional functioning of the addict. The central technology utilized in all 12-step programmes is the famous confession: “My name is X and I am an addict”, as Foucault notes in his important essay ‘Technologies of the Self’, “the association of a prohibition and a strong injunction to speak is a constant feature of our culture”[ii]. The injunction to speak, to confess, to self-identify as an ‘addict’ is a requirement of the programmes’ disciplinary complex, and one that is necessary in order that the addicted self recognize itself, and by it’s constant reiteration lock the addict into a pathologising view of itself which is a key product of the discursive formation of addiction-as-disease. The view that addiction is a disease that inevitably requires treatment leads to support for coercion into such treatment. The diagnosed addict is both patient and criminal.
In spite of the apparent hard scientific backing of the neurosciences however, diagnosis of addiction is never made on the basis of the use of such technologies. Rather, when presenting for treatment, the drug user tells a story describing their behaviour, and on the basis of this is diagnosed as suffering from the disease of addiction, it is a story in which the drug user is compelled to present themselves as sick. Most of the criteria to be met to justify such a diagnosis are purely behavioural, rather than neurological. No tests are carried out; indeed none of the technology of medicine is employed at all. Rather, the story of one’s life, in particular of one’s use of the designated addictive substance is interpreted in a particular way and labeled problematic or addictive. There are no laboratory tests to identify a pathogen, no objective problem can be located on an x-ray. The tests that are used, if they can be called ‘tests’, are rather elements of a discursive formation that identifies ‘symptoms’ that are social rather than biological. AS Mariana Valverde has astutely pointed out with regards to the US National Council on Alcoholism and Drug Dependence’s 26-point alcoholism test, it is “not an inquiry into drinking as much as a test of the soul’s relation to itself”[iii]. The difficulty of labeling addiction as a disease or medical condition is enshrined in the very definition itself. According to the International Classification of Diseases 10[iv] produced by the WHO, addiction is diagnosed when three out of a list of six criteria are met. The problem is that only two of the six criteria are objectively measurable physical phenomena, the others are based on users’ self-perception, elements of cognition, choice, and culturally variable phenomena. Hence a case of addiction could be diagnosed in the complete absence of any objectively measurable physical phenomena. Once so diagnosed, the subject is no longer in control of their destiny, instead they are othered, pathologised, infantilized, adjudged to be an affront to and beyond the norms of the self-controlled, autonomous individual that is the ideal of Western capitalist society, in Helen Keane’s words “[the concept of addiction] is tied to modernity, medical rationality and a particular notion of the unique and autonomous individual”[v]. I cannot but see this as highly stigmatizing. To recap, one tells a story in which one’s drug using has begun to interfere with other behaviours, in the jargon; it has become ‘problematic’. This problem needs resolution through the application, typically of a legally sanctioned medicine, for example, methadone, in place of the drug of choice e.g. heroin. Both however are opiates, supposedly inherently enslaving addictive substances. The sole difference lies in their legal declension, the one is a good opiate, the other bad. The difference resides only in the fact that that one is prescribed, the other not. Here again, not only the diagnosis, but the supposed treatment for the fictitious disease is purely socially constructed, purely behavioural. In other words, a stigmatized, criminalised behaviour such as the regular use of heroin is treated by subjection to a legally sanctioned ritualized behaviour – the consumption of methadone, backed up by a secular confessional, the weekly discussion with a drugs worker. The ultimate aim of such treatment is that one abstain from indulging in the problematic behaviour. What happens in treatment for drug related problems can, from this perspective, be seen more accurately as what Scott Vrecko has called ‘civilising technologies’[vi]. One could contrast this with other behaviours that can become all consuming, such as the pursuit of artistic excellence. The artist will practise their art, often to the exclusion of all other activities, but rather than being labeled pathological or disordered, they will be described as dedicated. The same applies to mountain climbing or the pursuit of other potentially dangerous activities, dedication to which is described as heroic – a mountain climber who dies whilst pursuing their chosen activity will be eulogized, seen as dying whilst doing what they love; the heroin user on the other hand who unfortunately dies as the result of their drug use will most certainly not be described in heroic terms! The only difference between the two categories of activity seems to be that the one is deemed illegal, whilst the other is seen as a heroic sporting venture.
However, drug use, even so called dependent use, is no more a disease or a psychiatric problem than homosexuality is, and it is worth remembering that the latter was considered to be such until the seventh printing of the DSM-II, in 1974, prior to which time all sorts of, what we would now see as barbaric, methods were used in a bid to ‘cure’ it. Similarly, it is nonsensical to describe the cessation of the use of those substances arbitrarily defined as drugs as a ‘cure’. It is merely the cessation of a behaviour that society has deemed to be socially unacceptable. One further word on the arbitrariness of which substances we are talking about when we are talking about addictive substances, this appellation is a socially, politically, culturally shifting one. Indeed we in the UK have just been through a protracted argument over how cannabis should be classified, and are in the midst of one about mephedrone, meanwhile in the US cocaine is defined as a narcotic when it is no such thing, and heroin is deemed to have no legitimate medical use whatsoever, whereas in the UK it is seen as absolutely vital in fields of medicine as diverse as palliative care and child birth where diamorphine has largely replaced pethidine as the painkiller of choice. The way in which drugs are classified and distinguished from medicines has no relation to their innate properties, or utility, but is rather an exercise in socio-cultural, symbolic and moreover theological politics.
The primacy of the pursuit and attainment of health or abstinence is best described as a wholly theological one, akin to the state of grace sought by various religious belief systems, attained by the avoidance or prohibition of certain activities or foods. The quest or journey to abstinence that is seen to be the only road to salvation for users of given substances is portrayed as akin to a pilgrimage or journey of spiritual salvation; this discourse can be summarised in Michel Foucault’s pithy observation: “health replaces salvation” (Birth of the Clinic 198), the corollary of which is that the addiction doctor is, in Peter Cohen’s words “the voodoo priest of Western man”. Only once one has attained this sainted condition can one be described as ‘clean’, can one be seen as having cast out the demons of possession under which one is presumed to labour when in the dirty condition of being addicted, apparently commanded by, one’s will or soul captured by, malign powerful demons called ‘drugs’. Furthermore, it is only when one is abstinent that one is adjudged capable of leading a productive, happy life. It is worth bearing in mind that the word abstinent is meaningless without a qualifier – abstinent from what? Well in this case abstinent from what are currently classified as illegal drugs, as well as from the legally sanctioned replacements for them. It is only when one has attained this state of grace that one is granted assistance with such vital tools as housing, education, training. Of course, someone who is dirty or spoiled, to use Goffman’s term in his work on Stigma: Notes on Spoiled Identity, wouldn’t be able to make use of such things (the new drugs strategy makes this abundantly clear).
The discourse of addiction is bound up with that of the images we create about the individual. Principally we have a definition of the individual that is that of the liberal, autonomous, self-controlled, free individual. To be one of the addicted is to find oneself classified as lacking in will and so to be not fully human: to be the victim of a disease of the will. This is a state from which one must be cured. In a cultural matrix in which the autonomous individual is the model, to be perceived as losing one’s self-control is a major affront to key notions about the modern individual, the modern subject[vii].
However, for many people the use of opiates and other drugs far from being akin to a state of possession is perfectly functional. One needn’t accept the idea that frequent or habitual use is a metabolic disease, but rather one may recognise that some people (I count myself amongst them) do require opiate type drugs in order to function, as Mike Ashton put it, “in ways which to them and to us look every bit as productive as the lives of many teetotallers or social drinkers. To focus on whether they are taking drugs is to miss the point - it doesn’t matter, what matters is the quality of their lives and their contributions to society” (Ashton 8). He goes on to write “some find the relatively normal, productive lives they seek more feasible on illicit opiates than when chained to the demands imposed by restrictive maintenance regimes” (Ashton 8), the same of course goes for those who need stimulants to function well, such as those who undiagnosed with ADD (itself a questionable term), find that stimulants such as cocaine or amphetamine type drugs help them to focus.
My point, and Ashton’s is that people can and do take so called dangerous addictive substances in a functional manner, and I don’t just mean on the weekend, but 7 days a week for many years. This reality has been demonstrated to Prof McKeganey’s great ire in work on functional heroin users by Dave Shewan and Phil Dalgarno, as well as by Hamish Warburton. It is simply intolerable and unthinkable to the so-called ‘new abstentionists’ that people can use currently illegal drugs, or indeed methadone, and live perfectly productive, functional, happy lives.
On an autobiographical note; some years ago I was a full time academic teaching philosophy at post-graduate level, I was also a daily user of heroin, however I was highly proficient at my job and none of my colleagues knew of my drug use – I displayed no symptoms of my supposed disease. However what would have made me dysfunctional, what would have caused my life to fall apart would have been entering into ‘treatment’. Entering into treatment would have required me to declare myself sick, victim of the only disease for which one can be removed from, or considered incapable of, productive employment; for such a declaration is the only one that is functional in the discourse of the drug clinic. As J. B. Davies points out “treatment for alcohol and drug problems is conditional on acceptance of a ‘sick’ label” (The Myth of Addiction 78). Entering into the treatment on offer would have meant trading in use of a drug that helped me to function happily and productively in return for declaring myself to be sick and receiving, under strict, punitive, and often demeaning conditions, including urine sampling, and daily supervised consumption of a substance that I discovered in later years made me feel extremely unwell (namely Methadone). In other words, submitting to the surveillance and discipline of the treatment system would have made my productive working life unsustainable and dysfunctional. As it was, I bought relatively large amounts of heroin at a time that suited me and was thus able to get on with my work. Submitting myself to the demands of a local pharmacist for supervised consumption (and that was what I would have received from the local drug treatment service, Hackney in the 1990s), counseling that I didn’t need, and all sorts of intrusions that would truly have made the quality of my life miserable and profoundly interfered with my productivity. And this is without mentioning the massive stigma and discrimination that is directed at users of illegal drugs, or even of drug services. When even the drug treatment sector is reluctant to employ current users of either illegal drugs or their prescribed substitutes, what hope is there of maintaining or indeed gaining a job in other sectors if you come out as or are found out to be a user of illicit drugs?
Now here is the rub, and this is where the abstentionists have a point. Most methadone delivery systems are ones that produce dysfunction where it didn’t previously exist or exacerbate it when it does exist. They turn their clients’ lives into a virtually full time pursuit of methadone (a drug which incidentally many don’t find to be a suitable replacement for heroin, hence the large numbers of people who, like me, prior to entering the maw of ‘treatment’ used only heroin, now become consumers of crack and alcohol). As Philippe Bourgois has pointed out “too many heroin addicts who are prescribed methadone in the United States suffer negative side effects that range from an accentuated craving for polydrug abuse to a paralyzing sense of impotence and physical and emotional discomfort”[viii]. It takes up so much of your time that you are simply not able to do anything else, whilst at the same time destroying what ‘recovery capital’ you might have had left. As Mike Ashton’s article on the rising tide of ‘new abstentionism’ put it “criminalisation, imprisonment and stigma tear apart the family and social ties and destroy the opportunities for decent housing and employment which could be clung to as anchors to help people haul themselves out of a bad patch with drugs. The few of these recovery resources dependent drug users may have started with are systematically dismantled by the same state which then tries to mitigate the damage”.
Now some might counter that the point of being abstinent is that it frees people from this intrusive treatment system. This is a valid point. However, there are many other ways in which people could be freed, principally by being allowed to function outside it, with or without their drug of choice. This could be achieved by conceiving of drug use not as a disease but as one of the plethora of things to which humans form strong attachments or bonds. Such attachments or bonds are a perfectly normal part of the range of human behaviour, and the decision to label some of them pathological or diseased is purely a social construct[ix].
My ultimate point is that people who use drugs do not need treatment, nor do they need to be cured, since the consumption of currently illicit drugs cannot coherently be constituted as an illness, still less as a disease. What are needed are comprehensive harm reduction strategies and services, as well as fair and equitable social policy to ameliorate the dire social conditions, the endemic poverty, the decrepit educational and housing systems which lead a disproportionate number of the underprivileged to become criminalised solely for attempting to seek some solace and relief from an unrelentingly cruel and harsh world.
The last taboo: pleasure
Whilst the preceding sentence implies that the sole, or predominant, driver behind the use of illicit drugs is as a coping measure for lives devoid of other choices and as a means to give meaning and structure to those who are deprived of educational and employment opportunities, this would be misleading. We have to recognize that an equally important motor behind the desire to alter consciousness through the consumption of psychoactive substances, a desire which is, as Siegel has persuasively argued, a fundamental and universal human drive[x], is to achieve a wide range of different effects actively sought by the consumer. These effects include, but are not limited to, the sacramental use of various substances in a range of religious practices (including Ganja use by both Rastafarians and Hindu sadhus, ayahuasca by Amazon Basin Indians, wine by both Cbristians and Jews, peyote by various Native American peoples), to enhance concentration and stave off tiredness (ranging from the use of amphetamines by truck drivers in Thailand, coca by Andean peoples, and Khat by Yemenis and others in the Horn of Africa, and not least of all the sanctioned use of both amphetamines and opiates by soldiers in warfare), to pleasure seeking and enhancement in sociable environments (the examples that could be cited here are almost limitless, but the inextricable links between youth culture and the use of a wide range of drugs is a topic in and of itself). Amongst these categories of use it is the latter that I wish to concentrate on as it most pointedly undermines the pathologising of those who choose to use illicit drugs.
As I have argued, the dominant public discourse around illicit drug use is a pathologising one, one that is directly counterposed to, and dismissive of, the construction of drug use as an act of pleasure seeking. There is of course a discourse of pleasure in neurological accounts of drug use, but it is a discourse that locates the pleasure found in drug use as a negative or false one, conceptualising recreational drug use as a hijacking of the brain’s reward or pleasure circuits, this discursive formation however is inherently pathologising and necessarily defines the pursuit of pleasure through drug use as “an irrational behaviour that serves no useful purpose”[xi]. In David Moore’s words “harm reduction policy and practice, in its construction of a neo-liberal drug-using subject, limits opportunities for considering the role of pleasure in drug use”[xii]. To remedy this erasure, serious consideration of the role of pleasure in drug consumption is beginning to be articulated amongst drug user activists[xiii]. This latter is however what Michel Foucault would describe as a minor or subjugated knowledge “that is to say techniques and knowledges gathered experientially rather than through orthodox medical science, the knowledge of the psychiatrised, the patient”[xiv] in contradistinction to ‘professional’, erudite or major knowledges that are inexorably connected to, generate, and perpetuate, power (Foucault considered the connection between knowledge and power to be so fundamental that he often spoke of power/knowledge).
The very concept of pleasure however requires some problematising and it is interesting to note that Foucault in a rarely quoted interview set up some guidelines for this problematisation with specific reference to the question of drugs:
M.F.: What frustrates me, for instance, is the fact that the problem of drugs is always envisaged only as a problem of freedom and prohibition. I think that drugs must become a part of our culture.
Q: As a pleasure?
M.F.: As a pleasure. We have to study drugs. We have to experience drugs. We have to do good drugs that can produce very intense pleasure. I think this Puritanism about drugs, which implies that you can either be for or against drugs, is mistaken. Drugs have become a part of our culture. Just as there is bad music and good music, there are bad drugs and good drugs. So we can’t say we are ‘against’ drugs any more than we can say we are ‘against’ music.
Q: The point is to experiment with pleasure and its possibilities.
M.F.: Yes, Pleasure must also be a part of our culture”.[xv]
It is in this sense that drug use represents a key example of what Foucault called a technology of the self which permit “individuals to effect by their own means or with the help of others, a certain number of operations on their own bodies and souls, thoughts, conduct and way of being, so as to transform themselves in order to attain a certain state of happiness, purity, wisdom, perfection or immortality [ERA emphasis added]”[xvi].
[i] Bourgois, Philippe (2000), ‘Disciplining Addictions: The Bio-Politics Of Methadone And Heroin In The United States’, Culture, Medicine and Psychiatry 24: pp. 165–195, p. 165.
[ii] Foucault, Michel (1997a), ‘Technologies of the Self’ in Essential Works of Foucault vol. I, Ethics: Subjectivity and Truth ed. Paul Rabinow. The New Press, New York, 223-51, 224.
[iii] Valverde, Mariana (1998), Diseases of the Will: Alcohol and the Dilemmas of Freedom, Cambridge: Cambridge University Press, 25. Quoted in Helen Keane (2002), What’s Wrong with Addiction?. Melbourne: Melbourne University Press, 37.
[iv] Klein, Axel (2008), Drugs and the World. London: Reaktion, 65.
[v] Keane, Helen (2002), 6.
[vi] For more details see Scott Vrecko (2010), ‘‘Civilizing technologies’ and the control of deviance’, BioSocieties Vol. 5, 1, 36–51 available at http://www.palgrave-journals.com/biosoc/journal/v5/n1/abs/biosoc20098a.html
[vii] Peter Cohen elaborates on the pivotal position of the autonomy mythology in the construction of the ‘addiction-as-disease’ construct in his paper ‘Is the addiction doctor the voodoo priest of Western man?’, extended version of an article that appeared in Addiction Research, Special Issue, Vol. 8 (6), pp. 589-598. Available at http://www.cedro-uva.org/lib/cohen.addiction.html
[viii] Bourgois, Philippe (2000), loc. cit.
[ix] I owe the term ‘bonding’ and the theoretical armature that it suggests to Peter Cohen (2010), ‘The Naked Empress. Modern neuro-science and the concept of addiction’ at http://www.cedro-uva.org/lib/cohen.empress.html
[x] Siegel, Ronald, K. (1989), Intoxication: Life in Pursuit of Artificial Paradises. New York: Dutton.
[xi] Keane (2002), 93.
[xii] Moore, David (2008), ‘Erasing pleasure from public discourse on illicit drugs: On the creation and reproduction of an absence', International Journal of Drug Policy Volume 19, Issue 5, pp. 353-358.
[xiii] See for example White, Cheryl (2010), ‘From Pain to Pleasure’, Junkmail 13, pp. 28-31.
[xiv] Foucault, Michel (2003), Society Must Be Defended: Lectures at the Collège de France, 1975– 1976. London: Penguin, 7.
[xv] Foucault, Michel (1997b), ‘Sex, Power, and the Politics of Identity’ in Essential Works of Foucault vol. I, Ethics: Subjectivity and Truth ed. Paul Rabinow. The New Press, New York, 163-73, 165.
[xvi] Foucault, Michel (1997a), 225.