‘Making Ground’ : An Ethnography of ‘Living With’ Harmful Methamphetamine Use and the Plurality of Recovery

Methamphetamine Related Harm in Australia

The significance of this research is derived in part from the urgency of methamphetamine related harm as a public health issue. In 2016, up to 4.96 million people were dependent on amphetamines (Degenhardt et al., 2018), with Australia recording nearly the highest prevalence in the world (Farrell et al., 2019). The Australian Needle and Syringe Program recently released a 25 year report based on data from 57,000 respondents indicating that prevalence of methamphetamine as the last drug injected doubled between 2010 and 2019, and was reported by almost half of all respondents in 2019, a greater prevalence than heroin (Heard, Iversen, Geddes, & Maher, 2020). Between 2011 and 2016 the number of publicly funded treatment episodes in which methamphetamine was the primary drug of concern also doubled in Australia (Australian Institute of Health and Welfare, 2017b). Use of crystalline methamphetamine versus powder also increased during this time (Australian Institute of Health and Welfare, 2017a), a form of the drug associated with an increased risk of harms such as psychosis (Degenhardt et al., 2017).

This study was conducted in the state of Queensland, where methamphetamine related harm has been particularly acute, with dramatic increases in methamphetamine related hospital presentations, ambulance calls, and treatment service visits in the last 15 years (Queensland Health, 2017). Prevalence of methamphetamine use has been declining within younger age groups (Australian Institute of Health and Welfare, 2017b) and increasing among older populations, particularly injection drug use (Degenhardt et al., 2016; Heard et al., 2020). In 2016, the average age of PWUM in Australia was 34 years (Australian Institute of Health and Welfare, 2017b). There is a need therefore to better understand this older population of PWUM, and the role played by methamphetamine outside of the younger recreational context in which prevalence has historically been higher.

Addiction and Disease

Understanding how people experience methamphetamine recovery requires examining the concepts upon which it is constructed and presented to people who use drugs (PWUD). The biomedical perspective on drug use has dominated research agendas, interventions, and public health messaging for decades (Satel & Lilienfeld, 2013). These regimes have persistently reinforced the binary construction of harmful drug use versus abstinence focused recovery, both contained within disordered individuals. This perspective views dependent, harmful drug use as primarily a maladaptive brain state producing physiological compulsion that leads to risky behaviour (Levine, 1978; Volkow, Koob, & McLellan, 2016; Wiens & Walker, 2014). The brain disease model is partly based on significant neuroscientific discoveries such as the endogenous opioid system, neurobiological differences within the brains of PWUD, and the effect of drug use on neuronal ‘circuits’ which govern impulse control and incentive responses (Kauer & Malenka, 2007; Nichols & Volkow, 2014). The addictive quality of some drugs is therefore attributed to rapid increases in dopamine release which elicit a conditioning process, leading to repeated behaviours linked to environmental stimuli (Volkow et al., 2016).

Whilst the role of neurotransmitters in drug related behaviour is irrefutable, the brain disease model views the individual as the primary site of dysfunction and emphasises changing behaviour by intervening on neurological events within the individual’s brain (Frank & Nagel, 2017). In terms of social consequences, this model is not so very different from early 20^th century personal deficit theories that focused on psychopathology, or the existence of an ‘addictive personality’ (Weinberg, 2002). Each of these models ascribe some fundamental dysfunction to the sufferer, implicitly expecting them to be the site of change, thereby reinforcing neoliberal ideals of individualism and personal responsibility (Netherland, 2012). By emphasising the various neurobiological discoveries outlined above, the brain disease paradigm can imply that these aspects of the brain are the most important elements of drug use to address, excluding social context, social determinants and structural factors such as criminalisation and poverty (Satel & Lilienfeld, 2013).

Whilst its proponents have emphasised its potential social value, there is limited evidence to validate the effect of brain disease concepts on stigma, and the only available research has implied that internalisation of the brain disease model could decrease PWUD’s perceptions of their own ability to change (Trujols, 2015) (Wiens & Walker, 2014). As Frank and Nagel (2017) argue, medicalising the discussion and treatment of addiction does not necessarily de-moralise the subject, given the frequent social marginalisation of those suffering from illness or disability. Disease also implies a lack of agency, despite many PWUD experiencing and demonstrating agency throughout their trajectories of use (Satel & Lilienfeld, 2013). Other evidence indicates that binary disease model thinking may reduce harmful drinker’s capacity to recognise the problems their alcohol use is causing which do not rise to the level of clinical addiction (Morris, Albery, Heather, & Moss, 2020).

The brain disease model also appears to have made little systemic impact. The United States has trended toward increasingly punitive federal policies regarding drug use, and this trend did not change with the introduction of the brain disease paradigm by NIDA in the 1990s (Courtwright, 2010). Overall, the brain disease model has failed to provide a basis for new effective drug use interventions, and its social or policy impact has been modest (Hall, Carter, & Forlini, 2015). Meanwhile it presents a theoretical perspective that pathologises and medicalises individual experience, divorced from social context. There is a need for approaches to drug use that acknowledge the empirical validity of studies showing brain-level effects and changes related to drugs, and the commonalities between addiction and some chronic health concerns, but with a clearer theoretical framework that is more applicable to the world and experience of PWUD and clinicians.

Recovery as Biopower

Framing drug use in these biomedical terms shapes what kinds of services are conceptualised, legitimised, and implemented, thereby shaping the trajectories of PWUD. For these reasons, the disease model of addiction can also be viewed as an example of how ‘biopower’ is expressed throughout populations. Conceptualised by Foucault (2007) as a body of ethics, laws, and norms which emerge from the regulatory systems and discourses operating within a society, biopower works to shape the population towards certain political, social, or material ends that usually align with the interests of those in power through diffuse regulation of bodies, behaviours, and related values. In this context, the apparatus of addiction treatment is constructed in response to these complex and pervasive forms of power, rather than only the perceived needs and interests of PWUD.

Responses to drug use are increasingly focused on supporting PWUD to undergo ‘recovery’, despite many people experiencing significant drug use related issues not identifying with this framing (Kelly, Abry, Milligan, Bergman, & Hoeppner, 2018). Recovery is often based around accessing treatment services and undergoing personal development, with the goal of long term abstinence, and increased capacity to function within contemporary neoliberal society (Brookfield, Fitzgerald, Selvey, & Maher, 2021; Brookfield et al., 2019; Kaskutas et al., 2014; McIntosh & McKeganey, 2000). This formulation is written into policy and treatment protocols (Fomiatti, 2020) and enacted by PWUD, clinicians, and other representatives of recovery services (Schlosser, 2018). The regulation of drug use through systems of biopower can be seen within wider sociocultural forces such as the stigmatisation of methamphetamine use as not only unhealthy, but deeply antithetical to the values and norms of society, and a generalised moral concern (Armstrong, 2007; Dwyer & Moore, 2013; Omori, 2013). In this context, PWUM are seen as ethically as well as practically obligated to engage with ‘recovery’ (Fomiatti, Moore, & Fraser, 2018) despite limited treatment availability and efficacy.

Many alcohol and other drug (AOD) services assist individuals to recover with a holistic approach that incorporates drug use, relationships, career aspirations and civic participation (Fomiatti, 2020). The overarching responsibility for this recovery, however, is located within the individual, through a form of ‘intensified neoliberal political rationality’ (Fomiatti et al., 2018, p. 2), which PWUD are encouraged to adopt through self-assessments of their own recovery capital. Recovery from harmful methamphetamine use frequently takes place within this kind of ‘hierarchical logic’ (Fomiatti et al., 2018, p. 2) which not only individualises the recovery process, but prescribes a particular recovery trajectory. Limiting acceptable recovery in this way risks excluding the experiences, strategies or values of some PWUD (Neale et al., 2014), and inhibiting their progress towards their own recovery goals. There is a need, therefore, for theorisations of drug use to account for the diversity of progressions and regressions which can occur across different drug use trajectories and question the binary logic that puts health behaviours in opposition to ongoing drug use (Moore et al., 2017). Rather than approaching recovery as a stable artefact to be described, it can also be seen as a dynamic process shaped by social, cultural and material forces. Our aim was to explore how people engaged in methamphetamine recovery within contemporary biomedical systems experience this process, and how their experiences may critique and undermine binary understandings of recovery as a state of health in opposition to the ‘disease state’ of harmful drug use.

Life Course Perspective

The life course perspective has been applied to drug use by Hser, Longshore, and Anglin (2007), combining chronic illness trajectories with pre-existing ideas of drug use ‘careers’, and life course concepts within criminology. In contrast to individualised, or purely structural explanations, life course approaches situate someone experiencing drug related harm within a multifaceted and dynamic array of influences and intentions that change across time (Teruya & Hser, 2010). Hser et al. (2007) describe drug use trajectories as articulated through key turning points, transitions between social roles, and the individual’s social capital. This approach has been applied previously to the understanding of methamphetamine use trajectories (Brookfield et al., 2019). We contend that these mechanisms must also be understood in the wider context of discourses such as the brain disease paradigm, and narratives of linear or perpetual recovery. The structure and nature of turning points or transitions in the trajectory of PWUM are constructed through the value structures in which people are embedded, and through which recovery is administrated and navigated. We draw on a critical ethnographic approach to explore the role of these discourses in recovery for PWUM, identifying drug use trajectories that feature aspects of recovery without adhering to the prescriptions of contemporary recovery ideology. We argue for an expansion of the life course framework to incorporate intermediary spaces where people live and grow alongside harmful drug use, to critique the values that produce and legitimise these life course components, and a reconsideration of how PWUM can best be supported in a way that respects alternative and complex value systems.

A Critical Interactionist Approach

PWUD navigate recovery through social interactions with other PWUD, clinicians, and family members, and also through larger social, economic, cultural and moral forces such as governments, medical bodies and the media (Fomiatti et al., 2018; Omori, 2013). Gaining an understanding of how these factors interact requires a theoretical approach that can integrate multiple levels of analysis. We have therefore drawn on critical interactionism, a theoretical framework proposed by Martins and Burbank (2011) which combines critical social theory and symbolic interactionism. The symbolic interactionist approach understands human behaviour as organised around the meanings people develop for their surroundings, which are derived from ongoing processes of social interaction (Blumer, 1969). Critical theory focuses on the workings of power within society, and how it is exerted through regulations, societal norms and institutions (Rexhepi & Torres, 2011). A critical interactionist framework is therefore designed to enable analysis of micro-scale, interpersonal interactions without losing the wider structural contexts of power and history, both of which are key aspects of drug use trajectories.

Critical Ethnography

Data collection and analysis was informed by critical ethnography, an approach which interrogates and reflectively chooses between conceptual alternatives within a particular field of study (Thomas, 1993). This contrasts with conventional ethnography which focuses more on detailed description of phenomena that are taken to be stable and classifiable. As Thomas (1993, p. 4) summarised, ‘critical ethnography is conventional ethnography with a political purpose’, aimed towards critiquing bodies of knowledge and systems of power, in addition to widening the basis of evidence upon which to build new systems. It is the difference between approaching recovery as a stable trajectory to be described like an artefact, or as a dynamic process to be engaged and interacted with. Our aim was to critique ideas of recovery by exploring how they impacted and were disrupted by the experiences of PWUM.

Recruitment

Participants were recruited through an inner-city AOD outpatient clinic, and AOD brief intervention team at a tertiary emergency department in Brisbane, Australia. Experienced AOD nurses screened and recruited potential participants based on training received from the principal researcher, and with reference to the list of inclusion criteria and participant information and consent forms. The criteria for inclusion were people aged over 18, who did not suffer any cognitive impairment or intellectual disability, for whom methamphetamine was a primary drug of concern based on self-report and with reference to the DSM-5 criteria for lifetime methamphetamine dependence, and were voluntarily presenting to recovery services. Each of the recruitment services provided similar combinations of abstinence-based and harm reduction strategies, delivered through counselling, outpatient withdrawal treatment, and referral to the network of other services available in Brisbane. Due to our recruitment strategy, the participants were mostly experienced regarding the language and concepts used by publicly available recovery services, and the ways their trajectories and ideas may have been commonly shaped by this context should be considered when interpreting our analysis. The project received approval from the University of Queensland and Royal Brisbane & Women's Hospital Human Research Ethics Committees.

Interviews

The principal researcher (S.B.) conducted all data collection. Semi-structured interviews were recorded with each of the 12 participants at the beginning of the project, and then at three and 6 months, with the exceptions of Jack, Michael, and Oliver who were lost to follow up or withdrew from the project. Interviews were based on an interview guide with open ended questions regarding participants’ experiences with drug use and recovery. First interviews included more questions regarding life history, with follow up interviews primarily addressing issues and events arising during ethnographic observation. Whilst the guide was available as a reference point, the order in which points were discussed was largely unstructured, and participants were free to introduce new subjects, ask questions, and direct the flow of conversation. Interviews were conducted in participants' homes, nearby cafes, or in private rooms at AOD services. Most interviews went for about 1 hour, and each participant was provided with a $50 supermarket voucher for each interview immediately after it was completed.

Fieldwork

Ethnographic fieldwork was conducted between the series of three formal interviews. S.B. accompanied participants when they attended various recovery related appointments such as with doctors, counsellors, parole officers, or court proceedings. He also would meet people’s families or their partners, help them move house, accompany them to buy drugs, and go for visitation sessions at Child Safety Services (CSS). Fieldwork also included observing participants at home whilst looking after their children, fighting with their partner, or just trying to organise their life. These observations were focused towards those activities most directly connected to participants’ recovery, and aimed to record data across personal, social, and clinical or institutional settings to explore how they experienced these different contexts of recovery. Some of these observations were audio recorded with participant consent. Other observations were recorded as fieldnotes. Data collection occurred over an 8-month period with approximately 160 hours spent in the field.

Positionality

The principal researcher conducted all interviews and fieldwork, and therefore their positionality is a key consideration for interpreting our analysis. As an emergency nurse, S.B. has participated in the acute clinical management of drug use many times, observing the power which healthcare workers can exercise over PWUD in terms of their practical access to services but also in defining the concepts, metaphors, and narratives available to them to understand their experiences. This sensitised our research to the central ideas guiding critical ethnography, including that ‘all social life is constructed in contexts of power’ (Noblit, Flores, & Murillo, 2004, p. 4), meaning social phenomena should always be interpreted as something produced by shifting disparities in influence between groups, individuals, and discourses. Part of the task of critical ethnography is for the ethnographer to ‘resist domestication’ (Madison, 2011, p. 6), which the principal researcher has attempted both in their clinical roles and as a qualitative researcher. This has meant observing the practical and conceptual constraints that defined each role and intentionally working to interrogate them throughout this form of ethnographic research. This led to a focus, therefore, on the experiences of PWUM engaging with services and also how their recovery was constructed within the binary logic of biomedical, or abstinence-based services.

Data Analysis

Data analysis was conducted using Iterative Categorisation, as developed by Neale (2016). Interview transcriptions and fieldnotes were thematically analysed through a critical interactionist lens. Codes were developed which attended to how the meaning of drug use was socially constructed and enacted, and how these both shaped and were shaped by wider discourses and structures of power. Collections of text associated with significant codes were extracted as coding files which were then analysed line by line to construct the general theme. Codes and themes were developed both inductively and deductively, initially with reference to the focus areas of the interview guide regarding drug use initiation and experiences of harm and recovery, but then also incorporating additional subjects, elements, and modes of discourse introduced by participants. Key participants were then identified that exemplified different aspects of that theme, and their excerpts were combined with written analysis to create sub-themes that articulated different aspects of the findings (Neale, 2016).

The analysis for this paper focuses on five participants: Carl, Stephen, Kira, Jane and Bridget. Together these participants illustrate the range of capacities, concerns and uncertainties which characterised the overarching theme of ‘living with methamphetamine use’. Similar to the presentation of psychoanalytic case histories, this ‘style of reasoning’ (Hacking, 1990, p. 7) has been used frequently in psychology and medicine, to establish ‘exemplars’ that can ground and orientate the development of theories and bodies of knowledge (Forrester, 2017; Kuhn, 1977). Focussing on these case studies enables our analysis to present in full the detailed complexity of methamphetamine recovery in its social context. These participants were selected because they were representative of the group in terms of their drug use trajectories throughout data collection, and the significant factors shaping their experiences. Some participant details have been altered to protect confidentiality.

Participants

Stephen

Stephen was in his early thirties and lived with his very supportive parents and sister. He grew up in Brisbane and had worked intermittently as a labourer and in construction, fitting out kitchens and bathrooms. Stephen started using methamphetamine in his early twenties and it rapidly progressed to daily use. He described first thinking his drug use was a problem about five years previously, when he started suffering serious cardiac arrhythmias that required cardioversion. Since then, he had had extended periods without using, the longest being 20 months, with lapses of up to a few weeks. He had been arrested multiple times for drug possession, driving under the influence, and driving without a licence, and was still on probation. S.B. visited Stephen at his home four times and attended a visit to his parole officer. Between the first and last interviews he had five lapses of between two to five days. He was receiving phone counselling and felt that he was progressing toward using less and reducing the harms every time he did use. In his latest lapse, he became paranoid and climbed onto a boat on the Brisbane river, causing him to get arrested. He was awaiting court for this and believed he would have to serve some prison time due to his record.

Personal Progress

S.B. met with Carl every few weeks at one of the cafes or parks near his apartment to talk about what had been going on in his life. Carl had not accessed any formal recovery services in recent months, avoiding residential rehabilitation in order keep his job in hospitality and trying to work towards abstinence in the community. He was frustrated by how he felt his drug use was limiting his progress towards career goals, like attending university and working in early childhood education. When discussing how he felt about the previous few months in the final interview, however, Carl constructed his trajectory in positive terms, based on his reduced frequency of drug use, drug related harms, and self-harm.

Yeah, I was back into it a bit there for a while. Definitely, since then, definitely better. I feel healthier in the body, mentally and physically… I got some tests, got some bloods done, the doctor and all the stuff that was done in the red at that time … All them things are good now, so… Yeah, I’m not as bad as- Like, (in the lapse earlier in the year) I sunk too far into it and I started to accept again that I was just on it again. Where even now, even though it’s been a two-week thing, it is still constantly on my mind, I constantly want it to end. I haven’t just accepted that I am just, oh well I’m on it again. I haven’t been like that at all this year, really.

When questioned about drug use, Carl describes his wellbeing in more generall terms than duration of abstinence, focussing on the results of biomedical tests and changes in mindset. He constructs a topography, where he had ‘sunk’ ‘deeper’ into drug use, however, whilst he goes through this process of rising and falling he highlights the forms of change and progress that still occurred. He identifies what he considers a significant step towards his goals by focussing on his mentality, rather than his behaviour. Carl refers to a category shift between abstinence and being ‘on it’, and he resists the identity of being ‘on it’ again. This expands ideas of health and recovery beyond frequency of drug use, to incorporate attitude and intentionality, and ways to maintain different identities in the context of ongoing drug use.

Later in the same interview Carl discussed how he viewed the preceding few months in the context of the last few years of his life.

Carl: I think I feel like I’ve come a fair way, like I’m still in recovery and I’ve got a long way to go. But I feel like the recovery has come a long way.

Carl’s recovery was a combination of reducing drug use and reducing the impact of his self-harm ‘over the last several years’, a process which had occurred mostly without accessing treatment services and without maintaining abstinence. Whilst he had been engaged with abstinence-based recovery since accessing treatment at the start of the research project, he saw the limited changes that he had made as part of a longer and more complex journey outside of recovery services. He acknowledges the recovery discourse which might diminish the significance of his progress and accepts that he has ‘a long way to go’, whilst insisting that he has still ‘come a long way’. He then contextualises this within the perspective of his family, adding more caveats around his claims of progress.

Yeah so, I definitely feel I’m making ground, even though sometimes it’s frustrating because it doesn’t look like it to the other people that care about me and stuff. Doesn’t look like I’m going so well, and stuff, I definitely do feel like I’m making ground.

These comments refer to the accepted trajectory for drug use, as consistent and continual progression towards abstinence, and Carl anticipates frustration at the fact that he is not adhering to this framework. Whilst he relates experiences of growing and living with his drug use, he is also always working against a more traditional concept of recovery trajectories, and the potential stigma related to ongoing drug use despite recovery attempts. How Carl interprets his experiences is always in negotiation with the wider context of abstinence-based recovery within which he accesses healthcare and receives support from his family.

Stephen described a strengths focused, harm reduction perspective regarding his drug use, identifying strongly with the concept of lapses, rather than relapses. He reported using about 100 days out of the last year, compared to around 250 days the year before ‘so hopefully each time I’m getting a bit stronger'. Stephen would monitor his own psychology by identifying days off work coming up when he would have the opportunity to use or recognise when he was thinking that using again was inevitable. From his perspective, these felt like different forms of growth and change that were more complex than whether someone was abstinent from drugs.

In the final interview S.B. also asked Stephen how he felt about the preceding months. He had lapsed recently and been arrested by the police and was concerned about an upcoming court appearance. Similar to Carl, Stephen added caveats and qualifiers to how he experienced and understood progress.

Stephen: Since New Year’s, yeah, good. Good. I mean, I fucked up pretty bad once, but, other than that, like, my personal, like, where I’ve been at, personally, if you cut out that one few days, fucking really happy. But that one mistake’s going to cut into my life in a couple of months, for a little while so, personally, drug wise I think I’m going good. I’m happy with it. I’m happy with the road that I’ve taken, bar that one mistake, so. It’s all good.

Stephen identifies forms of progress in terms of reduced urges, reduced use, but also reduced harms during episodes where he had used. This growth and progress is framed however as a ‘personal’ perspective, a word he employs multiple times, putting this perspective within the context of dominant recovery narratives that may require abstinence. By defining his progress in personal terms, Stephen can protect his sense of achievement from the potential stigma attached to repeated episodes of drug use, thereby both accepting and challenging the values and expectations embedded in abstinence focused recovery services. Similiarly to Carl, Stephen is finding ways to explain his experience of positive harm reduction in a context where any methamphetamine use may be legally and culturally intolerable.

Competing Values

For Kira, navigating recovery meant negotiating between different values and goals, choosing when to pursue abstinence-based recovery, and when to work on rebuilding her family. Kira spoke often about her desire to reunite her family and was consistently focused on maintaining contact, rebuilding her relationships, and working towards regaining custody through CSS. S.B. accompanied Kira to her supervised visitation, where she had to demonstrate her ability to parent and interact with her infant daughter for two social workers. Throughout this period Kira rejected the idea of residential rehabilitation because she viewed it as an interruption to the process of negotiating with CSS. In her second interview, she described the kind of placement she would consider.

If I could take the bub (youngest child), and that, and have them in that kind of recovery, however long I’m there for, if I could have them little things- But being kind of restricted and then limited to when I can come out, to spend that time, a day on the weekend with them… when I was so close to more than that, right now…

The gendered values associated with motherhood and family influence Kira’s trajectory, by making her feel like she needs to navigate between two competing, socially sanctioned value sets related to either family or recovery. By the end of the project, Kira had gone from supervised visitation with her youngest daughter to regaining custody and had found her own private accommodation where she was living with her son and youngest daughter. In her final interview, Kira reflected on the previous few months, and emphasised her experiences of growth, change and progress despite her ongoing drug use.

Even with the little bit of using now, I might high five myself at the end of the day to get to where I am. It’s kind of been a long time coming, it’s just felt like forever. I know, I can feel that I’m definitely in a better place, a better place in my head. [Tearful] I wanted these kids back, and I’m going to get them back.

While reflecting on the previous few months Kira highlights progress in terms of individual factors such as her mental state and relationships, and more structural issues such as her practical living situation and the regulations of CSS. Without maintaining abstinence during this time, Kira’s trajectory had still been towards a stronger position from which to work on her recovery. She viewed her own personal health and recovery as secondary to regaining custody of her children. Meanwhile as she progressively regained these responsibilities, fulfilled her goals of securing private accommodation, and continued to build more positive relationships, her drug use was also having less impact on her life. Kira worked towards these goals despite ongoing methamphetamine use, a process at odds with recovery paradigms that prioritise abstinence and associate continued drug use with only dysfunction and disease progression.

Defending Choices

Whilst some participants shared clearly articulated perspectives on their drug use and recovery, these were often communicated with an awareness of how they might conflict with dominant models or narratives of addiction. At the start of the project, Jane had been in a relationship with Ian for about six months, and they now lived together with their six children from previous relationships. S.B. visited their home many times during the project, which was always in various states of disarray, due either to Jane and Ian having recently used, or the daily counterattack on Jane’s heroic housekeeping led by the children. On the morning of the first visit with Jane, she was folding an intimidatingly large pile of washing. She was warm, down to earth, and clearly well versed in the language of recovery.

During the course of the project her trajectory was marked by conflicts with Ian, intermittent lapses, and the challenges of caring for their children. In her last interview, however, Jane referred explicitly to the growth she experienced during and through her drug use.

I think I’ve grown a lot since [the last lapse]. You know, every time we relapse, I learn more, and that’s what I take from it rather than getting depressed and upset that I’m still using… I’m not so hard on myself every time we do it, and realize, because that’s what, you know, the involvement with [community support organisations is about] … it’s not about having to give up, and staying stopped, it’s about when you use and what you need to do with the kids and stuff and having that support network. I guess it’s- it’s not giving you permission to do it, but it doesn’t make you feel like you’ve got so much pressure to stop and be stopped completely. But, you know, like I said, it’s never about- it’s only ever about that initial rush that’s what I’m addicted to. Anything after it I hate.

Jane describes a point in her trajectory where she has learnt to reduce the harms associated with her drug use through different practical and psychological strategies. By moving away from a focus on abstinence, she has been able to reduce internalised stigma and reduce harms. However, she still acknowledges the fact that living with drug use may not be an acceptable approach by saying ‘it’s not giving you permission to do it’. By framing recovery in this way, a harm reduction, strengths focused approach can be subordinated to the dominant expectations of sobriety, rationality, and progress towards normative health. Jane was using harm reduction strategies with her behaviour and self-talk, but also worked to actively defend these choices in the context of abstinence focused recovery discourse, and the stigma attached to continued drug use.

Bridget used similar language when discussing her own choices and progress. One day Bridget had an appointment with her GP to discuss her drug use and what treatment options she might be able to access. S.B. picked her up from her house and they drove to the doctor’s office. Sitting in the waiting room and whilst playing a game on her phone, Bridget started talking about the effect her drug use was having on her life.

It’s funny you know, even though I’ve got this problem I’m actually quite happy within myself, at the moment, and the way, like, things are going with regards to my relationship to my kids and home and stuff. It’s better than it’s been in a long time. There are, like, certain things about it [methamphetamine use] that aren’t bad, that actually- I interact- I just get on better with them sometimes when I’m in that state. Like not, like, ‘rrrrrr’, like full on- But um, it’s hard to explain.

Bridget differentiates between various states of intoxication with methamphetamine, acknowledging that it is possible for frequent drug use to negatively affect how she interacts with her daughter, and describing how smaller amounts of drug use could facilitate positive interaction. In the context her history of mental health concerns, methamphetamine became a strategically used tool to manage these other issues, and the focus of Bridget's recovery became more directed towards reducing and controlling use, rather than abstinence. Bridget then discussed some different experiences and risks related to methamphetamine use.

S.B.: Makes you a bit more social?

In describing her relationship with her daughter, Bridget expresses values related to how she interacts as a parent, and the quality of their time together, but then contrasts this with what she believes should be expected behaviours for parents to enact ‘naturally’. She then reaffirms her ability to interact with her daughter without using methamphetamine, taking care to emphasise the positive aspects of her use.

Bridget: And we’ll have deep conversations about school, and friends and whatever, like she said to me the other day that, she’s like, you’re the funniest mummy in the world, and things like that, she’s a real mummy’s girl that one though, and with [eldest daughter] we’ve never got on better than we are at the moment, which is full on, we’ve had lots of ups and downs.

Bridget credits using methamphetamine with making her less depressed and enabling her to communicate better with her older daughter. These benefits are discussed, however, within a wider cultural narrative regarding the expectations of motherhood and abstinence-based recovery. In this interaction, Bridget simultaneously reinforces and subverts these narratives, by acknowledging their authority yet maintaining her own experience as an exception. In Bridget’s account, the significance of her methamphetamine use goes beyond its biomedical effects, or potential harms, to include this reflective interpretation and construction. Leaving aside methamphetamine’s actual effect on her parenting, Bridget’s description disrupts the hegemonic behavioural norms implicit in public health and abstinence-based drug treatment. For Bridget, frequent or harmful methamphetamine use occurred alongside the management and pursuit of other priorities and interests, an arrangement which she frequently defended.

If Bridget stopped using methamphetamine, the benefits to her would arguably not be benefits she currently valued or aspired to. The neoliberal value framework of sobriety, propriety, and productivity can be seen to break down in translation to the social, familial, and psychological circumstances of some PWUD. These values may be more accessible for someone who desires the company, and feels like they can aspire towards the esteem, of their wider community. Bridget, however, constructs her values around localised resources within a tighter social circle, which are more culturally relevant, and which do not require complete abstention from methamphetamine.

Living with Methamphetamine Use

Each of these participants demonstrated personal growth, change, and progress, despite ongoing drug use. This could be presented as support for those models of recovery which analogise drug use to chronic, relapsing diseases, as another example of how health and wellbeing can be conserved despite ongoing ‘symptoms’ (Dennis & Scott, 2007; Duff, 2016). Diseases such as hypertension and diabetes are similarly manifestations of clearly understood pathophysiological processes that are influenced by an individual’s behaviour, whilst also being unequally distributed across societies due to systemic cultural and socio-economic differences (Weaver & Mendenhall, 2014). There has therefore been a growing focus on chronic disease treatment models as the most effective option for managing harmful drug use over the long term, rather than only providing acute, episodic care (Kim et al., 2012; Saitz, Larson, Labelle, Richardson, & Samet, 2008).

Using disease terminology, however, can be fraught in the context of drug use. Addiction has been called a disease of the brain (Leshner, 1997; Volkow et al., 2016), a disease of the will (Valverde, 1998; Worth & Rawstorne, 2005), and a social disease (Lewy, 2009), each of which can have well-established clinical, social, and policy consequences, as this designation traditionally puts drug use outside of individual’s ‘control’. These implications have been previously addressed in the context of methamphetamine recovery and agency (Brookfield et al., 2021).

Whilst claims that disease terminology can exclude social and structural factors which contributed to the creation of addiction in specific times and places are clearly valid, to discard this terminology also risks excluding or obscuring its manifestly significant health effects, and the biomedical interventions often required, whilst not being independently sufficient, to manage or resolve harmful drug use. We would argue, therefore, that critical drugs research and interventions work to reclaim and redefine the terminology of disease for some forms of drug related harm. Meanwhile the reductionist ‘brain disease’ paradigm is patently insufficient for explaining the full range of harmful drug related behaviours, particularly how they are distributed across populations (Grigson, 2018; Heim, 2014).

To resolve the poor fit between the complex reality of harmful drug use and models of disease, despite the many points of conceptual similarity, requires that we expand our conception of what constitutes health, disease, and the body. For the participants in this study, their health was not a categorical state or project distinct from periods of drug use. Instead their various ‘patterns of bodily articulation’ (Weinberg, 2011) entailed romantic, social, and professional relationships, complex webs of triggers, desires and material circumstances, navigated in the wider context of social, cultural and moral discourses of addiction and recovery. Harmful methamphetamine use was not simply a disease of the brain, but a biopsychosocial process that resisted reduction to singular factors or bodily organs. If harmful methamphetamine use can be at least sometimes managed as a disease process, then we need an understanding of disease that incorporates its social, structural, and cultural aspects and which can articulate how drug related harm and recovery is woven through and between individuals.

‘Living with drug use’ can describe this experience of chronic drug use combined with growth and change, echoing the language adopted for other chronic conditions. Heart disease, diabetes, cancer and more recently HIV are conditions which people are increasingly described as ‘living with’ rather than ‘suffering from’ (Camidge, 2001; Graber, 2010; Grinyer, 2007; Pryor, Page, Patsamanis, & Jolly, 2014). Using this framework to address drug use refocuses management towards how to have the most fulfilling life in the presence of a health condition. There is the analogous concept within mental health recovery of ‘health in illness’, where recovery exists always in the context of ongoing symptoms (Duff, 2016; Roberts & Boardman, 2018).

The complex and variable life courses of PWUM make definitions of recovery more difficult to establish and maintain. Whilst harm reduction is a well-established paradigm that works with people currently using drugs (Degenhardt et al., 2019), when and where the transition occurs to being ‘in recovery’ is less clear,. Abstinence focused recovery can exclude or marginalise the very common cyclical change that many PWUD undergo when attempting recovery (Kelly & White, 2010), and also the significant, complex, and long term work undertaken by PWUD such as Carl, Stephen, Kira, Bridget and Jane to improve their lives, prepare to enter treatment, or make multiple attempts at abstinence. This exclusion has been identified by other research with PWUD for whom recovery is more about ‘coping’ than ‘cure’, whilst recovery measures construct the recovered individual as a perfectible ‘superhuman’ (Neale et al., 2014, p. 29). For participants in this study, recovery began with a range of mental and practical preparations such as changing living conditions or managing changing attitudes towards drug use. These changes were all part of living with drug use, either prior to entering the more widespread narrative of ‘addict in recovery’, or as means to manage the stigma of their continued drug use, by challenging its perception as a ‘denial of the social order’ (Goffman, 1963, p. 144) that necessitates abstinence, moderation, and rationality (O’Malley & Valverde, 2004).

Plurality of Recovery

Participants invoked a wide range of values when discussing their drug use, acknowledging the ways in which they might deviate from the contemporary morality embedded within contemporary norms of health and citizenship (Greco, 2009). This produced multiple goals in recovery, including but also extending beyond abstinence. Both Kira and Bridget wanted to reduce their drug use but did not want to access long term rehabilitation because of its impact on their children, and because they were able to support their families whilst using methamphetamine. Carl felt he had ‘come a long way’ by controlling his drug use and improving his mental and physical health, but worried that his progress was not visible to his family because he was not abstinent. These attitudes align with some versions of harm reduction but contradict the neoliberal ideal of the fully functioning independent citizen (Randles & Woodward, 2018).

These different perspectives on health and recovery have been recognised previously in the literature discussing ‘counterpublic health’, which argues for the recognition of groups within the monolithic ‘general public’ with different values, priorities, and capacities (Duff & Moore, 2015; Race, 2009; Warner, 2002). Counterpublic health draws attention to how ‘health’ is constructed in relation to a homogenised and idealised public, which in reality will always include socially marginalised people whose norms and values may construct health and wellbeing differently (Bryant et al., 2019). This analysis of normative public health is therefore situated within broader critiques of neoliberalism and its construction of the ideal modern individual as rational, independent, and temperate (Wrenn & Waller, 2017), to which compulsive drug use will always be antithetical. This marks a shift away from Foucault’s (2004) identification of how disciplinary norms of health have been laboriously inculcated from above, towards a neoliberal environment where individuals accept the need for health and healthy behaviour due to the ambient norms of health within the culture and administrations of society (Brookfield et al., 2021). Interpreting participant’s statements in this context highlights the more subtle way in which drug use can still be constructed as ‘deviance’ (Becker, 1963; Netherland, 2012), and confined to the binary framework of health/pathology. Participants lived out their trajectories in the context of knowing they were not meeting the behavioural standard of a model neoliberal citizen with its associated values. Their experiences suggest the need for a more pluralistic understanding of recovery, and how this is enacted by constituents of the multiple ‘publics’ within the scope of public health (Duff & Moore, 2015).

A real application of counterpublic health would, therefore, entail a kind of value pluralism, where public health institutions recognise the existence of multiple potentially conflicting value systems among the population living within the policies and interventions they enact (Marino, 2017). The diverse trajectories of PWUD engaging in recovery encompass an array of objectives, including abstinence, drug related harm reduction, and other goals related to family and wellbeing. Bridget’s goal, for example was not abstinence but reducing her drug use, and whilst she was not a moderate, risk-averse participant in the modern health culture, she was living a life that still accorded with the value system she espoused. Effective public health interventions for Bridget may need different strategies to those directed at individuals who prioritise sobriety. This strategy would be based on a fundamental acknowledgement and validation of Bridget’s perspective and values, rather than uncritical adherence to broader predefined regimes of behaviour and morality. Recovery strategies built on this kind of validation will have diverse and multi-dimensional outcomes and may therefore be more effective at promoting the ‘health’ of the public.