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The Psychotropic Self/Imaginary: Subjectivity and Psychopharmaceutical Use Among Heroin Users with Co-Occurring Mental Illness

Abstract

Many people diagnosed with mental illnesses struggle with illicit drug addiction. These individuals are often treated with psychiatric medications, yet little is known about how they experience this treatment. Research on the subjective experience of psychiatric medication use highlights the complex, contradictory, and ambiguous feelings often associated with this treatment. However, for those with mental illness and addiction, this experience is complicated by the need to manage both psychiatric medication and illicit drug use. Using ethnographic data from a study of heroin use in Northeast Ohio, we explore this experience by expanding the pharmaceutical self/imaginary (Jenkins, Pharmaceutical Self: The Global Shaping of Experience in an Age of Psychopharmacology, School for Advanced Research Press, Santa Fe, NM, 2010b) to include psychopharmaceuticals and illicit drugs, what we call the psychotropic self/imaginary. Through this lens we explore the ways participants interpret and manage their psychotropic drug use in relation to sociocultural, institutional, and political–economic contexts. This analysis reveals how participants seek desired effects of legally prescribed and illicit drugs to treat mental illness, manage heroin addiction, and maintain a perceived “normal” self. Participants manage their drug use using active strategies, such as selective use of psychiatric medications, in the context of structural constraints, such as restricted access to mental health care, and cultural contexts that blur distinctions between “good” medicines and “bad” drugs.

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Notes

  1. All names used are pseudonyms.

  2. “Compliance” has more recently been referred to as “adherence” or “concordance” in an effort to respect patient perspectives and autonomy (Applbaum and Oldani 2010). However, following Applbaum and Oldani (2010), we continue to use the term “compliance” in this manuscript to reflect the large body of research that indicates that “the patient remains vulnerable and subject to powerful individual and institutional forces outside of their control” (120).

  3. This research was conducted with the approval of the Case Western Reserve University Institutional Review Board.

  4. Participants clearly identified heroin as their primary addiction and rarely described their crack cocaine use in depth. Crack use was typically reported to occur sporadically and infrequently (e.g., approximately once a month). As a result, there is little information on how participant’s crack use interacts with their mental health in contrast to the detailed narratives on how heroin use interacts with mental health.

  5. Interview transcripts and field notes from all 34 participants were indexed for psychopharmaceutical use to identify narratives on how participants view psychopharmaceutical use in relation to illicit drug use and the role of psychopharmaceuticals in the illegal drug market. Interview transcripts and field notes from the 15 participants who self-reported diagnosed mental illness were coded for themes related to how these individuals view and manage their psychopharmaceutical and illicit drug use in relation to self-perceptions and contextual factors.

  6. Susan stressed that at this time she was “sober” since she significantly reduced her use of heroin or other illegal drugs. She categorizes methadone as a “medicine” instead of a “drug” in contrast to the views of many users in this and other studies. Other participants in this study consider ORTs (specifically, methadone and Suboxone) “just another addiction.” Such views and experiences of ORTs are consistent with those of heroin addicts taking prescribed ORTs described by other authors (Agar 1977; Agar and Stephens 1975; Bourgois 2000; Bourgois and Schonberg 2009b; Koester et al. 1999; Saris 2008; Schwartz et al. 2008).

  7. Susan’s categorization of some of her psychiatric medications as “drugs” in contrast to their conventional categorization as “medicines” parallels the previously noted findings of many other scholars regarding addicts’ experiences of methadone as a “drug” despite it being regarded as a “medicine” by state and medical authorities (Agar 1977; Agar and Reisinger 2002; Agar and Stephens 1975; Bourgois 2000; Bourgois and Schonberg 2009b; Koester et al. 1999; Saris 2008; Schwartz et al. 2008).

  8. Susan also reported taking methadone as prescribed until she returned to heroin use and was withdrawn from the methadone program.

  9. Like these psychopharmaceuticals, ORTs are bought in the black market to self-medicate heroin withdrawal, to attempt to control one’s heroin habit, and to self-detox when access to formal detox is restricted or when one prefers to avoid formal treatment. These dynamics have also been documented elsewhere (e.g., Saris 2008).

  10. The use of heroin to treat insomnia is reminiscent of the use of heroin and other narcotics as a sleep aids in the nineteenth century (Martin 2010), further highlighting the socially mediated, historically contingent nature of drug/medicine distinctions.

  11. “America” refers to the United States of America.

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Acknowledgments

This research was supported by a grant from the National Science Foundation [NSF BCS-0724320] awarded to Lee D. Hoffer (Principal Investigator). Members of the Case Western Reserve University Social Dynamics Research Team contributed to data collection. An earlier version of this paper was presented as part of the session The Anthropology of Psychopharmaceuticals: Cultural and Pharmacological Efficacies in Context at the Society for Psychological Anthropology 2011 Biennial Meeting in Santa Monica, CA. We thank Janis Jenkins, who served as discussant for the session, for helpful comments. We also thank an anonymous reviewer for emphasizing the need to critique the structure of biopsychiatric treatment. Finally, our greatest thanks to study participants for sharing their lives and experiences.

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Schlosser, A.V., Hoffer, L.D. The Psychotropic Self/Imaginary: Subjectivity and Psychopharmaceutical Use Among Heroin Users with Co-Occurring Mental Illness. Cult Med Psychiatry 36, 26–50 (2012). https://doi.org/10.1007/s11013-011-9244-9

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Keywords

  • Addiction
  • Mental illness
  • Illegal drugs
  • Subjectivity
  • Psychiatric medication