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<p>Methadone: Six Effects in Search of a Substance Author(s): Emilie Gomart Source: Social Studies of Science, Vol. 32, No. 1 (Feb., 2002), pp. 93-135 Published by: Sage Publications, Ltd. Stable URL: http://www.jstor.org/stable/3182979 . Accessed: 10/05/2011 10:29Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unless you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you may use content in the JSTOR archive only for your personal, non-commercial use. Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at . http://www.jstor.org/action/showPublisher?publisherCode=sageltd. . Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed page of such transmission. JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.</p> <p>Sage Publications, Ltd. is collaborating with JSTOR to digitize, preserve and extend access to Social Studies of Science.</p> <p>http://www.jstor.org</p> <p>SSSABSTRACT What is the difference between heroin and methadone? Isthis difference one of interpretation, where an 'opiate-like' substance is 'labelled' differently through social processes that arbitrarilydescribe methadone as 'legal' and 'therapeutic', and heroin as 'illegal' and 'harmful'?To study the nature of this difference, I follow two experiments in the United States and in Franceof methadone substitution, where medical practicesattempt to replace heroin by methadone, and thereby to reduce the user's (illegal) drug use. In these trials, the experimenters ask preciselythis question. The question of the nature of the difference between the substance's actions is further illustrated by the comparison between the substitution trials:when the experimenters describe methadone differently in different places and times, do they 'interpret'the drug differently, or is the drug itself different? I show that far too many elements vary from trial to trial to say that the 'interpretation' of the substance is all that varies. In order to explore the variation in detail, then, I draw on works about 'performance',and on the actor-network 'theory of action': what heroin and methadone do, but also the very way in which they 'pass into action', is what varies in each trial. In the end, this question about difference is a question about action. In each trial, there is not from the start one substance with fixed or vague properties which one can then interpret in various manners. 'Substance'does not contain inherent actions from the start ('properties').Rather,following the experimenters, it is possible to say that 'effects' are primaryand that only at the end of the trial do the experimenters laboriously 'find substance' to effects. Keywords drugs, experiment, history,mediation, pharmacology</p> <p>Methadone: Six Effects in Search of a SubstanceEmilie GomartThe Loss of SubstanceSince the mid-1960s in the United States and the 1970s in Europe, addiction treatments have included a treatment called 'methadone maintenance' or 'methadone substitution'. In these treatments, methadone (an opiate-like and addictive drug) has been offered in medical settings to opiate drug users in an effort to eliminate or reduce their use of other(illegal) drugs. Numerous commentators (often sociologists) have remarked that such a treatment comes down to the replacement of one illegal drug (heroin) by another (legal) drug. They suggest that any difference between the two drugs, methadone and heroin, is one of social 'interpretation' orSocial Studies of Science 32/l(February 2002) 93-135 ? SSS and SAGE Publications (London, Thousand Oaks CA, New Delhi) [0306-3127(200202)32:1;93-135;024027]</p> <p>94</p> <p>Social Studies of Science 32/1</p> <p>'labelling'. One is 'legal', medically controlled and taken to be 'therapeutic', whereas the other is 'illegal' and 'dangerous' when, according to these critics, nothing about the substances themselves justifies such an opposition.1 What then is methadone? What does it do? What is the nature of the difference between methadone and heroin? Is there a difference of substance or only of interpretation? These questions are clearly not simply academic ones. They have sparked heated debates among drug treatment practitioners as well as sociologists. In this paper, I will explore these questions by focusing on two experimental trials of methadone substitution. Not only does each experimental report describe the difference between heroin and methadone in different terms, it is striking that they also describe a different methadone. In 1965, in the report of their first trial at the Rockefeller Institute,2Vincent Dole and Marie Nyswander write that methadone is a 'medication'. Its effects are dramatic and, when dispensed in a medical setting, clearly different from the effects of heroin. Methadone blocks drug-craving and returns the user to a useful social life. The second report, arising from the first French experimental trials of methadone, at the Sainte-Anne Hospital in Paris, published in 1975,3 describes methadone as too similar to heroin to be a medication, for most patients. Methadone is only rarely therapeutic; it does not cure but is very instrumental in 'revealing the psychopathology' of the drug user. It is a therapeutic tool for psychiatric diagnostics. What is the nature of the difference between heroin and methadone, and between these two methadones? Is the difference located at the level of the interpretations? Or is it a question of substance? Are there two distinct methadones? If we take each experimental report as equally valid, as the experimenters do when (as I will show) they cite each other's works, how are we to reconcile the multiplicity of accounts with what we might expect to be the unity of substance? What varies, what remains constant? Would historians (experts, one would think, on what varies and what remains constant, reversible and irreversible) provide a first insight? There are strikingly few histories of drugs. Why this silence on the nature of the difference between drug effects? If drugs have not been a common topic for historical work, does this not suggest that, for these authors, drugs are outside history? 4 That drugs are a-temporal? Are drugs then so evidently different in nature from humans caught in the rush of events, of human passions and labour?The recent collection of historical writings on opiates edited by Roy Porter and Mikulas Teich,5 was an explicit attempt to attend to the lack of a history of drugs. However, neither of the two kinds of historical approaches to drugs found in this book relinquishes the assumption that drugs are non-temporal, un-changing while human uses and strivings are historical and temporary.6 According to a first historical approach, diverse accounts of a drug should be classified in chronological order, with each account progressively converging upon the true properties of substance. For example, according to Andreas-Holger Maehle,7 the historicity of a drug is produced by the</p> <p>Gomart: Methadone: Six Effects in Search of a Substance</p> <p>95</p> <p>progressive discovery of its action. Maehle describes the debates about opium in the 18th century, focusing on the evidence found in the contemporary 'trials' and 'control experiments'. He describes the ensuing progressive establishment of opium's 'mode of action' and 'pharmacological' activities. He uses modern concepts of the recent field of (psycho-) pharmacology and the latest criteria for 'good' scientific experiments to evaluate the progress of experimenters in the 18th century. He uses a late-20th-century pharmacological epistemology of science to describe an object in the 18th century. Thus, it appears from his analysis, the object, the natural world, is stable through time.8 Only descriptions change. In this analysis, there is no room for 'new' properties of a drug: there are not different methadones, only newly-discoveredproperties. The whiggish character of this analysis might be condemned. Alternatively, it might be taken to emphasize the recurrent difficulties met by historians of drugs. Indeed, it points to the fact that when writing about drugs, the analyst must implicitly or explicitly answer several questions: Does the drug really do different things at different moments in history? Is it different or is it made to act differently? Is it discovered or constructed in different ways? If it is a construction, does a durable substrate 'manifest' itself variously or, more radically, does a drug have a 'propensity' to exist in different ways? 9 A second path traced by Porter and Teich's historians of drugs is to suggest that diverse accounts are social interpretations of a fixed substance. For these historians, the uses and interpretations change, but the substance is a fixed substrate that can never be accurately represented (particularly not by a historian). Caroline Acker tries this approach.'1 She focuses on the transformation of the place of opiates in the toolkit of doctors from 1840 to 1940. Thus, instead of importing her own epistemology, her topic is the epistemology of opiates during that period. However, her study prudently restricts itself to the realm of the social and cognitive frames of the scientists. Even as Acker describes in great detail the technical transformations of the dispositifmobilizing the drug,11 what varies for her is the human handling of opiates. At no point is there any suggestion that the substanceitself might vary in history. The dichotomies set up by essentialists' and social constructivists' analyses rig historical descriptions of drugs. They force a choice between two kinds of explanation, which focus either on objects themselves or on human actors. Essentialists root for a substance with discoverable attributes always already there, invariable, irreversible.They shove outside their focus the impure construction of that entity, its uncertainties and contingencies. In contrast, social constructivists assume that the world of objects is fashioned by humans who project on to it representations which have no necessary correspondence with the object itself. They are blatantly silent about the question of the reality of the object and write only about human constructions. In their accounts, then, these constructions are what varies.</p> <p>96</p> <p>Social Studies of Science 32/1</p> <p>between these approaches to drugs, but rather It is not the difference their common points, that is the crux of the problem. Both these (historians') paths suggest that the substance itself is that which by definition does not change. The substance is given and constant. It is only what people do, know or claim which can vary. Nature remains, the human world rushes on.12 These two approaches, however criticizable, clearly designate the problem to be surmounted before one can empirically address the question of what changes and varies: the a priori assumption is that substance is outside history. What it is and does will remain stable no matter what ingenious trials it is made to react to. The critique of methadone (mentioned in my introductory paragraph) shares in this assumption: what the substance is and does 'pharmacologically' is a constant which might be interpreted in various ways (action -&gt; interpretation). At the bottom of this problem of the a-historicity of substance, is the question of action: is a substance this cause it is made out to be, fixed and pre-given, the screen of projections, the basic stuff for manipulations? That which comes first and remains? The first task here, then, is to transform the shape of the problem: rather than being obligated to choose between humans and drugs as the source of variation of drug 'accounts', it is crucial to exit from this situation of forced choice. Social constructivists locate variation in the freedom of the subject to act (interpret, use) in varying ways; essentialists also locate variation in the subject's (more or less accurate) descriptions, but insist on the stability of the actions of the drug. The price to pay for the exit from the social-constructivist/essentialist dead-end then is the following: reworking anew and head-on the question of how the drug and its user, nonhuman and human, act. Ethnographers have documented the ordinary actions of drug users. Often inspired by the symbolic-interactionist tradition,13 these ethnographies indeed describe with great subtlety the 'uses', 'careers' and the ordinary daily actions of drug users. They emphasize the multiplicity of drug 'uses'. One common aspect of these studies is that they aim to demonstrate that drug use is not (psycho- or socio-) pathological, and therefore need not be explained aetiologically, as the expression of a cause within the subject. These studies on 'careers' claim to deploy non-deterministic theories.14 However, they focus on the human subject, his/her social skills, adaptability, situated rationality, but do not ask the question of the ontology of substance. They do not tackle head-on the question which preoccupies me: if there are multiple forms of use (many or all of them non-pathological), as they insist, is the difference between the 'heroins' described by those they interview a difference of interpretation or of substance? (More about these approaches below.) To help us understand the nature of the difference between accounts of methadone, one needs allies who have directlyaddressed the question of the nature of action of humans and substances. Two allies can be mobilized: the first is perhaps unexpected, the second familiar.</p> <p>Gomart: Methadone: Six Effects in Search of a Substance</p> <p>97</p> <p>The first are pharmacologists studying drug effects and, in particular, those experimenting with methadone (for example, the Dole/Nyswander and French/Sainte-Anne teams). They are 'unexpected' allies because they are natural scientists. We might indeed be tempted to think (after the sketch I have given above of the difficulties in studying substance) that the problem of reconciling a multiplicity of accounts with the unity of substance is an artefactof the human sciences: sociologists and historians see different (descriptions of) objects when there is only one; natural scientists, one might assume in contrast, reveal the artificiality of this problem when they effortlessly select from all these accounts a single and scientific one. This argument is refuted by one salient fact:...</p>