Keywords

“WE CAN'T STAND IT!” we say.

“I can give you diazepam,” They say.

“HELP US,” we say.

They are being ruthless and that outrages us.

(Johanna Gustavsson “We Are This Place or This Condition”Footnote 1 2017, p. 34)Footnote 2

Orders of dirt and cleanliness based on time, place, context, class and gender are, as I have shown, fundamental elements of the women’s drug use practices. But what role do the drugs themselves play in attitudes towards drug use? How are the boundaries drawn and what constitutes a legitimate drug use practice for the women? In this chapter, I examine how the interviewees’ various arguments can be understood in relation to the concepts of illness, health and personal responsibility, and to a society increasingly influenced by the possibility of altering states of mind with the help of psychoactive drugs.

1 Medicines

Most Swedes will be prescribed medication by a doctor countless times in their lives and will pick it up at a pharmacy: it is an entirely legal, everyday process. As I mentioned before, more women than men in Sweden use controlled psychiatric drugs, while the opposite is true for illegal drugs (CAN 2019; Swedish National Institute of Public Health 2010). In 2022, antidepressants alone were used by approximately 15 per cent of women in Sweden (Swedish National Board of Health and Welfares statistical database at socialstyrelsen.se). This might lead to the assumption that the interviewees would view the consumption of psychoactive prescription medication as a legitimate and appropriate practice, and that illegal drugs with the worst kind of reputation, like heroin and crack (cf. Petersson 2013, pp. 412f.), would occupy the other end of the scale. But the issue is more complex than that. Whether or not the women see drugs as legitimate depends on factors extending beyond legislation and medical science, their views can only be understood from a broader perspective. This section and the next discuss the interviewees’ stances on medicines in relation to the concepts of sickness, health and personal responsibility, but also in relation to compliance and potential resistance.

I am sitting in a cafe with Angela on a sunny day, at a table overlooking Björns trädgård Park in Stockholm, discussing her relationship with the medication she takes. In a frustrated voice, she says:

You can go along with it and feel like, because help is available, you’re obligated to regulate yourself. They talk about it like there are solutions. Like you’ve been offered solutions and then it’s up to you whether you… [inaudible].

Angela describes expectations that she will “regulate [her]self” with the help of medication and her own experience of feeling obligated to do so (cf. Boyd 2004; Du Rose 2015), mainly with reference to anti-anxiety sedatives and amphetamine-based products to relieve the symptoms of ADHD. When Angela claims that people expect her to regulate herself, I understand her as meaning a combination of a perceived sense of general expectations plus actual insistence by the healthcare professionals who treat her and the social workers she is in contact with because her children have disabilities.

The historian Nancy D. Campbell believes that women’s use of different substances is met with the same expectations of adaptation that they are expected to display in other areas of life—that is: the expectation that they will use certain products to help them fulfil their duties, while simultaneously making sure their drug use never prevents them from carrying out those duties. Campbell writes that the extent to which women adapt themselves determines the rights they are granted:

Women’s rights depend on the degree to which women fulfill their responsibilities as contingent workers, consumers, and caretakers. Women purchase their autonomy at the price of good behavior and social conformity. (2000, p. 4)

Angela does not want to conform, as evidenced by both her distinctive style and her statements, but neither does she want to lose custody of her children. Her frustration with her medication is not rooted in any aversion to mood-altering substances and their effects as such; all her life, she has experimented with and used both prescription and illegal drugs. Nor does the way in which she views herself clash with the diagnoses she has been given—of ADHD, anxiety and depression. When I interview her, Angela often refers to these diagnoses, as explanations for why she has acted, acts and thinks in certain ways. Every once in a while during our conversations, she will mention her neural health, basing her analyses of herself on it and saying, for example: “yeah, so my brain, because I’ve got these autistic tendencies and stuff, that’s why […]”. So Angela largely views herself as a neurobiological subject, yet feels reluctant to regulate herself with medication. Where does this resistance come from?

Sociologist Nikolas Rose (2003) argues that medicines such as those Angela describes being offered as a solution are psychiatric healthcare strategies that have become routine ways of rewiring humans’ subjective capacities since the mid-twentieth century (cf. Campbell and Ettorre 2011). Rose portrays psychiatric, commercial medication as an integral part of a changed world, in which humans have come to understand themselves in new ways. He believes that a new ontology has emerged, based on the view that the brain is the centre of the self. He links this ontology to what he calls well-developed, liberal and democratic societies, which he says have turned into psychopharmacological societies. People in these societies (of which Sweden is one) now view themselves as neurochemical selves inhabiting a neurochemical world (Rose 2003, p. 46). Rose is critical of this increasing use of psychiatric medication, calling it an adaptation to the neoliberal and capitalist norms, values and assessments that he argues are embedded in these medicines (ibid., p. 59). Seeking the cause of mental health problems in individual brains makes people responsible for their own well-being, responsible for “regulating themselves” in Angela’s words. This takes the focus away from circumstances such as class-related conditions and workplace stress. The fact that the cause of depression, for example, can be rooted in economic conditions, unreasonable working conditions or social conditions, he argues, is overlooked when the focus is on the treatment of brain chemistry (Rose 2003, 2019). Consequently, the cures offered are about balancing neurotransmitters or numbing emotional sensations through the intake of prescription drugs, while grief, stress and anxiety may be explained by the material and social situation. I will return to this criticism at the end of the chapter.

Another approach is presented by Skeggs, who uses the concept of “the optimizing interested self” (2004, p. 63) to demonstrate a valuable model of the self in a capitalist economy, which functions as a neoliberal subject. “The optimizing interested self” is a split self, which is both morally responsible for taking care of itself, and a rational model that understands its value on the market. The combination of an optimising interested self and a self that understands itself as a neurochemical subject provides a picture of what the expectations that Angela feels may look like. The self-regulation that she feels is expected of her is a requirement for achieving such a valuable self, which is internalised through expectations of taking responsibility. But this responsibility, Skeggs writes, cannot be taken by everyone.

Self-regulation then is a matter of establishing a moral code under which the self can be assessed as being or becoming responsible. Forms of ethical conduct are a form of labour and governance imposed upon the self by the self. The self becomes obliged to “become” in a particular way: But all ways are not open to all, and some positions are already classified as in need of help, of being irresponsible, of having deficit culture, or of being pathological. (2004, p. 73)

So I take it that Angela understands herself, at least in part, as precisely a neurochemical subject within a discourse that locates the causes of thoughts, feelings, emotions and behaviours in the brain. Consequently, this means that she directs her efforts towards the brain, using psychoactive substances of various kinds when she wants to change her behaviour. But this does not mean that she unquestioningly accepts the medication prescribed for her. She does not aspire to the ideal of “the optimizing interested self”. She proudly talks about her disability allowance and about risky and experimental adventures, relationships and parties. At the same time, she wants to be a good mum and feel good. Throughout the course of this study, Angela tells me about her anxiety, about going off her medication and then taking it again, reducing and increasing her dosage. Sometimes, she uses illegal drugs, and she drinks quite a lot of alcohol. I understand that, for her, the use of psychoactive substances is a legitimate practice insofar as its regulation is in line with her changing intentions, regardless of whether she has been prescribed the substances or not.

One interpretation of Angela’s way of handling her substance use would be that these objects start to mean something to her when they appear along the lines she is following. Depending upon how they are encountered, and how they are experienced after she has ingested them, they mean different things. An encounter can give her the feeling that she is on the right path or a sense of disorientation. Ahmed writes:

How does […] “matter” matter? It is crucial that “matter” does not become an object that we presume is absent or present: what matters is shaped by the directions taken that allow things to appear in a certain way. (2006, p. 165)

Matter, according to Ahmed, becomes significant not by being, or not being, this or that object, but by the directions taken that allow things to appear in specific ways. For Angela, the meaning of the drugs and medicines is shaped by the directions, towards and through the drugs, that she sets out on her way forward. From that path, the drugs and medicines appear to be useful in different ways at different times. The perceived obligation to regulate oneself is contrasted, for example, with the possibilities of creating forbidden, intimate drug-use spaces with friends, as described in previous chapters. A person who has regulated themselves according to external instructions may not want to go to an all-night party, for example. Following a line through the medication prescribed by a doctor does not necessarily mean that she will get where she wants to go, where she feels orientated.

Angela has some trust in the health professionals who prescribe medicines and encourage her to use them. For example, she says:

then they convince me that I [emphasises the remaining words] have to understand that not taking my medication hurts me more… than taking medication. That it wears me out to be, to feel bad.

However, the underlying theme of this quote is that Angela’s ambivalence towards the drugs is also because she sees them as harmful, even though the healthcare staff say that it is even more harmful not to take them. Reluctance and ambivalence lead her to constantly make new decisions about whether or not to take the medicines she is prescribed, negotiations that are also ongoing during the interview period. This difficulty in deciding whether the drugs are good or bad for her health is an ambivalence she shares with many patient groups. Ethnologist Åsa Alftberg’s study of older people’s attitudes to medicines reveals similar anxieties, noting: “A medicine cannot be said to be either curative or harmful, it is both at the same time” (2015, p. 6, italics in original; cf. Derrida 1993). This makes medicines a constant source of concern. Questions about the potential dangers and benefits of medicines, combined with increasing expectations that patients will take an active role in their own treatment, make for a challenging situation (Hansson 2007). Patients must weigh potential benefits against potential harms and hope that the decisions they make will lead to an improvement. In Angela’s case, sometimes she sees illegal drugs as potentially better, at other times she takes greater or lesser quantities of her medicines than have been prescribed.

So how, then, can we tell what constitutes a medicine and what constitutes a drug? Where does one end and the other begin? While visiting the Sorgenfri medical centre in Malmö, I came across an information sheet that provides a picture of the healthcare sector’s attempts to define (il)legitimacy (Berman et al. 2005). Patients are asked to fill in a run-of-the-mill form ahead of a blood test to check for vitamin deficiencies. The form includes the question: “Do you use any drugs?” and suggests that patients refer to the back of the page to determine which box they should check (yes or no). Under the title, “List of Drugs”, the first half of the back of the page, cites a number of illegal drugs; the rest of the page lists a number of controlled drugs. “NOTE: NOT ALCOHOL!” is written in bold, capital letters immediately below the title. The lower half of the page provides an indication of how dividing controlled drugs into legitimate versus illegitimate substances requires the user to assess themselves by questioning their intention. According to the text, prescribed medicines become drugs if the patient takes them with the intention to “have fun, feel good, get ‘high’ or find out how [they] will be affected”. But the text emphasises that pills do not count as drugs “if they were prescribed by a doctor and if the right dose is taken”. A medicine could thus make a patient “feel good” without being considered a drug, but would turn into a drug if it was the patient’s intention to “feel good”.

Historian Virginia Berridge describes how such distinctions between intentions, linked to drug use, were already being made in the nineteenth century. The use of opiate-based drugs for the purpose of intoxication was then called “luxury use” (2013, p. 15). The concept of luxury use indicates that such use was perceived as non-essential, but as something that some people could indulge in. A psychoactive substance could thus be used to a greater extent than a medical condition requires, and thus have a different use. The medical centre’s form, on the other hand, indicates that the substance itself changes when the intention is to experience effects beyond those intended. It becomes a drug, when it was previously a medicine.

Sara Ahmed uses the concept of “forness” to illustrate how an object can be defined by its use. She gives the example of birds laying eggs in a postbox, and how the laying of eggs turns what used to be a postbox into a nest.

Something is what it provides or enables, which is how what something “is” can fluctuate without changing anything at the level of physical form. […] To refer to something as a postbox is to refer to a use of a thing or even a use not a thing. (2019, p. 35)

Thus, to refer to something as a postbox is to refer to its use, which maintains the notion of the postbox in that it is used as a postbox. This, she says, can lead to confusion if that same postbox is used for something else that the shape allows it to be, such as a nest.

Describing what something is for is a partial account of what it can be. Forness helps reveal the partiality of an existence. (2019, p. 35, italics in original)

In the case of medicines, the definition by use is as clear as a postbox. Medicines are for healing, while drugs are for drugging oneself. Thus, when the patient’s intention was to be drugged, what were previously medicines become drugs, through the way in which they are used. But the medicine’s function—its ability to cure, for example by helping someone who suffers from anxiety to feel better—and using that same medicine in an inappropriate way to “feel better”, that is: drugging oneself, is not quite as different as a postbox and a nest. Whether a product is used to heal or to drug oneself, the outcome is confusingly similar, and this shifts the focus onto the person using it. A postbox is used by humans, while a nest in a former postbox is used by birds small enough to slip through the slot at the front. A what change can thus be a who change (ibid., p. 34). The person using the drugs must judge their character by employing the same judgement that determines what the intention of the drug or drug use was. Was it a medical patient or a drug user who used it?

I interpret the health centre’s differentiation between terms as a way of absolving medicating patients of the stigma that drug use would entail. But this differentiation also shows that patients are forced to make a difficult choice, drawing sharp lines where the reality is blurred and fluid. Several of the controlled drugs that are listed, for example, are used precisely for anxiety, that is: to feel good. Patients like Angela need to ask themselves what their intentions are. It becomes a question of knowing who they themselves are in relation to feeling better, if they are to be able to determine whether or not the medicine was a drug according to the information sheet. Angela and several other interviewees are constantly navigating through these identity-creating fields of different behaviours and intentions that construct medicines and illegal drugs from the same materials.

There is also a large and growing interest in the alternative use of currently illegal medication, and investigations are being conducted into whether what are now considered drugs could have a different “forness” than drugging. In Sweden, and around the world, research on psychedelic drugs is ongoing. For example, the hallucinogenic club drug Ketamine is attracting interest due to its potential usefulness as a cure for depression (Tiger et al. 2020; Kvam et al. 2021). At the same time, MDMA, LSD, and psilocybin mushrooms are being researched as potential cures or aids in diagnoses of such conditions as post-traumatic stress disorder, depression, anxiety and addiction (Brown 2023; Liechti 2017; Lundgren 2023). Altogether, such uses construct a thicket of non-intoxication-motivated uses of drugs, which are usually sold illegally, and narcotic and prescription medicines, where their “forness” runs counter to use as temporary opportunities for release and (potentially controlled) loss of control. Instead, their use is aimed at functioning in society (cf. Sandell 2016). How, then, does the orientation between and through these substances take place?

Alftberg discusses the concept of “poor adherence” (also called “poor compliance”), a term used by the healthcare sector. She problematises it as a “normative term that highlights the relationship between the ideal and practise, that is: the relationship between the doctor’s prescription and how the drugs are handled by the individual who uses them” (2015, p. 4). The concept thus focuses on the direction indicated by the doctor and the patient’s propensity to follow it.

From the healthcare sector’s point of view, as well as that of the law, Angela’s consumption could be described as “poor adherence”. The lines she follows are based on directions that are progressively pointed out, sometimes in line with healthcare instructions, and sometimes not. But while her adherence may be poor, it is not non-existent.

1.1 A Troublesome Brain

From time to time, Angela takes the doctor’s recommendations to heart. She sometimes tells me when we meet that she is drinking alcohol in moderation, taking her medication and staying away from drugs. However, she often describes having anxiety. In those moments, she views her body as “troublesome”, to use Signe Bremer’s words (2011, pp. 43ff.). Bremer uses the term “troublesome body” in her study of transgender individuals, in the sense of bodies that do not fit into the expected templates of the healthcare system. She uses it to illustrate how, for example, masculine-coded body lines on a person who perceives herself as a woman can be difficult to recode. The body can be perceived as refusing to allow itself to be recoded by means of clothing, for example. In such cases, Bremer explains that it can lead to the healthcare investigators who make decisions about gender reassignment not perceiving the person who wants such reassignment as credible (ibid., p. 103).

The concept of “troublesome bodies” highlights body parts that the patient wishes would follow prescribed lines, but do not. The body thus goes against both the patient’s wishes and the healthcare system’s expectations of how it should be expressed. “By defying normalisation and at times refusing to do what we want, [the body] makes trouble” (ibid., p. 45). In my own research, I have discerned a neurological troublesomeness in people whose treatment plans failed to regulate their brains. Angela has a brain that does not react to medication in the way it should: it “defies normalisation”. Sometimes, medicines do not make her feel better. I interpret her words, quoted near the beginning of this chapter, as expressing a sense of guilt for failing to adjust her dosage until everything is all right: “you’ve been offered solutions and then it’s up to you”. Often, it is Angela’s very attempts to fix the shortcomings of her medical treatment that lead her down crooked paths. Her goal is always the same: to feel good, in different ways. Yet she also wants to quit her medication. When it does not work, she walks away from it; when it does, she finds herself facing a paradox. I ask her about her recurring decisions to quit her medication, to which she replies: “When I stop taking my medication, I often do so because I… maybe… yes, because I… you know, I feel good”.

From a bodily point of view, it does not make sense for her to take medication that might harm her when she is feeling good. In the same vein, Alftberg describes how the potential dangers inherent in medication versus its ability to heal creates tension for its users, who begin to notice the way their body reacts to it:

One therefore constantly monitors one’s body, and symptoms and sensations outside of the ordinary cause one to focus on the medication and its impact on the body. The body and the prescription are thus sometimes pitted against each other, with the individual forced to decide which he or she should heed and act on: the experiences of one’s own body or the medical prescription. (2015, p. 4)

Alftberg reveals that approximately half of all patients who are long-term medication users do not use their medication in the way that was recommended. This means that “poor adherence” is a common problem. In Alftberg’s quote, as well as in Angela’s statements, a line that runs through the body is visible, a line that is able to eclipse the doctors’ guidelines, and then she can think about using the medicines again. Her reluctance to take medication, therefore, also seems to be related to the link between these medicines and deficiency states. Introducing medicines into the body to remedy a deficiency becomes an option when she has previously given up those medicines and feels bad, but their use clashes with experiences of feeling good and being healthy and thus complete. Karin Johannisson writes: “To be ill is to allow feelings of weakness and inadequacy. It is to establish a language between the body, the self and society” (1995, p. 8). As in Alftberg’s study, the language established between body and self focuses on risk and health, but in Angela’s case, I interpret the focus as being on how communication with the third party, society, is experienced. The medication becomes a way for society to tell Angela what she needs, and she resists this. At times, she tries the prescribed line, and at other times she stakes out her own. Angela questions the ability of medication to bring about and maintain sanity when the drugs are in her body, both when she is well and when she is not. Her attempts to take control of her own well-being with medicines in varying doses and with illegal drugs take on an experimental character, resisting compliance.

Madelene also finds herself in a similar situation of disbelief, hope and alternating adherence and non-adherence to prescribed drug treatments. When she lists the drugs she has been prescribed to alleviate depression and reduce anxiety, the list is long. They include various SSRIsFootnote 3 for depression, but also several drugs, opiate-based and variants of benzodiazepines, to reduce anxiety. These are classified as highly addictive and can also cause fatal overdoses. When I ask her how it is possible that she could have received these drugs, which should only be prescribed with “caution” (see fass.seFootnote 4), she replies:

How did I get it? It’s so easy. I get exactly what I want. […] or I didn’t ask for it. It was suggested after a burnout. Which I had.

When I question the high dosages she is on, she says:

But he always adds “SIC” to my prescription, you know, you know, that you can exceed.

By “SIC”, Madelene is referring to her doctor adding a specific abbreviation to her prescription to allow for large withdrawals that exceed the recommendations for controlled drugs. When I express surprise at the number of drugs prescribed to her—she says there were 27 at one point—she replies:

Yes. I don’t know if they used me as some kind of guinea pig or something but, they didn’t work. I tapered them off [incrementally decreased her dosage to zero] myself all the time, so that, it was just, madness.

Madelene’s case puts the term “poor adherence” in a different light. In Angela’s case, the prescribing of drugs appears to be part of treatment plans (even when they do not work), based on caring purposes, but Madelene specifies so many drugs that the prescribing doctor’s prescriptions do not appear to be guidelines. Instead, the doctor’s adherence comes to the fore when she says: “I get exactly what I want”. If her statement is true, the doctor’s legitimacy can be questioned. Madelene describes the way in which she tapers off her medication of her own volition as a responsible way of navigating an uncontrolled number of prescribed medicines, but also of navigating towards illegal drugs, like the heroin she uses.

Thus, Angela and Madelene do not take responsibility for their drug use by following the doctor’s instructions to the letter, but by using their own bodies as their point of departure to experience and judge their use. However, feeling good does not mean that their use stops; instead, their use may have other intentions than addressing deficiencies, as medicines and drugs also have the potential to elevate states of mind in various ways. Conversely, illicit drugs may consist of the same active substances as medicines, and thus be used for curative or “regulatory” purposes. This also applies to some substances that are never, or very rarely, prescribed as medicines in Sweden, such as LSD and cannabis. So what is the role of such illegal use in the women’s lives, and how does it relate to other kinds of drug use?

2 Drugs as Medication

That people are, in Angela’s words, “obliged” to take personal responsibility for their lives and health is a neoliberal ideological paradigm (Gilbert 2008; Campbell and Ettorre 2011; Du Rose 2015). One aspect of this paradigm is using medicines as prescribed, another is not using illegal drugs. Someone who does not conform to this paradigm can be viewed as belonging to a group that puts its health at risk. In a report on socioeconomic differences in drug use, the Swedish Public Health Agency links this group to disease and death:

Drug use increases the risk of harm from both a medical and a social perspective. Both morbidity and mortality rates are much higher among drug users compared to the general population. (Public Health Agency 2021, p. 11)

In other words, using illegal drugs is presented as an act that is diametrically opposed to taking responsibility for one’s own health. Some people who use drugs contest this juxtaposition, claiming that it is precisely because they take responsibility for their own health that they have approached illegal drugs. The global battles over whether cannabis should be legal or not often involve such arguments. For example, Nanne says: “from the time I started smoking pot [cannabis] when I was 18 until I got pregnant, I was almost never sick”. On another occasion, she triumphantly announces over the phone that her doctor said it should be illegal not to recommend CBD oil for pain management. In these statements, she takes a stand in favour of the medical use of cannabis preparations, with her doctor vouching for the oil. She contrasts this with the side effects she experiences from prescription opioids and other painkillers. She describes some of the drugs she has tried as having unpleasant effects: “Uneasiness, fatigue, stomach ache, cramps and just no! It just feels wrong in the whole body”. When Nanne talks about cannabis and the prescribed medicines, she emphasises the terms “chemical” and “natural” as distinguishing markers for artificial preparations and plant extracts or plant-based preparations, such as marijuana and CBD oil. It is clear that “natural” for her has positive connotations (cf. Lindgren 1993). Looking at it that way, the combination of human plus psychoactive substance can be interpreted as human plus nature, while introducing artificial products into the human body is a clearer embodiment of human + technology: a half-dead, half-alive technobody, a cyborg with monstrous features (Preciado 2013, pp. 44f.).

The latter stands in contrast to a natural, namely herbal, aid that helps the body to function. Nanne is open about her use of CBD oil to relieve pain—something that is not, in fact, illegal in Sweden. Legislatively, CBD oil is a grey area, as Sweden’s Medical Products Agency has ruled that it is usually a medicine rather than a foodstuff, but medicines may only be sold if their efficacy has been proven by peer-reviewed studies.Footnote 5 When I ask if there is anyone she would not want to tell about her use, she laughs cockily and says: “No, I write [about it] on Facebook directly”. As mentioned earlier, she also argues in favour of using THC-containing cannabis, even though she no longer uses it herself. I read a pride in her alliance with the natural world.

Even though there has not been quite as vocal a pro-cannabis movement in Sweden as, for example, in the USA, where many states have legalised medical marijuana, Nanne is not alone in believing cannabis to be therapeutic. In one notorious case from 2014 to 2015, Swedish tattooist and young father Jens Waldmann was charged with and found guilty of growing and using marijuana to treat his chronic depression. He was given a conditional sentence with community service, but has since continued to advocate for cannabis use, considering a career as a “cannabis influencer” (Höglund 2021). Like Nanne, Waldmann contests the belief that a healthy lifestyle as a member of a well-functioning society would not be compatible with the particular kind of drug use he would like to engage in. Waldmann compares himself without cannabis—someone who is depressed and cannot function, who only wants to sleep and is unable to work, regardless of whether he takes the benzodiazepine sedatives his doctor has prescribed him—to a well-functioning marijuana smoker who has no problem working and sleeping. Waldmann’s final words in a pre-trial interview with Jnytt, the online version of local newspaper Jönköping Nu, were: “I just wonder what society would gain from me going to prison…” (Johansson 2014; see also Foltmar Elfton 2014).

Neither Nanne nor Waldmann questions the paradigm of taking responsibility for one’s own health: what they want is to create new distinctions within that paradigm. They compare responsible personal drug use to other types of use. In the Jnytt article, Waldmann calls himself “a normal, functioning human being and parent” who is afraid of “being written off as a junkie” and “lumped together with addicts” when he goes public with his use. His goal, in other words, is not to question the stigma attached to “junkies”, but rather to redraw the boundaries of the concept itself. He argues from a socioeconomic perspective, focusing on health and the image of a well-functioning human being who happens to also use cannabis—the opposite of the junkie. Waldmann says that he is ill but that cannabis makes him better, not that it turns him into a junkie. In other words, both Nanne and Waldmann prefer cannabis to the medication offered by doctors, for the sake of their own health and thus also for the good of society.

But while cannabis is hotly debated in the media, other debates are drawing different lines between medicines and harmful drugs.

2.1 Illegal Chemicals

The discourse on cannabis as a natural rather than a chemical medicine is just one of many blurred lines when it comes to the healing properties of illegal drugs. Boel, who, like Angela and Madelene, uses drugs both to function and to lose control, distrusts the SSRIs she has been prescribed for depression. She says:

I once got a prescription for Zoloft [a common SSRI] about twelve years ago. Felt like crap and quit three days later. “What is this shit?” They went: “Yeah, but here are five other meds to counter the side effects.” I don’t have to deal with that when I buy MDMA.

She not only questions her medication’s ability to help her, but also raises its side effects as a negative factor. Medicines are thus portrayed as both bad and harmful, and their side effects, in turn, serve as starting points for increased medication needs. But Boel’s arguments are not about chemistry. She sees MDMA, which, like SSRIs, is produced in a lab, as more effective than SSRIs and free from side effects. I ask her what her take is on consuming chemical products.

it depends on the way you look at it, whether you view the chemical as something that contaminates your body. Then it’s an attitude. Then it ruins the effect of the chemical. The way I see this chemical is just that it stimulates other chemicals in my body, makes them react in a certain way.

So Boel sees MDMA as a chemical product that stimulates substances that are inherent to her body, which is different from how she views SSRIs. What she calls “an attitude” could also be described as her bodily starting point, from which she then embarks upon a journey in a certain direction. Her use of SSRIs is part of a system, in which she needs to submit to being labelled ill and being prescribed whichever medicines her doctor selects for her. MDMA, on the other hand, is something that she—who is capable of committing a crime and getting in touch with the drug market—buys herself. The line she draws is based on the attitude that she does not need anyone else, and differs from another line she finds less appealing: allowing herself to be labelled and medicated.

Submission to control and responsibility for self-monitoring, Skeggs argues, is fundamental to how class has been constructed historically and how class positions continue to be defined (2004, p. 178). The ideal “optimizing interested self” is expected to be in control of itself and has to manage its resources in a way that strengthens its individuality. So Boel defines her class by making her own assessment as a healthy and rational person, and thereby avoids the control to which she would have been subjected as part of a pathological group (Skeggs 2004, pp. 10, 20, 73ff.).

MDMA can also be intoxicating, producing hallucinations and feelings of euphoria (Iversen 2012). This could be another reason why Boel feels MDMA serves her better than SSRIs, which do not have any intoxicating effect. However, even if illegally acquired products did not get her high, Boel would still rather use them to be able to cope with work when she feels bad. She tells me about the way she handled a difficult period by taking micro-doses of ecstasy.

Boel::

I’ve micro-dosed both ecstasy and acid [LSD]. I micro-dosed ecstasy last winter, when I was completely swamped at work. And I was forced to keep my shit together even though everything was falling apart. […] One of my colleagues was fired, my boss had a breakdown, and I had to take on both of their jobs. And become, like, my own colleagues’ boss. And, I went home and cried. [Sad voice, thinking back] And then I realised like, okay, how am I going to do this? [Happy, hopeful voice] I’ll micro-dose.

Emma::

Okay. Did it work?

Boel::

Yes! It went really well.

Emma::

Which worked better?

Boel::

E [ecstasy]. Definitively. For sure. Acid makes you a bit more withdrawn. […]

Emma::

How much is a micro-dose then, give or take?

Boel::

Hard to say with E. […] I crushed it, into extremely small pieces. Tiny, tiny, tiny, just such small bits it was like… dust.

Emma::

But it still had an effect on you?

Boel::

Mm. Absolutely. It stops you from… from being so easily thrown off. I became a little more stable.

Emma::

All day long?

Boel::

All day long.

Boel thus describes how micro-doses of ecstasy, in portions so small that she describes them as grains of dust, helped her during working days when she was under great pressure. The route she chooses, which becomes an embodied experience, from the acquisition to the end of the working day, is different than if she had chosen to go to a doctor for help with stress management. The who-question is thus linked to the what-question, even though the “forness” of the substances, to address depression, may be the same. The deviant line does include breaking the law, but she is never identified as sick and copes with her workload as a “stable” and capable self. The chaotic working conditions, under the influence of an illegal grain of dust, cannot disturb her. In other words, illegal drugs become preferable according to the neoliberal paradigm of taking responsibility for one’s own health.

2.2 Performance Enhancers

Healing or drugging (in the sense of wanting to become intoxicated in a way that does not increase one’s self-control) are thus not the only two possible “fornesses” of medicines and drugs. The “forness” that Boel calls micro-dosing refers to the way in which certain psychoactive substances can be used as cognitive performance enhancers, also called nootropics. This is a “forness” that has an unclear boundary with medicines. Is it a deficiency that is being corrected, or something that enhances a completely healthy person’s ability? What do illness and health mean? A fourth “forness” in turn complicates the boundaries between intoxication and performance enhancement. Pernilla describes the effect of amphetamines and cocaine when she is out dancing: “you become awake in a different way, it’s more like a heightened reality in some ways”. When the intention of drug use is to sharpen the senses in a pleasurable, intoxicating experience, the difference between what could have been helpful for pilots flying long distances, for example (Iversen 2012), and what is taken for pleasure, is the difference between a performance-enhancer and a drug. Again, the change in what also becomes a change in who. Is it a worker or a party-goer who is using the substance?

According to some researchers, drugs that can increase concentration, boost self-esteem, reduce fatigue and/or create other changes are becoming increasingly popular as cognitive performance enhancers (Schifano et al. 2022; Lanni et al. 2008).

As problems are increasingly treated with psychopharmaceuticals—in Sweden, prescriptions for antidepressants increased by 32% between 2010 and 2022 (Swedish National Board of Health and Welfare’s statistical database at socialstyrelsen.se)—even people without any documented psychological issues have become interested in enhancing their brain functioning. Products used to improve performance include prescription-free herbal remedies sold at health stores, medicines prescribed to patients with established concentration difficulties (including amphetamine-based or amphetamine-like products like Ritalin, Concerta, Medikinet and Elvanse, among others), illegal drugs such as micro-dosed LSD or ecstasy, and amphetamines, either illegally produced or prescribed by a doctor but then sold on to others seeking to stay awake for many hours, for example (Lanni et al. 2008; Ragan et al. 2013). Antidepressant medication too, like SSRIs, can be seen as performance-enhancing, because it can improve well-being and boost performance, for example by improving concentration and regulating sleep, even if that person is not suffering from depression (Lanni et al. 2008).

Lanni and her co-authors conclude their review of different studies on the (often dubious and/or unresearched) cognitive effects on healthy people of both legal and illegal substances with a rather agitated appeal. They suggest that researchers embrace the possibilities of pharmaceuticals to modify people’s mental capacities and conduct more research in the area.

Perhaps it is time to face with an open mind the fact that our mental abilities are at least in part based on biochemical reactions amenable to pharmacological modulation. If we are willing to benefit of this possibility without harm, serious researches and study programs under the Control of national research agencies have to be implemented in this field. (pp. 209–210)

These researchers argue that, because the use of performance-enhancing drugs is already so popular—despite the uncertainties of a poorly controlled legal market and an even less controlled illegal market, and despite the fact that the little research that has been done has often shown questionable results—research institutions need to take responsibility and pave the way for a regulated market.

Ragan et al., who conducted a review of studies examining the prevalence and efficacy of various substances used for performance enhancement, disagree with Lanni et al.’s argument. They argue that neither the extent of people’s use nor the effects of performance enhancers have been sufficiently investigated to conclude that their use is widespread and increasing. In addition, they argue that the risks associated with cognitive enhancement drugs make it unlikely that research institutions would invest in the ethically controversial development of drugs that do not serve a medical purpose (Ragan et al. 2013, p. 592).

The claim that even people without a diagnosis might be very interested in cognitive modification is in line with Rose’s theory that humans view themselves as neurochemical beings who have adapted themselves to a neoliberal world order (2003). Lanni et al. appear to want to present this new subjectivity as a reasonable starting point for the scientific community’s future research. But the very fact that people’s mental capacities can be chemically altered leads to existential questions about human beings’ relationship with their bodies. To what extent can psychoactive substances be added to the body without “taking over”?

In her cyborg manifesto, Donna Haraway posits the post-humanistic idea that technology does not have to be scary and coercive: it could instead be a prerequisite for subversive opposition to the neoliberal order (1991, pp. 149ff.). She writes that we do not need to either dominate or deify technology because it is already part of our bodies, part of what it means to be human.

A cyborg body is not innocent […] Intense pleasure in skill, machine skill, ceases to be a sin, but an aspect of embodiment. The machine is not an it to be animated, worshipped, and dominated. The machine is us, our processes, an aspect of our embodiment. (ibid., p. 180)

If the drug-using body is interpreted as a cyborg—part human, part technology—among other cyborgs who do not know what it means to be human in any other way than in symbiosis with technological solutions, then the use of psychoactive drugs does emerge as a possible adaptive tool in line with a neoliberal world order. Amphetamines as a tool to stay awake and make it easier to endure monotonous tasks can, for example, facilitate night work and long working days (Iversen 2012), or make it easier to clean the house (Campbell 2000). At the same time, using medical technology could be an act of resistance: a way of trying to stretch the cyborg’s limits and expand its capacities, rather than submissively adapting to life in a neoliberal world. Haraway compares the cyborg’s technological features to potent growths on injured bodies:

For salamanders, regeneration after injury, such as the loss of a limb, involves regrowth of structure and restoration of function with the constant possibility of twinning or other odd topographical productions at the site of former injury. The regrown limb can be monstrous, duplicated, potent. We have all been injured, profoundly. We require regeneration, not rebirth. (1991, p. 181)

Haraway calls the desire for rebirth a hopeless and sentimental longing to return to a state that never existed. The subversive power is instead found in regeneration, in rebuilding the body from its broken condition. This is an optimistic perspective on neurochemical creatures’ potential in a neurochemical world: while Rose’s Foucauldian analysis paints a picture of patients in the hands of the psychiatric care apparatus, Haraway gives the guilty, monstrous cyborg, the medicating patient–subject, a power of action based precisely on its fusion with technology.

Rose sees the neurochemical world as a framework that determines the conditions under which subjects can understand themselves. Still, he argues that a freer psychiatric healthcare apparatus, in which patients have a greater say and care is largely provided within patient groups, would reduce demand for medication (2019, p. 186). But I perceive his description of people as neurochemical subjects as contradicting his claim that—as long as conditions, that is: the world, remained unaltered—patients would not want as many psychoactive substances if they were able to decide for themselves. Boel’s narrative, as well as those of Angela, Madelene and Nanne, instead depicts a cyborg-like way of managing feelings and moods through drugs and medicines. Life sometimes brings these women anxiety and pain, but they also derive pleasure from their ongoing experimentation with different doses and products.

Researchers who advocate acceptance of humankind’s opportunities to enhance its cognitive functioning through psychoactive products because they believe there will always be a craving for these products reflect Haraway’s cyborg theory. But, while the benefits referred to in the article by Lanni et al., such as improved concentration and increased alertness, are predictable and in line with a neoliberal paradigm, there is an unpredictability in the potential of the monstrous cyborg. The “forness” of products can be multifaceted.

3 Legitimate Hedonism

Some interviewees refrain from using anything that could have any kind of curative and/or performance-enhancing effect. When I ask Pernilla whether she will be using performance enhancers in her new job, she answers with a slightly indignant laugh: “Fuck that [laughs], I’m not going to drug myself for work. I only do that for pleasure”. By saying this, she signals that she is healthy and does not need anything to “fix” her. She considers drugs a supplement that do not prevent her from living her life, as long she only consumes them on carefully selected occasions. She does not perceive the drugs she takes (mainly marijuana, amphetamines and cocaine) as health-promoting but as something that should only be used by a person who is healthy to begin with. This is also why she does not intend to “drug [herself] for work”. I interpret her statement as a political critique of a society in which people put their health on the line for the sake of their careers by striving to attain the ideal of “the optimizing interested self” (Skeggs 2004, p. 63).

For Pernilla, drug use becomes legitimate not because it functions as medicine; rather, she justifies it by asserting a healthy but risk-taking position. She links drug use with risks of physical and psychological harm, as well as relationship issues and dependency. Agnes, who enjoys amphetamines, also gives examples of how she adopts a conscious, risky position when she uses drugs: “your heart can stop beating and, the risk of schizophrenia is really high with amphetamines. […] your coronary artery can be torn, off […]”. For these women, taking drugs means subjecting themselves to something that could make them ill and therefore requires a healthy and responsible user.

Boel takes an approach that occupies a mobile position between those of Nanne, Pernilla and Agnes. For Boel, the drugs she uses (mainly MDMA and LSD) are both harmful and curative. She says that the daily micro-doses of MDMA have gotten her through difficult periods at work due to their medicinal properties, but that drugs also serve as an aid to “let go of control” and take a break from high-performance work. Thus, depending on the situation, she, like Angela, uses them both in order to be a more effective part of society and to revolt against it. She emphasises even more clearly than Pernilla that she sees herself as a strong person who can cope with drug use, and finds several ways to develop what it means to be a person who is neither a junkie nor in medical need of a curative substance, but rather a person who is capable of using a drug even though it might be dangerous. In the following excerpt, she describes both the kind of people who are suitable and the kind who are unsuitable to do drugs with, explaining that this suitability depends on whether someone takes drugs to fix a problem or to complement who they already are.

The right company is people who are not afraid of themselves. […] If they have a lot of issues and can’t even handle a beer, there’s no point in sitting there when they start taking other things. If they have a hard time at work, they have a hard time at home, so you know they’re not going to be comfortable. They’re going to be really annoying. [Thinks] Those people can often lose their footing a little in this nice feeling…. Or they discover the difference between their reality and this [drug buzz], and then they lose it. I… prefer to… be around people who just think everything about them is enhanced. “I become more of me and my surroundings become more of what they are.”

Thus, for Boel, it is about being healthy enough to handle drugs. If neurochemical subjects are required to manage their feelings with the help of psychoactive drugs, then the drug-using company that Boel avoids is described as having added something inappropriate when drugs are taken with a “forness”, i.e. evokes a sense of “feeling good”, when life without the drug is difficult. According to Boel, the cyborg should not replace something that is missing, but only desire more of what already exists. For her, “having a hard time” is a bad reason to get high. Yet, having a hard time might actually be a powerful incentive for a person to want to change the way they feel; some might even see it as an obligation to, as Angela puts it, “regulate oneself”. This results in a catch-22: those with the strongest desire to alter their state of mind are seen as unfit to use certain drugs.

Ahmed writes about the word “use”: how objects can be considered useful, such as doors and chairs, but in fact address a limited group, namely the people who have a suitable form and functionality to use those objects (2019, pp. 57ff.). Those who are unable to use the chairs and doors become “misfits”, they do not fit into the environment. In Boel’s description, the usability of drugs is limited to those who are mentally fit to use them, which seems difficult for potential users to determine since those who have a great need to alter their minds must refrain. Once a drug has been used, the person who used it reveals themselves to be “comfortable” or a “misfit” within the group. Thea’s analysis is similar to Boel’s; in a discussion about the hallucinogenic LSD, she says that she too feels it is inappropriate for someone to use drugs when they feel bad. But her story is based on her own experiences of discomfort and the way in which she herself takes responsibility.

you reinforce things in yourself, that’s what I mean, that’s why I’m precise and careful and cautious when I take something. Because, it can reinforce something bad. If you’re not stable and you feel bad, then it becomes difficult. The last thing you should do is take LSD or something, then you get one of those, monsters. Like your brain is on fire.

To prevent LSD from conjuring up monsters and setting the brain alight, the starting point must be stable when taking it. For Thea, such a starting point is about temporary states of mind when she perceives intake as appropriate, and the ability to use drugs in a rewarding way is about being able to judge when such occasions occur. Instead, Boel describes how she gets through unpleasant experiences by embracing them, and the ability to handle drugs is described as a permanent feature:

I never lose it in the sense that, like, I become one of those people who just want to flee […] On the contrary, I want to stay even more and really get into things. When I’m in it, I really want to know, feel that, I want to soak up all the beauty right where I am, sort of. And I want to see things just as they are, even the ugly, the awful – fuck, if it’s awful I want to face that it’s awful.

Boel describes herself as someone who is unswayed by the shifts in the high of the drug from beauty to ugliness, reality to euphoria. In such representations, a weak person who feels worse by using drugs is contrasted with an image of a strong and capable drug-using person. To be fit to use drugs, someone who uses them needs to be in such good health that they can handle something that could harm others. They exist at the far end of a scale that ranges from the vulnerability of a junkie to something that, in Boel’s description, resembles invincibility. Thea, on the other hand, suggests that the ability to avoid vulnerability is more about being able to determine whether one is sufficiently invincible from the start to be fit for drug use.

4 Responsibility for Oneself

But are they really talking about invincibility? Because I interpret their quotes as an aspect of their significantly more apparent and oft-referred to fear of “getting hooked”, “losing it”, and being out of control. Their words can be interpreted as an expression of hope that the strategies they employ—scheduling when they use drugs, choosing the right drugs, their attitude to drug use, etc., in other words: taking responsibility for their own lives—will suffice to make everything go well, and an expression of gratitude when, looking back, things did indeed go well. Even Boel and Katy, the two interviewees most intent on constructing images of themselves as strong women, describe unpleasant situations in which drugs made them feel bad. They give detailed accounts of how, on these occasions, they took responsibility for the situations. Katy explains that she can hear the voice of a psychologist friend in her mind, reassuring her when she reacts with fear during a cannabis rush. She lets her friend guide her, while also telling herself more brusquely to snap out of it:

And then it’s like I hear her, inside of me, “let’s take a deep breath now”, and then I identify: “what is it I’m feeling?” Where I think it’s coming from. Why it’s affecting me right now. I guess I always have a pretty open inner dialogue […] it’s probably a combination of my need for control, that I have to go “okay, now you’ve got to calm down.” Kinda. “You’re gonna take this one step at a time, and then…” It can happen sometimes, because everything’s different, some [drugs] are stronger than others, that you smoke something and you’re like “oh Christ, what was this?” You know. But… then I can also just [tell myself] “this will soon be [over], just wait an hour and it’ll disappear”. So… I’ve got my strategies.

Katy describes a strategy that is a combination of an understanding attitude towards herself and strict self-control that does not allow any frightening feelings to take over. Boel too describes a mixture of understanding and control when it comes to dealing with the days after she has taken MDMA. Once again, she emphasises the importance of being a person who is capable of taking MDMA; her words are a lecture on how to understand and handle the comedown:

It's also important, I think, to inform your, the people you’re closest with of how you’re doing during those days. So you get the support you need. That’s really important, I think. And that you don’t get anxious, you know I think that when drugs are associated with anxiety or childhood taboos, then you should really stay away from them because then you’ll just feel bad during those, days. But if you don’t have that then it’s… You’re… a little, sensitive, you’re a little exposed. You’re kind of like you don’t have any skin, like all your nerves are on the outside, sort of. And of course you might, start crying and you might feel bad and you might get angry but that’s just when you don’t, play along. You’ve got to understand that, the days after you do drugs, the drugs are playing you. And you’ve got to keep up.

These quotes from Katy and Boel reveal that it is not just the (mental) health of the person who uses drugs that matters: they also see friends who are therapists, friends who are understanding, a good childhood and the means to hide out from the world as prerequisites for being able to weather the unexpected effects or aftereffects of drugs in a good way. Not having any skin, as Boel puts it, paints a picture of an extremely vulnerable state that requires a special setting. This highlights once again how class matters for their ability to handle drug use. Social and material vulnerability and a starting point as a member of a pathologised social group, as Skeggs describes the conditions of the working class, is a radically different points of departure for a skinless person who feels exposed than if that same person had been in a strong position and able to designate a space to sit out their temporary vulnerability. But, instead, the women seem to interpret the life circumstances of people who use drugs as personal mental abilities. Without professional advisers, temporal and spatial locations that can make it easier to cope with feeling skinless, and the freedom to wait for unpleasant states to pass, the person who uses drugs seems to run the risk of being judged as mentally unfit to use them.

Tales of personal strength and of coping with the effects of drugs are told in a way that depicts the interviewee as taking responsibility. Thus, the interviewees express acceptance of the paradigm of individual responsibility for one’s health, presenting it as an argument for their right to use drugs (cf. Rödner et al. 2007, p. 52). Someone who fails to take responsibility should not be using drugs, they claim. Responsibility entails knowing the effect that these substances will have and how one’s body and mind will react to ingesting them. However, this is often not possible, for several reasons. One is that illegal substances tend to be unregulated, which means they may contain unwanted ingredients and it can be difficult to get the dosage right. This is different from alcohol and regulated medication. Another reason is that the effects of psychoactive substances can differ depending on the consumer’s state. In addition, a reasonably pure version of any particular drug must be tried before the person who uses it can know anything at all about how they react to that drug. Responsibility must, therefore, be temporarily released and replaced by the hope that things will go well, if drug consumption is to take place at all. This hope relates partly to the quality of the drugs, but, as Katy explained, varying quality can be an acknowledged factor—“sometimes you smoke something and you’re like ‘oh Christ, what was this?’”—that people who use drugs need to be able to handle when things do not go as planned. Responsibility, therefore, ultimately appears to be about possessing personal qualities that become an expression of a self with the capacity for self-monitoring (Skeggs 2004). But it is also about access to tools and conditions. The person who uses drugs must not only have the knowledge needed to choose the right drugs at the right time and limit their intake, but also have the right background, as Boel described it: “if drugs are associated with anxiety or taboos from childhood then you really shouldn’t use them”. Being able to handle the drug in a good way, such as managing a period of not having skin, is thus a matter of having access to a web of resources.

For these women, the legitimacy of drug use and pharmaceutical use is about the directions they have taken and how the preparations take shape from there. But these directions are often ambivalent; the drugs’ “partiality” (Ahmed 2019, p. 35), i.e. their multiple meanings and uses, mixes up intentions and transforms the women’s starting points into questions about who they are. Blurred boundaries between drug users, patients, professionals and pleasure-seekers make the judgements about what, when and how to use important positions that construct the self. Both from a healthy and a sick position, “the optimizing interested self” can be something to strive for or to oppose. The women are navigating through a psychopharmacological society (Rose 2003) with a sense of responsibility—a responsibility that is about assessing, in advance, the ability of one’s brain and of products to align themselves with one’s chosen directions.