Addiction Treatment as Prison Governance: A Critical Discourse Analysis of Methadone Delivery in Kyrgyz Prisons

Methadone treatment is prescribed by evidence-based medicine as the most effective tool for the treatment of opioid addiction. Its implementation into high-need prison settings worldwide has been met with challenges, particularly in Eastern Europe and Central Asia where the opioid epidemic continues to expand. To address these impasses to intervention translation, we turn to post-structural approaches to policy analysis. These approaches open space for (re)thinking the ways that translated interventions emerge locally, by treating policy texts as social practices that make interventions in specific, sometimes unexpected, ways. We leverage Carol Bacchi’s post-structuralist analytic framework to interrogate how the object of methadone is constituted in Kyrgyz prisons through an analysis of the national legislative document, the “Government Program,” which provides the legislative basis for opioid addiction treatment administration in the Kyrgyz Republic. Rather than the medicalized methadone for the treatment of opioid use disorder, contained in the distinct objectivization of methadone emerging from this policy text, is the previously unexamined assumption that methadone is a particular type of governance. We describe a methadone object tied up with the shifting social structures that govern Kyrgyz prisons, divided between formal (state-run) and informal (prisoner-run) governance. In Kyrgyz prisons, where opioid policy discourse produces a divide between formal and informal governance, methadone emerges as a tool of the formal prison administration to regain control of the prisons from the practices of prisoner subculture. Although this study takes the Kyrgyz case as an example, the enactment of methadone as formal governance is likely to resonate throughout Eastern Europe and Central Asia, where there is a strong legacy of self-governing prisons. We conclude with a call for global health policymakers to consider how opioid addiction treatment is constituted within local governing relations, in ways that may depart sharply from the evidence base.

Managing Opioid Agonist Therapy in the Post-Soviet Limbo

According to Dante, “Limbo” is the first circle of Hell located at its edge. Unlike other residents of Hell, the Limbo population suffers no torment other than their lack of hope. We argue that a lack of hope in post-Soviet Ukraine is expressed by a lack of conditions for a better future since the past is overrepresented in the present. Therefore, every movement transforms under the past’s pressure, changing its course in order to reproduce and perpetuate ghosts of what is long gone. We argue that the current state of Ukraine can be framed as “post-Soviet limbo.” If the great stability of the Soviet regime was a result of overregulation and extensive control, or of “uncertainty avoidance,” then a post-Soviet limbo is a result of “managing uncertainty” simultaneously influenced by Soviet legacies and neoliberal promises of growth, calculability, and deregulation on the part of the State. “Soviet legacies” are dominant and represent a mix of formal overregulation explicitly presented through laws and policies and informality which, according to some authors, became even more widespread in the post-Soviet period than it used to be under the Soviet rule. We do not aim to consider the past legacies as being opposite to neoliberal features and futures, but negotiate the way the two are interrelated and mutually reinforced in the present to produce the post-Soviet limbo. Ukraine’s performance of Opioid Agonist Therapy (OAT) coverage is consistently estimated as insufficient and needing further improvement. However, we argue that that there are two modes of OAT implementation in Ukraine: state-funded (formal) and privately-funded (informal). The latter’s size does not fall into official estimates since the national reports on OAT performance never include the numbers of patients involved in informal treatment. We suggest, that the informal mode of OAT implementation appeared as a result of contrasting efforts towards intensive regulation and extensive growth. To understand how these two modes are produced in the context of post-Soviet narcology, how they differ and where their paths cross, we analyze two types of texts: legal and policy documents regulating substance use disorder (SUD) treatment, mainly OAT; and qualitative data, including interviews with OAT patients and field notes reflecting the environment of OAT programs. Finally, the presented article seeks to answer how the state’s contrasting efforts to manage the uncertainty of SUD treatment through OAT regulation and implementation reproduce the post-Soviet limbo and, thus, people with SUD as “patients of the state” who are frozen in a hopeless wait for changes.

Enacting Safety and Omitting Gender: Australian Human Rights Scrutiny Processes Concerning Alcohol and Other Drug Laws

Global momentum for drug law reform is building. But how might such reform be achieved? Many argue that human rights offer a possible normative framework for guiding such reform. There has been very little research on whether human rights processes can actually achieve such aims, however. This paper responds to this knowledge gap. It explores how one human rights mechanism—the “parliamentary rights scrutiny process”—deals with alcohol and other drugs. We consider how four Australian parliaments scrutinized proposed new laws that would deal with alcohol and other drugs for their human rights “compatibility.” We find that laws that would limit the rights of people who use alcohol and other drugs were routinely seen as justifiable on the basis that alcohol and other drugs were inherently “unsafe.” Crucially, safety was conceptualized in a gender-neutral way, without regard to the potential role of gender, including specific masculinities, in the production of phenomena such as family violence and sexual violence and other public safety problems. Instead, such problems were regularly constituted as consequences, simply, of alcohol or other drug consumption. In making this argument, we build on the pioneering work of David Moore and colleagues (e.g., 2020). Their work asks important questions about how the causes of violence are constituted across different settings, including research and policy. Drawing on ideas from scholars such as Carol Bacchi and John Law, they identify “gendering practices” and “collateral realities” in research and policy on violence, in which the role of men and masculinities are routinely obscured, displaced or rendered invisible. We find similar problems underway within human rights law. In highlighting these gendering practices and collateral realities, we aim to draw attention to the limitations of some human rights processes and the need for more work in this area.

“Blurring the Line”: Intoxication, Gender, Consent, and Sexual Encounters Among Young Adults

Social concern about sexual practices and sexual consent among young adults has increased significantly in recent years, and intoxication has often played a key role in such debates. While many studies have long suggested that alcohol plays a role in facilitating (casual) sexual encounters, intoxication has largely either been conceptualized as a risk factor, or researchers have focused on the pharmacological effects of alcohol on behaviors associated with sexual interaction and consent. To date little work has explored how young adults define and negotiate acceptable and unacceptable levels of intoxication during sexual encounters, nor the ways in which different levels of intoxication influence gendered sexual scripts and meanings of consent. This paper explores the latter two research questions using data from 145 in-depth, qualitative interviews with cisgender, heterosexual young adults ages 18–25 in the San Francisco Bay Area. In examining these interview data, by exploring the relationship between intoxication and sexual consent, and the ways in which gender plays out in notions of acceptable and unacceptable intoxicated sexual encounters, we highlight how different levels of intoxication signal different sexual scripts. Narratives about sexual encounters at low levels of intoxication highlighted the role of intoxication in achieving sexual sociability, but they also relied on the notion that intoxicated consent was dependent on the social relationship between the partners outside drinking contexts. Narratives about sexual encounters in heavy drinking situations were more explicitly gendered, often in keeping with traditionally gendered sexual scripts. In general we found that when men discussed their own levels of intoxication, their narratives were more focused on sexual performance and low status sex partners, while women’s and some men’s narratives about women’s levels of intoxication were focused on women’s consent, safety, and respectability. Finally, some participants rely on “consent as a contract” and “intoxication parity”—the idea that potential sexual partners should be equally intoxicated—to handle relations of power in interpersonal sexual scripts. Since these notions are sometimes deployed strategically, we suggest that they may serve to “black-box” gendered inequalities in power between the parties involved.

Young People Who Use Drugs Views Toward the Power and Authority of Police Officers

Many young people who use drugs are structurally vulnerable to policing powers given the ongoing criminalization of drug possession. Police authority limits and the expression of that authority may play a significant role in police encounters among young people who use drugs. This qualitative study explores the views of young people who use drugs toward police power and authority in their recent encounters with police officers. Interviews were conducted with 38 young people who recently used illegal drugs in British Columbia, Canada. We found five interrelated themes related to perceptions of police authority: (1) skepticism and distrust toward authority; (2) paternalism and authority over drug use; (3) officer use of force; (4) police as power-hungry; and (5) officers above the law. Participants described police authority as limitless, unpredictable, untethered, easily abused, and lacking accountability. Participants feared holding police officers accountable to power abuses in a criminal justice system that they saw as stacked against them. Moving forward, institutional reforms may consider and account for the expression, limits, and use of police authority among young people who use drugs and other structurally vulnerable communities.

“Looking After Yourself Is Self-Respect”: The Limits and Possibilities of Men’s Care on a Night Out

Notions of masculinity have played a central role in social and cultural research on men’s drinking events. Within this context, masculinity is regularly called on to explain the problematic disparities that mark men’s alcohol consumption, including men’s disproportionate involvement in drinking and a range of alcohol-related harms. More recently, however, researchers have begun to emphasize men’s drinking events as sites of care and support, leading some to suggest that men’s drinking masculinities are evolving in affirmative and health promoting ways. While unsettling the tendency of scholars to problematize men’s drinking masculinities, foregrounding the possibilities of men’s care potentially obscures its complexities and constraints. In this paper, we are concerned to critically re-examine the relationship between masculinity, care, and events of men’s alcohol consumption. Where some authors have positioned men’s care as an innate or uncomplicated good, we draw on a feminist ethics of care approach to explore its complexities, constraints, and exclusions. Through focus group discussions with 101 men, our analysis describes how ideals of masculine autonomy emerged through men’s accounts of drinking events, fundamentally shaping the constitution, practice, and possibilities of care. For the men in our study, the valorization of autonomy fostered ambivalence and tension around care, hindering their capacity as care givers and receivers. In turn, opportunities and accountability for care were overlooked, avoided, or displaced onto women. By highlighting the complexity of men’s care, our account complicates existing scholarship on men’s drinking while also gesturing toward new avenues for public health practice. We conclude by outlining how a more concerted focus on care may be integrated into public health policy, research, and programming and, in the process, contribute to the promotion of more health affirming and ethical modes of masculinity.

Trade-offs in Substitution Treatment: A Qualitative Study of an Opioid Substitution Therapy Clinic as an Enabling and a Risk-Environment

This article present results from a study of clients experiences of attending a substitution treatment clinic in Copenhagen, Denmark. The study is part of a research project about the everyday lives of marginalized drug users in Copenhagen, their risk environments and their access to formal and informal resources. Thirty-eight clients participated in structured interviews, covering topics concerning, drug use, income, housing, social relations, violence, use of health and social services. A risk environment/enabling environment framework was developed to analyze the data. The research shows that the methadone clinic give the clients access to different material, social and affective resources, but that access to resources often involve different trade-offs. Such trade-offs include accepting control or socializing with drug users to get access to substitution medicine. Some clients accept such trade-offs, others do not and choose find other ways to get resources, exposing themselves to potential harm. This means that the clinic can function as an enabling, constraining and a risky environment for different clients.

CommunityStat: A Public Health Intervention to Reduce Opioid Overdose Deaths in Burlington, Vermont, 2017–2020

From 2017 to early 2020, the US city of Burlington, Vermont led a county-wide effort to reduce opioid overdose deaths by concentrating on the widespread, low-barrier distribution of medications for opioid use disorder. As a small city without a public health staff, the initiative was led out of the police department—with an understanding that it would not be enforcement-oriented—and centered on a local adaptation of CompStat, a management and accountability program developed by the New York City Police Department that has been cited as both yielding improvements in public safety and overemphasizing counterproductive police performance metrics if not carefully directed. The initiative was instrumental to the implementation of several novel interventions: low-threshold buprenorphine prescribing at the city’s syringe service program, induction into buprenorphine-based treatment at the local hospital emergency department, elimination of the regional waiting list for medications for opioid use disorder (MOUD), and the de-facto decriminalization of diverted buprenorphine by the chief of police and county prosecutor. An effort by local legislators resulted in a state law requiring all inmates with opioid use disorder be provided with MOUD as well. By the end of 2018, these interventions were collectively associated with a 50% (17 vs. 34) reduction in the county’s fatal overdose deaths, while deaths increased 20% in the remainder of Vermont. The reduction was sustained through the end of 2019. This article describes the effort undertaken by officials in Burlington to implement these interventions. It provides an example that other municipalities can use to take an evidence-based approach to reducing opioid deaths, provided stakeholders assent to sustained collaboration in the furtherance of a commitment to save lives. In doing so, it highlights that police-led public health interventions are the exception, and addressing the overdose crisis will require reform that shifts away from criminalization as a community’s default framework for substance use.

Foreign Natives: Psychoactivity, Policing, and the Elusive Corporeality of the Post-Soviet Rave

This article focuses on the rave subculture of St. Petersburg in the 1990s and demonstrates how new forms of psychoactive control and resistance emerged in the wake of the Soviet collapse. By staying sensitive to the material and corporeal aspects of these phenomena, it contributes to the socio-material studies of drug control and emphasizes that the physical body itself should be an important venue for drug research. In doing so, we build on existing literature that discusses bodies as information resources to detect drug use and identifies resistance strategies to increasingly technological drug control measures. We advance this discussion by suggesting that the psychoactive setting of rave in post-Soviet St. Petersburg gave rise to a highly particular yet notably elusive and difficult-to-define type of corporeality. On the one hand, this corporeality could be positively interpreted as a marker of resistance and belonging on the “inside.” At the same time, it could also be employed strategically by law enforcement officers to detect and prosecute drug-consuming individuals. Moreover, we propose to view this psychoactive “rave body” as deeply embedded in its spatio-temporal context—thus accounting for the influence of time and space on the materiality of drug control and resistance. In examining these dynamics, we draw on a wide range of sources, including memoirs, press materials, early Internet archives, publicly printed interviews, photographs, and video materials.