Emile Gomart - Effects

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 10:29
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ABSTRACT 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
Methadone: Six Effects in Search of a Substance

Emilie Gomart
The Loss of Substance
Since 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' or
Social 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]
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Social Studies of Science 32/1
'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
Gomart: Methadone: Six Effects in Search of a Substance
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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.
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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 -> 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.
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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: even chemists and pharmacologists offer divergent accounts of what methadone and heroin are, and they are not quick to agree about the nature of these differences. They quarrel about these substances' different properties, and do not fix upon, once and for all, what exactly is durable and what is not. As I will show below, even though the American substitution trials were considered authoritative by the later French experimenters, the latter did not just 'import' an invariant, pre-defined, taken-for-granted substance into their practice. They were not content with projecting on to a stable substrate new interpretations, or engaging 'it' into new uses. They do not in their practice begin with a priori distinctions between what is reversible/irreversible, substance/ interpretation. They do not take for granted that methadone and heroin are different substances, and that this difference endures. Rather, I will show, the French methadone experimenters cannot help defining methadone and its difference with heroin all over again in flowery objects, gestures, skills which make any comparison with the American methadone extremely difficult. The sheer multiplicityof differencesmakes it impossibleto hold that substanceis constant, whereasinterpretations vary. I take these experimenters to be allies (or 'colleagues') because, for them too, the question of what is 'substance' and what endures, is precisely the empirical question posed in the experiment, rather than taken for granted at the start of the trial. To follow these first allies, the substitution experimenters, into the intricacy of their experimentations on action, I have another group of colleagues: science studies authors concerned with devising a new vocabulary for describing action in terms which exceed the constructivist/essentialist dualisms. Three points on action have been made in this literature, and I will try to reproduce them in what follows. A variation on the third point will be mine. 1. From Stable, HomogenousEntity to Heterogeneous Networks: Rather than attempting to describe entities in terms of what they 'are' (a description caught in requirements of accuracy, mimesis, correspondence),
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Berg's example, the focus shifts towards the 'the techniques in the laboratory and at the bedside of recording, perceiving, writing'.'6 Scientific entities then are coextensivewith an entire network of practices. The entity as 'network' does not have fixed contours; rather, these fluctuate with the extension and transformations of the network. This shift has the advantage of detouring the opposition of belief/reality, which had fixed a priori what can change (the former) and what could not (the latter). It is a first nonessentialist/social constructivist focus on what occurs. 2. From Entities with Pre-Given Propertiesto 'Performances' 'Dispositif': and Science studies authors describe entities as 'performed by' specific trials and associations. They also describe how entities 'perform' others (for example, how the patient is performed by a certain treatment). Since these entities are not what one begins with but what gets constituted (to use another term) through the practices, the focus switches to these actions that localize, temporize, embody, subject, 'frame' them."7 Even entities which had seemed indivisible, foundational, are shown to be achievements, shaped in and through practices.18They are not taken to enter a set-up as entities already possessing traits. The subject, for example, does not exist outside of and before the schools, army barracks and other disciplinary routines which produce it. The set-up or dispositifis crucial in the production of these entities. It does not corrupt an original identity of entities, but rather is just what allows them to achieve an autonomous status. The 'specificity' of humans and nonhumans is produced through, emergent only in these settings.'9 The second non-essentialist/social constructivist move, then, is the focus on the dispositif.20 3. FromAction to Mediation, Emergence,Effects: For this literature, the shift to the 'performance' of entities has meant a To focus on the exact meaning of the 'construction' of entities in a dispositif. say that the drug is a 'construction' or 'achievement' forces the analyst to reflect on the weight of the techniques, the biases of the experimenters and the social context, in producing the end result. Actor-network theorists have searched for words that might allow that 'construction' is not a mere addition of forces, the sum of the 'input' into an experimental setting. They do not want to say merely that the dispositifeither 'determines' or 'reveals'. Terms like 'mediation', 'emergence' and 'event' offer alternative descriptions of what occurs during an experiment. These terms challenge what these authors call a 'traditional theory of action' - that is, what they take to have been the obstacle to social analyses of experiments, and what perpetuated the a priori dualism of essentialism/social constructivism. This entails two subsidiary points: Action does not have one source:action is delegated or passed. Thus, for example, the artefact designed by an engineer 'prolongs and deviates from' his/her plan. The excessof the action is crucial, as it allows both
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that action can be an innovation and that this innovation cannot be explained by its source. The focus shifts away from the interior of objects (which are discovered as they always already were) to 'what emerges'. Again, emergence is described by referring, not to agents (which would ensure that the description be about the sum of predictable actions), but to 'that which lets/makes happen',21 and this 'that which' is the dispositif. Since action does not have a priori a source, the attributionof a sourceis an achievementwhich has to beperformed post hoc, and with much labour. The smooth traditional course of action (source -> action) is cut up into two moments: a) a first moment of 'indetermination', where a multitude of elements ('actants'),22 are transformed and swap properties, and where it is impossible to say 'who acts'; and b) a second moment when much effort has to be spent in order to say 'who acted'. There is a moment in the course of action when the question of the identity of actors (who they are, what they are capable of) has not yet been posed.23 Only later will there be a time when it finally becomes possible to say that it was methadone that acted and that it has inherent properties. An action cannot be explained by the nature of its source; rather, the source is a post hoc achievement. To use Bruno Latour's words, 'causality follows the events and does not precede them'.24 This third point then focuses on the quality of the constructionwhich occurs in the dispositif(what kind of construction unfolds there?), as well as on the actancy of the object which emerges from it (does it in the end emerge as a cause with inherent properties?). Dispositif and Action
My problem now has been transformed. Drawing on the work of these allies, it becomes possible to say that one does not have to choose between interpretations and substance to explain the difference between heroin and methadone, or between the French and American methadones. Instead, I can focus on the dispositifsand the actions. In this paper, I will try to reproduce these three steps. In particular, I will insist on the moment of 'indetermination' described by actor-network theorists. I will describe how the experimenters lose substance. Substance becomes what they search for in the end, not what they begin with. More specifically, following the experimenters in the American and French trials, I will show that substance is not an essence which, from the start of the trial, possesses a series of properties from which it is possible to deduce what it will do (substance -> predictable action). Neither does it follow the traditional sequencing, common to essentialists and social constructivists (pharmacological action -> inter-subjective interpretation). Rather, I will suggest, the experiments begin with performing what actor-
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network theorists have called an 'effect', and only later do the experimenters laboriously search for the source (that is, the 'substance') of these effects. The direction of the arrow is reversed (effect -* substance), as the meanings of 'substance' and 'effect' are thoroughly transformed. This paper will attempt a variation on the third point. Many studies have described the 'mediations' of human and nonhuman entities, and insisted upon the difference between this mediation and what is expected from the point of view of a traditional theory of action. However, little attention has been paid to different modesof mediation.25 Does the dispositif always 'perform', 'mediate' in the same way? Can the object (that emerges in the end) be something else than a (constructed) cause? I will propose that the difference between the American methadone and the French one is not a difference of interpretation, nor of substance. Rather, the respective dispositifs(and the methadone produced in the end) 'mediate' in two different, un-traditional ways. The literature I mobilize, then, is concerned with action, rather than with drug use per se. I briefly mentioned that ethnographies of drug use do not address head-on the question of what endures or varies, which is crucial to defining the nature of the difference between, in my case, an American and a French methadone. Howard Beckeron Drug Use and Drug Action Let us take a close look at one example, Howard Becker's classic statement on 'careers of drug use', a recurrent tool for many ethnographies of drug use, to demonstrate the problems posed when this question is not topicalized. In his book Outsiders,Becker writes that his symbolic interactionist study seeks to describe marijuana use without referring to a supposed (medical, moral, psychological) pathology of the user. Attempts to account for the use of marihuana[sic] lean heavily on the kind of behaviourin an indipremisethat the presenceof any particular vidualcan best be explainedas the resultof some traitwhichpredisposes or motivateshim to engage in that behaviour.In the case of marihuana use this trait is usuallyidentifiedas psychological,as a need for fantasy cannotface. [42]26 and escape from psychological problemsindividuals In contrast, Becker seeks to describe deviant behaviour not as something already contained within the nature of certain persons, but as a developing behavioural pattern which follows a gradual sequence of changes in an individual's perspective and behaviour ('carriers') as he learns from and communicates with a deviant group. Anyone might then, if s/he went through these stages, become 'deviant'. What are at stake then are practices, rather than inherent qualities of the person. Becker's work, then, avoids the determinism implicit in medical and psychiatric definitions of deviance by discussing, not the interior of persons, of but their 'behaviours' - or, better, the emergence deviant behaviour. In a move similar to those in science studies who went from entities to networks and dispositifs,the focus is shifted in Becker's study from fixed entities to
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the techniques and social practices which perform them. These practices constitute 'experiences', 'interpretations' and 'perceptions', categories traditionally taken to be pre-existing and contained within the individual human subject. In one of his striking formulations, Becker describes how deviant behaviour is not the consequence of deviant motivations; rather 'the deviant behaviorin timeproducesthe deviant motivation' [42: my emphasis]. Becker's theory seems to get rid of determinisms by making 'motivation' (in this passage) not the source of his action but the productof group processes and techniques. And yet a nagging problem remains. In key passages, Becker reintroduces traditional notions of how drugs act. For instance, in the sentence immediately following the last indented quote above ('Attempts ... face' [42]), he writes about a 'physical experience' which not only manifests itself first and at a physiological level, but can be analysed separately, before 'interpretation'. The 'traditional theory of action' where the drug is the source of action, and acts first, before interpretation, manifests itself in these passages. I quote the following passage in full to seize this unexpected ambivalence in Becker's analysis: ... Vagueimpulsesand desires... are transformed into a definitepattern of action throughthe social interpretation a physicalexperiencewhich of is itself ambiguous. Marihuanause is a function of the individual's and conceptionof marihuana of the uses to which it can be put, and this with the drugincreases. conceptiondevelopsas the individual's experience we [He sets up his study in two parts.] In thischapter, look at the develwith opment of the individual'simmediate physicalexperience marihuana. In thenext,we considerthe way he reactsto the various socialcontrols that havegrownup arounduse of the drug.What we are trying to understand here is the sequence of changesin attitudeand experiencewhich lead to the use of marihuanafor pleasure.This way of phrasingthe problem Marihuana doesnotproduce at addiction, least requiresa little explanation. in the sense that alcohol and opiate drugs do. The user experiences no withdrawal sicknessand exhibitsno ineradicable for craving the drug.The most frequentpatternof use might be termed 'recreational'. drug is The used occasionallyfor the pleasurethe user finds in it, a relativelycasual kind of behaviourin comparisonwith that connected with the use of Medicine Bulletin and addictingdrugs. [He cites an articlein the NewYork a New YorkCity Mayor'sCommitteeon Marihuana supporthis claim to that marihuana non-addictive.] using the phrase'use for pleasure',I is In mean to emphasize the non-compulsive and casual characterof the behaviour.[43-44: my emphasis] In this passage, Becker employs the term 'experience' in two distinct ways. The first (as in the sentence, 'What we are trying to say ...') refers to a category emergent through techniques and social practices; but the second is synonymous to a physiological (not yet consciously or socially interpreted) perception (as in the expressions 'immediate physical experience' and 'the user experiences no withdrawal sickness'). Thus, in the midst of a theory on emergent 'behaviour' and 'experience', there is another, quite traditionally deterministic, on the action of substances. The second might even be supporting the first. Indeed, why does Becker suddenly shift from
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an analysis of entities emergent through practices to a qualification of the nature of the drug itself ('marijuana does not produce addiction')? Is this the expression of a doubt about the capacity of a symbolic-interactionist analysis to be performed on the use of an addictive drug? Similar ambivalences emerge in other passages. For example, in a paragraph demonstrating that users do not use for pleasure unless they are first able to 'get high', the term 'effects' goes through a similar 'dedoublement'. The 'effect' of the drug refers to a collectively achieved perceptioninterpretation and also to a purely physiological action of the drug: Withoutthe use of some such technique[wherethe smoke of the drug is inhaledwith 'a lot of air']thedrugwillproduce effects the userwill be no and unableto get high. [47: my emphasis] A footnote to this sentence confirms my interpretation, as Becker adds: 'A pharmacologist writes that this ritual is in fact an extremely efficient way of getting the drug into the blood stream. See R.P. Walton ...'. Here, Becker juxtaposes his own subtle symbolic-interactionist theory with a mechanistic take on drug action. it If nothing happens, is manifestlyimpossibleto develop a conceptionof the drug as an object which can be used for pleasure, and use will therefore discontinue ... the user must learn to use proper smoking techniquesso that his use of the drug will produce effects in terms of whichhis conceptionof it can change. [47: my emphasis] The term 'effect' then, here, (like 'experience' in the earlier passage) refers, no longer to a collective and heterogeneous accomplishment, but to a physiological impact. The effect of the drug is at times a collection of 'symptoms', and at others the collective achievement of the perception of these symptoms as 'pleasure'. causedby [Being]high consistsof two elements:the presenceof symptoms marihuana and the recognition use thatthese symptomsand theirconnection by the user with his use of the drug. It is not enough that the effects be present;alone, they do not automatically provide the experienceof being high. The user must be able to point them out to himself and beforehe can consciouslyconnect them with havingsmokedmarihuana have this experience.[49] Unlike the little deviations of action of mediators, the 'symptoms' are not already heterogeneous achievements. Indeed, the techniques of use (smoking) do not 'perform' the drug's impact by granting it specific effects it would not have had otherwise; the techniques simply activate the drug. Becker writes that by speaking with other more experienced users the novice does not transform his perceptions but merely 'made [him] aware of specific details of his experience which he had not noticed or may have noticed but failed to identify as symptoms of being high' [49: my emphasis]. It seems then that this level of (physiological) 'experience' cannot be socially accomplished, that social interpretations and communications merely activate the substance and attract the attention of the user to 'symptoms' already there.
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Because Becker's analysis of 'becoming a marihuana user' is ambivalent, it cannot help us to understand the nature of the difference between the American and French methadone. Instead, Becker's study is an instance of a traditional theory of (drug) action. In later work, Becker goes so far as to classify drugs in terms of the vagueness of their effects: opiates, unlike marihuana, are less likely to be interpreted in various ways: 'the grosser the effect, the harder to ignore', he writes, and adds, 'the culture is then limited in the number of possible interpretations it can provide'.27 One can then characterize Becker's theory of drugs in the following manner: * drug action is sequenced: (1) first the pharmacological substance produces more or less vague impact on the senses; (2) after the manifestation of substance on the biological substrate, interpretations of these effects follow; the variety of interpretations will be proportional to the vagueness of the (primary) pharmacological effect. Interpretations are 'congruent' with actual effects. Thus clear primary manifestations of the drug will reduce interpretive freedom.
In this paper, rather than adopting one such theory of drug action, which fixes from the start what can vary and what endures, my aim is to describe what varies and endures in different practices involving methadone. In this way, rather than assume that substances themselves do not vary, are not part of history, I hope to describe the specific historicity of methadone. To do this, I study two different methadone trials, referring to a heterogeneous body of texts and retrospective interviews, but drawing most of my data from just two scientific reports authored by pharmacologists. These sources allow me to reconstitute snapshots of the substitution treatment at different moments and places in history. My demonstration of differences between performances of methadone is limited to a comparison between these 'stills' of methadone distribution. As such it is, as I will show, very efficient. Such a limited use of materials might also be criticized by a reader valuing exhaustivity. My goal, however, is not to write a teleology of methadone. Neither am I concerned with the representativity of these accounts for describing an 'American' methadone or a '1960s' methadone versus a 'French' or a 'later' methadone. As I compare the 'stills' and show instances of the changing actions and architectures of substance, I try to demonstrate the propensity for difference of a substance in these trials. I am concerned with spotting clues for an answer to the questions 'what is a substance?', 'how does it act?', 'what endures and why?', rather than with giving 'full' descriptions of each trial. Substitution: Dole & Nyswander (1965)
In this first section, I describe the socio-material achievement of methadone through the American trial. I focus on the shift which the experimenters themselves make from entity to a (semiotician-like) 'performance'. I approach the American experimental report using methods previously
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1 FIGURE Six Effects of Methadone Treatment?

Dole & Nyswander (1965) [D&N] Methadone [M] * M is different from heroin * In order for M to be useful, progressivelyhigherdosages must be used What does M do? * M dramaticallyeliminates ('blocks') the cravingfor heroin; it has a therapeutic effect * M can be craved just like for heroin; M is a silentdiagnostic tool; it has no therapeutic effect * M is similarto heroin * In order for M to be useful, progressivelylowerdosages must be used and patients carefullyselected Sainte-Anne (1975) [S-A]
borrowed from semioticians for the analysis of scientific texts by ANT authors, because they seem the most suited to let the 'texts deploy their own categories'.28 The analyst need not distinguish a priori what is substance and what is not. In this way the question of what is a substance (and of its action) becomes an empirical question. Figure 1 shows the properties of methadone described in the American and French 'stills' respectively ([D&N] & [S-A]). When I compare the two trials, in the United States and in France, my task will be to show that the six traits described in the boxes of the grid below do not refer to 'interpretations' or more or less accurate 'descriptions' of a fixed substance, methadone, but to six 'effects' in search of a substance. Dole and Nyswander'sEncounterwith Methadone Though it is not my purpose to describe the context of their experiment in depth, a brief sketch of the theories and skills Dole and Nyswander brought to the experiment can serve as a partial introduction to their work. Vincent Dole was a specialist in metabolic disease at the Rockefeller Institute. In 1962, he was asked to replace for one year the chairman of the NewYork City Health Research Council on Narcotics while the latter went on sabbatical. Dole protested at first that he knew nothing about narcotics, but then turned into a 'conscientious chairman' and 'fascinated student of
the field'.29 After this initiation, he changed his specialization from the
study of fat metabolism to clinical trials of methadone treatment. Early on, he contacted Marie Nyswander because she had written one of the rare clinically-oriented books in the field, The Addict as Patient (1956).30 Dole invited Nyswander to join him at the Rockefeller Institute to experiment with a new treatment. His approach was informed by the recent work on diabetes and insulin: he was familiar with concepts and techniques of
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metabolism and homeostasis, and with palliative treatments of diabetic patients. He proposed a 'metabolic' definition of heroin addiction. Explicitly comparing methadone for addicts to insulin for diabetics, he promoted the experiment of a medical opiate prescription for addicts (a treatment which had already been attempted in the 1920s using morphine, and had been judged a failure). Marie Nyswander was a psychiatrist experienced in the treatment of addicts. Like other specialists of drug and alcohol addiction, she had until then proposed abstinence as the a priori short-term goal of addiction treatment. She had worked at the Federal Addiction Treatment Center, in Lexington (Kentucky), a kind of prison-hospital for addicts, and was deeply unsatisfied with the conditions of treatment. Later she wrote about the horror Lexington had inspired in her, the inefficiency of abstinence treatments and her vain attempts to use psychotherapeutic techniques during these cures of abstinence.31 The skills she brought were considerably different from Dole's: they concerned, principally, clinical observations of patients that later became important in dosing techniques. As a psychiatrist, she had previously learned to dose analgesics during week-long abstinence cures, when the patient went into withdrawal and exhibited clinical signs of pain - such as convulsions, sweating, diarrhoea, and so on. At that time addiction was not an accepted psychiatric diagnosis; therefore, there were then no routinely prescribed psychiatric drugs in the treatment of addicts. As we shall see, in Dole and Nyswander's experiment, methadone cannot be described as the first psychiatric drug for addiction: rather, it was a biological treatment.32 From Isolated Drug to 'Treatment' Network33 Dole and Nyswander's 'methadone maintenance' treatment consisted in giving the user, once a day, a constant dose of a cheap opiate-like substance, methadone, for an indefinite period of time. The hypothesis was that methadone satisfied 'drug hunger', the intractable desire for heroin caused by a metabolic disequilibrium induced by chronic drug use and responsible for the rates of relapse of users. What exactly does this treatment consist of, according to the 1965 report [D&N], and how do the experimenters qualify the action of methadone? It is striking that the report's Abstract [D&N: 646] describes methadone as if it were a 'magic bullet', an 'x', isolated on a lab bench and just waiting to be useful in addiction treatment. Methadone is presented as a classical determinism when, at the head of the text, the Abstract (reproduced in its entirety below) flaunts a methadone acting dramatically: A groupof 22 patients,previouslyaddictedto diacetylmorphine (heroin), havebeen stabilizedwith oralmethadonehydrochloride. This medication induction sufficient tolerance block euphoric to the of effect an average of illegal doseof diacetylmorphine. this medication, a comprehensive With and program of rehabilitation, patientshave shown remarkable improvement; they have returnedto school, obtainedjobs, and havebecome reconciledwith their
appears to have two useful effects: (1) relief of narcotic hunger, and (2)
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Social Studies of Science 32/1 families. Mecical and psychometrictests have disclosed no signs of toxicity,
apart from constipation.This treatmentrequirescareful medicalsupervisionand many socialservices. our opinion, both the medicationand In the supporting programare essential.[D&N: 646 (my italics)]
In the conclusion of the report, too, methadone is an entity clearly defined among other elements of a treatment: We believe that methadonehas contributedin an essential way to the favorableresults, althoughit is quite clear that giving medicine is only This drugappearsto relievenarcotichungerand thus partof the program. free the patient for other interests, as well as protect him against rea block.A previous addictionto [heroin]by establishing pharmacological attemptby one of us (M.N.) to treataddictswithoutnarcoticmedication ended in failure. Other clinics attemptingto rehabilitate patients after
withdrawal, have had equally poor results ... [D&N: 650]
Is this report, then, describing a classical substance, a determinism, enduring through time? In these two quotations, methadone does look like a substance possessing properties and awaiting an occasion to 'express' or 'manifest' them. However, something peculiar seems also to be happening in Dole and Nyswander's treatment. Indeed, at no point in the experiment is there a question of any stable, durable, inherent therapeutic property of methadone, the substance itself. Methadone lacks this most crucial aspect of a classical determinism: that its properties, its capacities to act in certain ways, are located in the interior of the object. One sign of this is that, when speaking of methadone in the text following the Abstract, the experimenters do not claim the therapeutic value of a medication,of an isolated methadone substance; instead, they describe the medical benefit of a methadone 'treatment'.They shift from isolated substance to the description of a heterogeneous network of practices. The report itself begins with these words: The question of 'maintenancetreatment'of addicts is one that is often arguedbut seldom clearlydefined. If this procedureis conceived as no more than an unsuperviseddistributionof narcoticdrugs to addictsfor of self-administration doses and at times of their choosing, then few physicianscould accept it as proper medical practice.An uncontrolled supplyof drugswould trapconfirmedaddictsinto a closed worldof drug taking, and tend to spread addiction.... The question at issue in the by presentstudy was whethera narcoticmedicine,prescribed physicians, as partof a treatment program,could help in the returnof addictpatients to normalsociety. [D&N: 646] The experimenters insist that treatment is more than the handing out of a solitary object, a little 'x'. Indeed, if methadone had been handed out as such an autonomous object, it would be a heroin-like drug, not a medication. The description of the 'three phases of treatment' emphasizes again that the properties of 'methadone treatment' are attributable to a collective, not to an isolated entity:
Six Methadone: Effectsin Searchof a Substance Gomart: Division of ProgramInto ThreePhases
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Phase 1 - The addictpatientswere stabilizedwith methadonehydrochloride in an unlockedhospitalward, given a complete medical workup,psychiatric evaluation,a reviewof familyand housingproblems,and job-placement study. After the first week of hospitalization,they were free to leave the ward for school, libraries, shopping,and variousamusements usually,but not always, the with one of the staff.... During this phase of hospitalization, treatment unit was kept small (four to nine patients).This was felt necessarybecause most patients started the treatmentwith serious anxieties and doubts. The limitation of patient load allowed the staff to individualizethe daily ward
activities ...
Phase 2 - [Aftersix weeks], subjectsleft the hospitaland became outpatients, They were askedto drinktheir returningeveryday for methadonemedication. medication in the presence of a clinic nurse, and to leave a daily urine specimen for analysis.When indicated, this rule has been relaxed;reliable patientswho have been on the programfor severalmonths have been given enough medication for a weekend at home or a short trip.... The most importantservicesneeded duringthis phase of treatmentwerehelp in obtaining jobs, housing, and education. Phase 3 - This phase is the goal of treatment,the stage at which an ex-addict has become a sociallynormal, self-supporting person.The two patientswho are consideredto have arrivedat this phase are still receivingmaintenance medication since the physiciansin charge of their treatmentfeel that withdrawalat this time would be premature.... [The] only distinctionbetween patients in phases 2 and 3 is in the degree of social advancement.[D&N: 647-48] Thus, after a description (in the report's Abstract) of what might look like a determinism, methadone is described in the body of the text in a first non-essentialist manner (as a network). Strikingly, the passage from entity to collective is also a passage from drug to medication, noxious to therapeutic. The properties of methadone, then, cannot be detached from the trials and techniques of treatment. To use terms from the sociology of technology, drugs are not taken to enter the set-up as entities already possessing properties, their properties are 'resistances'.34 Not only can these properties not be isolated from the techniques of dosing, caring for the patient, locking ward doors and opening them later, social assistance and professional guidance, and the like. They appear also in a contrast with heroin use and with earlier treatments of drug patients. What methadone does (for example, 'blocks drug hunger') can only be described in relation to what heroindid to the user. The user stole, now s/he is a good citizen; s/he had craved for the high of heroin, now s/he can tolerate watching his/her friends inject heroin without wanting to do so him/herself. Whateverit was that heroin did, methadone's action is discernible only as a contrast. The properties of the drug emerge as relevant only in the course of treatment, and only in relation to other pertinent elements of the setting. Thus, methadone does not 'block' in a fixed manner, for any one, at any time or place. It 'blocks' only for drug users who crave heroin;
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for non-heroin-users, the contrast is lost with heroin, and methadone does not 'block' at all.35 Further, methadone treatment cannot be described without making references to other entities and networks outside of the treatment ward. More specifically, it is a criticism of abstinence treatments, where all narcotic drugs (medical and illegal) are withdrawn from the user rather than prescribed to him/her. What methadone does here (that is to say, act dramatically) is an implicit criticism of the (much publicized) medical and political failure of other addiction treatments.36This experiment's hypothesis of a metabolic disequilibrium is an attempt to turn over (socioscientific) relations of force which had held the drug user (and his famous 'lack of will power') responsible for his addiction. It is an attempt to 'perform' another user by performing another methadone. What is more, Dole and Nyswander's treatment, when it proposes to substitute heroin with another narcotic, methadone, and when it suggests that such a substitution might be 'therapeutic', rejects the essentialist definition of narcotics as a priori and under all circumstances noxious to the body and destructive to the morality of the user. Quite strikingly, Dole and Nyswander proposed that methadone (which might under certain circumstances be abused as a drug) can be beneficially used in medical treatments in such a way that the difference between heroin and methadone is topicalized and increased. Like sociologists of experiments, Dole and Nyswander focused on the (medical) dispositifwhich performs methadone, heroin and the patients. Whether methadone prolongs or cures addiction depends on whether the setting is informal or medical. The therapeutic property of methadone, therefore, is not an a priori property of the substance 'itself', but an achievement described by the experimenters in the paragraph on 'narcotic medication':
Narcotic Medication.
Patientshave differedmarkedlyin toleranceto narcoticsat the beginningof doses of treatment,and in the ratewith whichthey haveadaptedto increasing of medication.Individualization treatmentthus has been necessary.A rough was estimate initialtolerance made from each new patient'shistory of drug of usage, with allowancefor exaggerationsince addicts coming to [a] maintenance program usually fear that physicians will not prescribe enough medication, and with recognition of the fact that the number of 'bags' used by an addict is not a reliable measure of narcotic tolerance. The diacetylmorphine [heroin] content of a 'bag' obtained on the street today is low and variable. This estimateprovided a guide to initial dosage, but the only sure way to measure tolerance is to observethe reaction to test doses of narcoticdrugs.The schedule, therefore, differed for each patient. On admission patients usually have shown mild or moderately severe symptoms of abstinence, the last shot of [heroin] having been taken some hours before. These patients were relieved promptly [by doses of heroin], given
intramuscularly, and then started on oral methadone ... therapy. Patients ...
without symptoms were startedon a regimenof methadonewithout other medication, but were watched carefully for appearance of symptoms after admission.
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After the first 24 hours most patients could be maintained comfortably oral on medication alone. [D&N: 648 (my italics)] Among these practices for achieving a therapeutic methadone, one of them stands out. Methadone doses were first approximately matched with the equivalent of heroin doses taken by the user before they were increased: The dose of methadone hydrochloride was increased gradually over the next four weeks to stabilization level (50 to 150mg/day).... After the patients reached maintenance level, the morning and evening doses were combined by progressive reduction of the evening medication with an equal addition to the methadone taken in the morning. After discharge from the hospital patients could thus be maintained by a singledaily visit to the outpatient clinic. The patients who have had difficulty in spanning a 24-hour period with a single dose have been given medication to take at home; this has been a minor problem. [D&N: 648 (my italics)] This strategy of matching and increasing is described as a 're-equilibration' of the heroin user's metabolism. When his/her 'pathological drug hunger ... disappeared' [D&N: 648], the drug user could reveal his/her true potential as a responsible citizen: The most dramatic effect of this treatment has been the disappearanceof narcotichunger.All of the patients previously had made efforts to remain drug-free after withdrawal [i.e. medical abstinence cures], but were unable to resist the craving. Drug hunger became intolerable for most of them shortly after discharge from a withdrawal unit and return to their neighborhood. It became especially severe when they were exposed to emotional stress. With methadonemaintenance, however,patientsfound that they could meet addict friends, and even watch them inject diacetylmorphine without [heroin] withoutgreat difficulty.Theyhave tolerated frustratingepisodes feeling a need for diacetylmorphine. They have stopped dreaming about drugs, and seldom talk about drugs when together. Patients have even become so indifferentto narcotics as to forget to take a scheduled dose of medication [methadone] when busy at home. The extent to which the patients have ceased to behave as addicts, and their reliabilityin reporting illegal drug use, were verified by the results of urinanalysis.... [D&N: 648-49 (my italics)] It seems that Dole and Nyswander's experiment does not attempt to construct the power of methadone ex nihilo, from scratch. Rather, they draw upon the forces of heroin (matching and increasing) and bet on a form of action that is 'passed' (granted by another, heroin), rather than one that flows from an original source. But such a statement is at this point of the argument premature. Indeed, to grasp the 'action' that unfolds through Dole and Nyswander's experiment, to understand how this dispositif 'performs' and the kind of actor methadone emerges as in the end, it is crucial first to make a detour and describe the practice of pharmacology from which this substitution experiment originates. I will argue that substitution suggests an alternative
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to the traditional theory of action (source gists too had entertained. Substitution
action) which pharmacolo-
When pharmacology was constituted as a distinct discipline at the turn of the 20th century,37 it established its respectability upon the idea that it must be possible to predictfrom the chemical structure of a substance the actions it would have. Pharmacology not only sought to establish a strong correspondence between chemical structure and action. These scientists bet on the possibility of determiningaction from the chemical structure of a molecule. They dreamed of 'magic bullets' designed precisely and specifically for different ills.38They sought to isolate in different substances the molecules responsible for different ills: the chemical structure of morphine was cut down and modified in an effort to find an analgesic that was not addictive. In this way, the pharmacologists tried out a classical philosophical a priori which founds both the essentialist and the social constructivist take on substance: substances have fixed structures from which it is possible to deduce actions. These actions belongto the substance; they are containedin the structure. They are its 'properties'. The pharmacologists, like classical philosophers,39 began (or sought to begin) with objects already possessing properties, a world already containing a set of defined objects. However, the drift in the pharmacological experiments suggested to the experimenters that in order to manipulate 'properties', structure could not in practice be the starting point. It was very difficult to conduct an experiment designed on the assumption that once one knew the structure, one could predict action. One problem was, according to these pharmacologists, that it was 'not yet' clear which chemicals (structures) held which properties. Thus for example, the very model for the 'magic bullet', Ehrlich's Salvaran, a medication for syphilis, was the 606th of a series of substances which had had to be randomly tried out.40 It proved terribly difficult to perform in practice this classical movement from structure to (inherent) action. Likewise, when pharmacologists engaged upon the quest for a nonaddictive opiate,41 a hot topic between 1920 and 1960, they proceeded to transform methodically the structure of the morphine molecule. They thus began again with their cherished idea that, by changing morphine's structure, they might be able to modify its actions. They began with a classical definition of substance as a source of action. However, the technique that came to be established as the final test of addictiveness was not the one they had started out with. It involved instead the substitutionof morphine with the new substance. That is, patients addicted to morphine were given the new substance in a medical setting. If the subject went into withdrawal, the substance was taken to be non-addictive because it had been incapable to replace morphine (that is, to prolong the effects of morphine) for the patient. But if the subject showed no signs of discomfort, the substance
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was taken to act 'like' morphine for this user, and therefore to be addictive.42Thus if the pharmacologists' endeavour had begun with an attempt to isolate the molecules which made a substance act causally, deterministically, if it had begun with an assumption that 'addictiveness' could be attributed to a section of its pharmacological compound, the pharmacologists shifted in practice to an entirely different endeavour. With substitution, they no longer had to begin with molecules, compounds or structures. The 'addictiveness' described by substitution referred to substances that did not need to be known structurally a priori. One could talk about action without having to mention structure. Substitution, it should be insisted, is an experiment that does not delve vertically into the source of action. Instead, it shifts to a horizontal matching of 'effects', a move that explicitly detours the question of the source of actions. 'Effects', at this point, can be simply understood as a classical 'action' of a drug minus any assumptions about how the substance is the source of these effects. (An ugly but useful name for it could be 'truncated' theory of action.) 'Effect', like the experimental strategy of substitution, at the very least records a difficulty in beginning with a source. Even as pharmacologists sought to go from substrate to action, they were left groping with effects alone without knowing from whence they came. In the following passage, the famous French psychopharmacologist Pierre Deniker (whose work I will discuss again later) describes this disappointment, which seems to characterize, in particular, psychopharmacological experiments: A priori,we might thinkthat the simplestway to classifymodernpsychoindeed, tropicsubstancesis to referto theirchemicalstructure.Classically a chemicalanalogyshouldinducean analogyof pharmacodynamic action. ... Unfortunately,... we find for one type of psychopharmacological actioncompositesof chemicalstructures that arevery dissimilar.... Thus it has rapidlyappearedthat it was difficultto referto a single chemical actionto establisha classification modernpsychotropic of drugs.... [It is important]to emphasizefrom the start that the notion of a chemical structuredoes not guarantee all cases thatwe will be able to predictthe in actionsof a given substance,far from it.43 When Dole and Nyswander use the technique of substitution for designing a treatment of addiction, this experimental strategy allows them to continue to do what the pharmacologists had learned to do: to begin with 'effects', rather than with a source.44 In a move comparable to the recent philosophy of science,45 substitution records a moment when experimenters concede that effects (for example, 'methadone blocks'), not structures, are the first things one knows about a substance. A phrase, then, like 'methadone blocks', which might have been taken as a sign of the deterministic (dramatic, reliable) can now be read in a different manner, as the detourof the question of the source of action.
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Dole & Nyswander'sAlternative Theoryof Action Looking again at the three-phased procedure cited above, it becomes clear that methadone emerges as an 'effect', an action without a source. Indeed, in this procedure the drug 'itself' is not distinguished from what is 'around' it, from the gestures that handle it, the architectures that move it along, the skills that chart, record, compare it. Methadone 'treatment' then describes a moment when the substance is lost to a mass of other elements. It becomes senseless to seek to demarcate 'it' from the rest of the dispositif.It is not simply that methadone's action is 'distributed' to other elements of the treatment setting. This would imply that, apart from the multiplication of the sources of action, nothing much had changed in the architecture of action.46To say that one cannot demarcate the effect of methadone from 'the rest' allows that there is a moment of indetermination. pause is made, A time given for not knowing what or who acted. Here, 'it blocks' should be understood to have just as indeterminate a source of action as 'it is
raining'.47
The vocabulary of actor-network theory (ANT) makes the analyst sensitive to, and able to record, this moment of indetermination. The three-phased treatment is a 'collective of actants', where 'actants' are elements which do not have fixed and a priori capacities. In contrast, the traditional definition of 'action' imposed a specific sequence: action followed/flowed from a source. ANT's 'indetermination' precedes the attribution of a source. Further, the very sequence of action has been transformed. Indeed, according to ANT theorists, classical 'action' was taken to be the predictable, repetitive manifestation of a constant property of an actor, and was thus associated to the faith that once one knew its structure, one could anticipate what would occur. Structure precedes action; capacities precede manifestation. Instead, with 'mediation', the source is up for grabs: it is precisely what will be laboriously sought for during the experimental trial; it emerges only at the end of the experiment. Dole and Nyswander's treatment has the very architecture of this alternative mode of action. Their 1965 report, too, begins with a collection of actants (dosing, chartings, and so on) and ends with a competence, a 'single daily dose of methadone', with which the patient 'simply' feels normal. With some patients,treatedearlyin the study,the buildupof dosagewas too rapid;they becameoverlysedatedfor a few days,and two of them had transientepisodes of urinaryretentionand abdominaldistention.Other patients, given too little, have become abstinent, exhibiting malaise, With more accurateprenausea, sweating,lacrimation,and restlessness. scription, patients have not become euphoric, sedated, or sick from abstinenceat any stage of treatment. They have simplyfelt normal, and have not askedfor more medication.[D&N: 648] First, a moment of indetermination (a three-phased procedure of treatment) where a single source of action cannot be designated, and later, at the end of Dole and Nyswander's report, a methadone which has
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become the source of transformation of the patient. Methadone gains in definition and acquires properties at the very moment that it is 'coextensive' with a mass of other medical practices; and later, methadone becomes a 'single daily dose' of medication capable of making chronic heroin users indifferent to the drug. Action is 'passed' as methadone is foregrounded and other actants backgrounded. The expression 'single daily dose' encapsulates both the dosing techniques crucial in the (indeterminate) performance of methadone, and backgrounds these actions as methadone is shoved forward as 'the one' that acted. It describes both how the dispositif acts (as it performs a specific methadone, heroin, patient) and how methadone in the end acts (as a star actor). The alternative theory of action developed through this experiment bears a striking resemblance with the semioticians' notion of 'performance': [Performance] precedes the definition of competence [i.e. the properties of substance] that will later be made the sole cause of those very performances.48 The phrase 'narcotic medication', devised by Dole and Nyswander, turns out to be an extraordinarily concise 'semiotic' definition of methadone: the very ambivalence of the word 'medication' (the '-ation' allowing an oscillation between object already there and object achieved) suggests that methadone is a performance and a competence - or, rather, a performance and then a competence. The contrast with Becker's definition of drug action is immense. Becker had proposed that a substance acted first and that it was later diversely interpreted. His sequence supposed that it was a priori clear 'what causes' and 'who interprets', and the order in which cause and interpretation occurred. Here, an alternative to a traditional theory of action is traced by the very moves of the substitution experiment. Substantial Variations: Sainte-Anne (1975)
Comparing Dole & Nyswander's 1965 report with the later French report, I want to describe what varies from trial to trial. The sheer multiplicity of differences between the American and the French methadone will undo the claim that what varies from trial to trial are merely interpretations of substance. More specifically, I will suggest that in each trial a different effect emerges from different dispositifs.In each trial, too, scientists laboriously search for the substance of this effect. Substance is not what is given at the start of these trials, it is what we all are searching for and might find in the end. Contrasting it with the first experiment, I will describe what methadone does, detail how it is achieved and specify the mode of action it is granted in the end. It is important to note that by the time methadone was experimented with in France, between 1972 and 1975, the international media, as well as the specialized medical literature, were much more sceptical than Dole had been about the capacity of methadone to dramatically block the 'drug craving' of the user.49By then, methadone had been repeatedly assimilated
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to an illegal drug, confused with heroin, not just in words but also in practice: users injected it instead of, or along with, heroin. Many American doctors originally enthusiastic about the drug had begun to refuse to prescribe it as a medication. For the French experimenters, this meant that their task was to create a difference with the American methadone, to construct a relatively more efficient medication and one capable of maintaining a stable difference with heroin. When methadone was transferred to the French settings,50 the experimenters did not consider that this was simply a transport to a new context of an 'immutable mobile',51 a non-problematically durable methadone. They did not just 'import' methadone. Instead, they aimed to construct a specifically and 'originally' French methadone. How did they produce this difference? If they had been essentialists, they might have tentatively altered the chemical structure of the substance, or they might have chosen an altogether different substance. These experimenters proceeded otherwise: they modified the treatment procedures (the 'actants') involved in insuring that methadone was a medication. By meddling with the experimental set-up, they tentatively created new properties of methadone. The French actors, when they took on experimenting with methadone, tried to tailor it to fit the requirements of their practice. The limits of this 'tailoring' - that is, the limits of the malleability of substance - are precisely the question which these scientists asked.52What margins of manoeuvre and what techniques might be used in order to produce locally a different and more efficient variation from heroin? They, too, are concerned with what can (be made to) vary, and what must be left to endure. I now turn to the transformations effected during this French tailoring of methadone by the Sainte-Anne experimenters.53 Sainte-Anne's Point of Entry A brief sketch of the skills this team brought to their experiment on methadone can serve again to introduce the second trial. In 1972, Pierre Deniker's Service at the public psychiatric hospital of Sainte-Anne was authorized, experimentally, to try administrating methadone to a limited number of patients.54 The physicians Pierre Deniker, Edouard Zarifian, Henri Cuche and Henri L6o, authors of the first SainteAnne report on methadone in 1975 [S-A], were already then (or soon after became) highly influential psychiatrists because of their work in establishing psychopharmacology and biological psychiatry in France.55 SainteAnne Hospital was indeed the centre of French biological psychiatry. In the 1960s and 1970s, first Henri Ey,56then Pierre Deniker and Jean Delay, were promoters of a 'biological explanation' of mental illness. They did not search for intentions or fantasies, a subjective world of the mentally ill. At Sainte-Anne, the biological psychiatrists were not preoccupied with elements hidden from the clinical gaze ('unconscious' thoughts). The SainteAnne team equated what could be known with what could be seen by the
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clinician, or discovered through special techniques. (Psychosis could, for example, be modelled by rats turning incessantly in a cage). The task was to relate clinical portraits to specific psychiatric nosographic categories targeted (hypothetically) by specific drugs.57 I will show that methadone was performed as a slight variation from other psychotropic drugs used in this Service. Sainte-Anne had been asked by the authorities to test methadone. As reputed pharmacologists competent in testing a drug, this choice was evident. And yet, since this testing involved the design of a therapy for addiction, Sainte-Anne's involvement was less evident. It especially seems so today because, since the early 1970s, their definition of addiction has been forcefully contested. These psychiatrists have represented a minority camp in the French debate on addiction, opposed to psychoanalyticallyoriented psychiatrists, psychologists and social workers (who designate themselves today as 'the specialists' in addiction treatment). If Sainte-Anne psychiatrists believed that methadone could in certain cases participate in an efficient cure of addiction, the 'specialists' opposed any talk of 'efficiency', and denied the therapeutic utility of methadone or of any other psychotropic medication.58 After the Sainte-Anne tests of methadone in the early 1970s, the 'specialists' succeeded in making methadone a marginal and stigmatized practice, until they themselves were challenged in the 1990s.59 Losing SubstanceAgain The Sainte-Anne report [S-A: 75] opens with a figure illustrating methadone's chemical structure (Figure 2). Do they then 'begin with substance', as the early-century pharmacologists had dreamed of doing?: Sainte-Anne's experimenters explicitly mention structure, the hardest aspect of substance, in an introductory 'reminder of the chemical and pharmacological propertiesof methadone' [S-A: 75 (my emphasis)]. However, I would like to argue, indeed, that the description of the 'properties' of this 'structure' is so problematized that they cannot be said to refer to actions possessed by a substrate.60This drawing of the structure, supposedly the fixed substrate of methadone, is followed by intriguing comments
FIGURE 2 Structureof Methadone, according to the Sainte-Anne Report C2H5
I
0= C -CH CH,2 -N / CH3 \CH,
I
CH3
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which make plain the difficultyof comparingthe structure of methadone to (the chemical structures of) other substances of its class, analgesics: a) Chemicalstructure Itisa Methadoneisanoriginalmolecule:thedimethyl-amino-diphenyl-heptanone. derivedfrom diphenyl-methane which is found in the diphenyl-propylamine chemical structuresof other psychotropicdrugs. This group includes substances as diverse as anti-parkinsonians (orphenadrine),antinausea drugs [and] spasmolytics(adiphenine). (diphedramine), The chemicalstructureof methadonepresentsno affiliation(resemblance) to [that] of morphineor heroin. In the same manner, it differs radicallyfrom pethidine (Dolosal) and from pentazocine(Palfium),a drug which however belongsto a differentsub-group.[S-A: 75] Thus if in the section on chemical structure very little can be said, this is not the case about the actions of methadone: 'what methadone does' is the topic of comparisons and assimilations in the succeeding pharmacological section of the report [S-A: 76]: b) Pharmacology From the pharmacological point of view, methadonebelongs to the class of analgesics, a very heterogeneousclass which goes from codeine, a minor opiate,to Fentanyl(a neuroleptanalgesic). For the principalexperimentaltests, methadone comes close to morphine: [it] * depresses [and] respiration; * slowsdownthe intestinalperistatism; ... Methadone possesses to different degrees all the properties of analgesics, includingtheir addictive power.... It distinguishesitself throughits lengthof action,twice longerthan that of morphineon certaintests.... [S-A: 76] The contrast between the chemical and pharmacological sections is striking and crucial. It demonstrates that there is a disjunction between the chemical (structures) and pharmacological (properties), the absence of a tie between structure (or substrate) and action. The comments following the drawing of the chemical substrate of methadone and their contrast with those in the pharmacological paragraph outline an intriguing problem: there is no evident relation between methadone's morphine-like action and the chemical structure of the substance. Structure, though 'identified', is completely isolated. It explains nothing, founds even less. The relation between action and structure being unknown, methadone as it is represented in the drawing cannot be said to 'possess' these actions. Therefore, there can be no serious talk of 'properties' of methadone, only effects or performances. In this way, the Sainte-Anne report proceeds to describe methadone while detouring the puzzling question of the relation between action and structure. Just like the pharmacologists at the beginning of the century, just like Dole and Nyswander in 1965, the French experimenters are incapable
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of beginning with a fixed structure already possessing properties. They lose substance again. What Varies,What Endures How different was the French methadone from the American? The extent and nature of this difference are the topic of this section. One might expect to see, as we compare what methadone 'does' in America and in France, consistencies that had been so difficult for the actors to see at the level of structure. One might expect that the French and American treatment results converge to reveal, even vaguely, an identical underlying agent. Strikingly, however, it is just at this point that the variations and multiplicities of performances of methadone are the most numerous. From induction to indication. Like Dole and Nyswander's methadone, Sainte-Anne's is described as the performance of a collective, a drug which acts like a medication when it is inserted into a diversity of medical practices. However, this performance mobilizes very different actants. Dole and Nyswander had insisted that the first and crucial phase of treatment was 'induction', a stage in which methadone doses were increased until a 'blockade' was achieved and the heroin addict ceased to 'crave' for methadone [D&N: 646, 648 & 650]. Sainte-Anne's treatment, on the other hand, begins with the selection of the patient for treatment: treatment thus began even beforethe administration of the first dose of methadone: Criteria selection indications thecure. or of of seriousaddictionsto heroinhavebeen subjectedto treatment... Only The second criterionwas the durationof addiction(-- 2 years) ... Another requirementwas the personal request for treatmentby the addict Theconditions methadone maintenance verystrict... are of abstinencecure in a hospitalsetting ... [A] preliminary [The] patient'sacceptanceof the rigorousconditions of the cure, including daily consultationsbetween 8am and 1pm and regularurinarycontrols.The addicts are warnedthat the cure will be immediatelyand irremediably interto ruptedif they arediscovered haveused othernarcoticssimultaneously (with methadone). These conditionssometimescause a patientto give up on treatment,despite his initialrequestfor it. Thus in our experiment,9 of the 46 patientsdid not returnafterthe first consultation.[S-A:76-77] The addiction of the patient is investigated and evaluated; the addict's 'demand' is assessed and tested. The patient is interrogated, observed, expected to return and to behave in a manner coherent with his previous behaviour. It is striking that in this experimental report on methadone, the central actor is the patient, not the substance. In this vein, the treatment begins when the patient accepts the limited schedule for receiving methadone, the daily inquiries into his life, the humiliation of urinating in front of a nurse:61
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The counter-indications treatment]are in a way the inverseof the indica[of tion and concern: * * * subjectswho do not acceptthe obligationslinkedto treatment; psychopathologicallyunbalanced patients, very unstable and delinmotivationseems doubtful;... [S-A:89] patientswhose therapeutic
quent; ...
Here, the inductionof blockade through dosage techniques is not the first and crucial phase of treatment. Rather, at Sainte-Anne, treatment begins with techniques of indication,that is, of selection of patients. Dole's methadone, at Rockefeller, had turned even the most recalcitrant delinquent user into an ordinary patient [D&N: 650]: the 1965 American experiment had detoured the very question of the activity and compliance of the patient. At Sainte-Anne, however, these selection techniques make the patient one of the actants of treatment. Methadone's efficiency depends not only on a series of dosing techniques (as for Dole and Nyswander) but adds to these the participation of the patient (as he or she is constructed and revealed by the techniques of selection). The appearance of terms such as 'requirement', 'acceptance' and 'renouncement' confirms this. As in Dole and Nyswander's experiment, the precise contribution of each actant is unclear. It is unclear whether methadone works 'in itself' or because the patient cooperates and, as for Dole, this confusion is just the point. It is the palpable evidence that agency, or rather 'actancy', if it somehow includes both substance and patient, is indeterminate. At Sainte-Anne, the patient is drawn into the group of actants that collectively (and in the beginning, indeterminately) perform methadone. This intervention can be conscious, when the user for example uses methadone with techniques and intentions usually reserved for heroin. (More about this below.) His intervention can also, according to the experimenters, be unconscious on the part of the user: It is certain that the psychologicalprofile of the addict, which does not to entity,conditionspartiallythe success correspond a univocalnosographical of the treatment. It is thereforeuseful to put successes and failures into relationto the personalitiesof the users, which can be sketched out in the groups: psychiatric following4 nosographical
*
* *
*
psychotic personality ...
unbalancedpsychopathological personality... 'addictive'personality,where the main pathologicaltrait is summarized

by the addictive behaviour ... neurotic behaviour ... [S-A: 89]
Whether conscious or not, this actant, the patient is key. Treatments succeed or fail depending on the compliance and personality of the user, not the properties of the substance methadone: must be evaluated... in termsof the personThe indicationof treatment ality of the addict.The analysisof our results, successes and failures,in
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relationto personality, shown that successeswere those of psychotic has

personalities ... and addictive personalities. [S-A: 89]
Methadone treatment at Sainte-Anne, then, is a peculiar process which ends not with the construction of a dramatically causal drug but with an emphasis on the personality of the patient. What varies then in this first attempted comparison? The number of actants varies. And, as the experimenters modify the network or chain of actants involved in performance, they tentatively modify what methadone does. More specifically, they add actants in an effort to increase the difference between methadone-as-drug and methadone-as-medical-tool (American methadone and French methadone). What changes then are the specific details of treatment, or what William James called the 'particulars'. These particulars are actants acting at a moment of indetermination, before exact identities and boundaries can be drawn. Indeterminacy is not a vagueness or an immateriality but a lack of autonomy of action. Methadone's action is not autonomous, it emerges from the activity of the entire dispositifof treatment. What methadone does varies with the dispositif.If we ignored these particulars,we would ignore the most important and concrete evidence that 'methadone' is not at the start of these trials an object standing alone, already there but an 'in-between', an un-finished actant coextensive (for the time being) with the rest of the dispositif.Methadone in Paris and in New York is intricately tied to the dispositif, and cannot be described without referring to specific concrete details of the setting. If we ignored these particulars, we would take methadone to be an a-temporal, a-historical essence. When sociologists of substance erase them, they see 'just methadone', an a-temporal, a-historical form.62 An epistemological moat is dug around the substance and it is constituted as an entity separate from other entities in the world (that is, from the subject, ideas, context, and so on). This theory of action is traced by the very gestures of the experimenters at Sainte-Anne. When what methadone does is modified through tinkering with the dispositif,its action is taken to be coextensive with it. It is not just that methadone's properties are not fixed but achieved through the experiment. The performance of the dispositif,as well as the kind of actor that methadone is (achieved as) in the end, is also at issue. Here at SainteAnne, as with Dole at Rockefeller, there is also a moment of indetermination, what I described above as the semiotician's 'performance'. However, at the end of the experiment at Sainte-Anne, methadone had not achieved the same kind of stability and deterministic force granted to Dole's methadone by the American treatment techniques. Instead, the French treatment success depends not on methadone, but on the patient. The patient's action is in the end determining. Another alternative mode of action (or mediation) of methadone seems to be achieved, 'substantiated', in the Sainte-Anne experiment. How precisely to describe this substance which succeeds in making way, or, to use another semiotic term, 'shifting out' the action to the patient rather than keeping it for itself? 63
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From blockadeto the revelationof low dosages.The specificity of methadone can be defined by referring again to the collectives involved in the treatment at Sainte-Anne. Methadone becomes a drug which instead of 'dramatically' blocking and transforming the patient, withdraws to reveal the patient through techniques of indication, but also through specific dosing techniques. Dosage techniques at Sainte-Anne are considerably different from those used by Dole and Nyswander. At Sainte-Anne, methadone dosage is decreasedinstead of being increased over time:
Determiningthe dose.
There is no codifiedposologyof methadone,the dose being a functionof the durationof the addictionand of the severityof most recentaddiction ... To fix to the posology we at first referredto foreignpublications[noteherereferring ... Dole'sreports] [The] absenceof personalexperienceincitedus to use doses inferiorto the minimal doses [in the literature].In theory the maintenance to doses rangebetween50 and 120 mg per day.In our experiencewe preferred use inferior doses. We propose initial doses between 80 and 100 mg and maintenancedoses between 30 and 80 mg per day. It seems useful in the course of 'maintenance'and within this therapeuticrange to diminishprothe gressively doses, the subjectshavingbeen warneda prioriof the inevitable diminutionof their doses; in this way, posologicalabuses were avoidedand patientswho treatedmethadoneas anotheraddictiveexperiencewere eliminated. [S-A:79] The experimenters insist that low doses of methadone are 'optimal'. To understand this fact, it is important to clarify what the goal of treatment was for the Sainte-Anne team. At Sainte-Anne, the dose is adjusted to cover just barely the signs of withdrawal of the patient caused by his previous use of heroin, '... given the usual exaggeration of the addict to obtain more methadone or to prevent hypothetical need before it appears' [S-A: 79]. The avoidance of any positive 'subjective' (that is, heroin-like) effects is key to this prescription. Methadone must be just high enough to eliminatewithdrawal, but not so high that it induces a heroin-like pleasure: it 'equilibrates'.Further, in addition to just barely soothing withdrawal pains, it 'equilibrates' in the sense that it is also an attempt to correct the 'deficitary syndrome' taken at Sainte-Anne to be characteristic of addicts. One practitioner explains: a The 'deficitary syndrome'... is an indifference, lackof dynamism,a lack of initiative,etc.... Once the intoxication[i.e. drug use] is interrupted [with methadonetreatment,for instance], either there is restitution[of these capacities in the ex-addict] and we can say that his indifferent behaviourwas the 'deficitary syndrome',defined as the organicresult of his drug use. Or the deficitary syndrome persists, and then we ask whetherthere are other explanations[forhis behaviour]and these would factors.64 or concernpredisposing precipitating [psychological] For Deniker and his colleagues, methadone was a mere tool that allowed the clinician to determine whether the apathy of the drug user was a symptom to be included in a psychiatric diagnostic (and serve as basis for a prescription of other psychotropic medication) or the temporary effect of a
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long-term use of a narcotic drug. Methadone was a test because the 'deficitary syndrome' was corrected by methadone maintenance only for those addicts who 'despite' their addictive behaviour did not have underlying psychopathologies. Methadone, then, was an occasion for a diagnostic test which allowed psychiatrists to distinguish between 'pure' addicts and psychopathological persons who happened to be addicted. (More about this below.) At Sainte-Anne, methadone 'eliminates' and 'equilibrates'. With these non-dramatic actions, methadone helped the Sainte-Anne psychiatrist evaluate the symptoms of the addict and assign them to accurate nosographies. In itself it did not 'cure', nor ameliorate the mental illnesses of the patient. Methadone revealed, but did not transform the patient. This methadone 'acted' in a peculiar way. It was an usher for othertechniques. It worked when it withdrew itself. It worked when it silently, reliably, transparently let the psychiatrist do his job of diagnosing the personality of a
patient.
Let us, for the sake of contrast, recall how the technique of 'single doses' had performed Dole's methadone. Dole had sought to increasethe tolerance of the patient to methadone to reduce 'craving' for heroin; he therefore increased the doses of methadone to induce tolerance. In contrast, the Sainte-Anne team modestly withdrawing methadone does not 'induce' or 'dramatically' do anything. Further, for Dole, the 'single daily dose' had demonstrated that methadone had acted alone, autonomously. More precisely, the expression 'single daily dose of methadone' referred allusively to the techniques of dosage crucial to this dramatic action, while at the same time backgrounding these techniques; methadone had been foregrounded in the end as the sole actor. At Sainte-Anne, 'low doses' are techniques of control and of diagnosis of the patient which perform the substance as a different sort of actor. In the end, methadone is not foregrounded but backgrounded. These lowdosage techniques both bring methadone into the play and ensure that it will not in the end be a 'star', that is, the only source of the transformation of the patient. Because these experimenters take methadone as a drug which either acts strongly like heroin or weakly as the revelator of (not the cure for) mental illnesses, methadone in the end only 'assists'. Other substances will accomplish the important transformations of the patient. The Sainte-Anne report concludes:
Methadone is not a therapeutic panacea for opiate addictions.... [It] does not modify the pathological personality of the addict which underlies the addictive behaviour but it can facilitate its therapeutic approach. [S-A: 89]
Methadone should leave no trace upon the action that passes through it. Should we conclude that methadone is in the end taken by the experimenters to have little or no effect?The experimenters seem at first sight to have distinguished between over-determined substances (like psychotropic medication) and under-determined substances (like methadone).
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They seem to lean towards a symbolic interactionist definition of methadone action. Do they not find that methadone is an under-determined object which can and must be controlled, whereas other psychiatric medications are another kind of object, determined and autonomously efficient? Do they not find therefore that methadone is a specific ('soft') object, one which is particularly likely to allow several different interpretations of its actions? Are Deniker and his colleagues, in other words, demonstrating that their account of methadone is a social interpretation looming above a substance, and one that is only possible in this case because this substance's manifestations are vague and thus prone to 'interpretations'? If we follow the Sainte-Anne experimental report closely, it is evident that the conclusions of the experimenters are at a different level. It is not that their trial has discovered the a priori weakness of methadone; rather, this trial has succeeded in making a weak methadone. They have devised techniques to fabricate the 'weakness' and transparency of methadone. Indeed, the actors themselves take this 'weak' substance to be a conditional, temporary and tentative accomplishment because they devise these techniques (of dosage, but also of control and patient selection) to try to make sure that methadone remainsweak. They try to avoid the problems that arise at those moments when it ceases to be transparent, when it threatens to act for itself. At Sainte-Anne, we might even say, methadone is useful only when it is a weak actor, an usher for psychiatric treatment. The specificity of Sainte-Anne's methadone is not that it was performed to a lesser degree, that it benefited from less construction. The Sainte-Anne report sticks just as close to the 'particulars' as Dole and Nyswander's report. Sainte-Anne's methadone was performed just as much as Dole's, since its weakness is also the effect of a chain of actants so carefully described. In his dispositif,Deniker devised a substance that had a different mode of action. Actor-network theorists would say that it was a silent 'intermediary', in the sense that it acts in the end unlike the 'mediators' which deform action as they pass it along.65 However, methadone's property to be less than a 'mediator', that is, to pass silently, requires as much work, as much attention to the indeterminate work of the dispositif as the performance of capacities of fully-fledged mediators. 'Weakness' is performed by techniques of dosage, control, indication, and so forth. It does not refer to shorter or weaker chains, just to different ones. Thus, this 'soft' object is not soft in the beginning,like Becker's, but rather in the end. Its weakness does not facilitate a diversity of 'interpretations' by different experimenters. Its effect is not 'vaguer'. Rather, methadone is (fabricated as) markedly, determinedly weak, 'evidently vague'.66 to From metabolicre-equilibration psychopharmacological trial.The performance of methadone as a silent intermediary relied on a third technique. In addition to the techniques of dosage and indication, methadone was performed as transparent because it was the occasion for a psychopharmacological diagnostic trial for revealing the personalities of the patient. Methadone, then, was used in exactly the same manner as other
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psychotropic drugs developed and tried at Sainte-Anne. With this final difference from Dole's methadone, I continue to let the essential differences proliferate between Dole's metabolic methadone and this psychopharmacological methadone. Methadone is a diagnostic tool.67 Psychotropic drugs were used at Sainte-Anne not only to treat dysfunctions, but also experimentally to induce changes in behaviour, which the clinicians then defined as the result of the interaction between this specific mental illness of the patient and that particular psychotropic substance. The modifications introduced by certain chemical substances in the interestfroma diagnostic, neurological activityof man areof considerable therapeuticand theoreticalpoint of view.The effects of these techniques are rapidand transitory and, thanksto them, we possess a series of trials which allowsus to dynamically and [epreuves] explorementaldisturbances underlying personalities.68 Different categories of personalities were taken to respond differentially to these experiments.69The administration of certain substances constituted a trial [epreuve]during which a psychiatric diagnosis of the person could be more firmly established. If methadone is used like these drugs, it can in this performance no longer be simply called 'weak'. Methadone does not 'only' reveal because it withdraws itself modestly. Methadone is a subtle trial; it is that which lets appear and produces differences between different personalities. That methadone was such a trial is shown at one key moment of the treatment. I mentioned above that methadone acted on the deficitary syndrome in different ways: it might eliminate it, cover it partially or leave it unchanged.70 For each variation, a specific psychopathology was designated. The variations of results of methadone treatment were taken - like Deniker's drugs - to be attributable to the specific personalities of different patients. The crucial difference produced by the methadone trial is one between patients who have no other psychological problem than the use of drugs and those who have an underlying psychopathology: Results: ... Methadone, by erasing the difficultieslinked to addiction, changes the mode of life of the addict and can lead indirectlyto the re-establishment of and of socio-professional familyrelations.Howeverthe impossibility re-establishing these ties with a normalizedlife sometimes refers to an underlying pathology... and not to the addictionitself. [S-A: 82] If, after a time in the methadone programme, the deficitary syndrome disappears, the addict is a 'pure addict' and drug use is his only psychopathological trouble. With methadone,71 only the 'pure addict' returns to a productive life. In other cases methadone does not erase the deficitary syndrome, and the user does not return to normal life. Methadone helps in psychiatric diagnosis because it is a differentially efficient medication for different profiles of mental illness.
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Just as psychopharmacologists had differentiated the responses of the mentally ill to different drugs, the user was seen to respond specifically to different drugs. Agitated persons preferred morphine, a category of depressed persons preferred cocaine, and so forth. Interestingly, to this mode of prescription corresponded a definition of addiction: drug use was The patient used particular drugs to 'treat' his a form of 'auto-medication'. in a manner that mimicked the biological psychiatrist psychiatric problem who used psychotropic drugs to treat specific mental illnesses. In sum, methadone at Sainte-Anne does different things than Dole's methadone at Rockefeller. Not only what it does, but also its modeof action differs. It is a modest usher performed through different techniques (indication, dosage, psychopharmacological trial). Methadone is a silent yet locally and specifically efficient actant: it reveals and distinguishes different psychopathologies of the user. After 1975, the average doses of methadone continued to be lowered and the range of acceptable doses narrowed, in search of that tiny space of'equilibration' in between covering withdrawal and inducing heroin-like pleasure, where methadone can be a diagnostic test. It seems to have become extremely efficient in revealing psychopathologies. According to a Sainte-Anne report in 1994, 75% of all methadone patients were said to 'benefit' from a prescription of another psychotropic medication.72This inordinately high rate of psychopathology suggests that methadone was an excellent 'revelator' and usher for psychiatry.73 Over the years, this methadone also transformed the starting hypotheses of the experimenters on the nature of mental illness in general. I interviewed one practitioner in 1997 (adding my italics!): EG: Would you say that methadonehas made more evident the biological aspect of the psychiatricillness of users ... or even transformedthatto whichone referswhen one speaksof the 'biology'of mentalillness? Dr L: That is a very pertinentquestion!Yes, biology has become more importantfor me. Precisely.If one does not treat the biological, us will our interventions be useless.Methadone things. forces to clarify At the beginning,I hesitatedto say that a depressive person must Now I just say it brutally:'A depressionhas take antidepressants. neverbeen curedwith just psychotherapy!'. Sainte-Anne's methadone has continued to accumulate differences from Rockefeller's methadone. What can be said to endure and to vary?This was the question of the French experimenters themselves. They did not import a fixed substance, but rather began by acknowledging that it was much too difficult to deduce actions from structure. They tentatively devised techniques to transform methadone and make it endure as a silent usher, a tool for psychiatric diagnostics. They modified the dispositif, the particulars of the setting which at a certain moment of indetermination are coextensive with methadone. As they did so, the very mode of action of methadone varied. What is durable, then, is made so by these techniques. When these techniques endure, such as the low dosage techniques since 1975 at Sainte-Anne, a
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certain mode of action of methadone might also persist. Consistencies do not refer to a priori entities, substrates. Consistencies are results: they are produced through techniques which, if they are maintained, partially stabilize certain effects of methadone. Methadone endures as a shaky chain of actants, preferred techniques, tentatively and for the time being crystallizing a certain mode of action. Conclusion What is the difference between heroin and methadone? What is the difference between the French and the American methadones? To answer this question, I have described two experiments with methadone and searched for what endured between them. The reports on which I focused were not different accounts or interpretations of a unique methadone. Such an analysis would suppose that what endures is the substance, and what varies are interpretations. It would imply that it is possible to begin with a definition of a substance and, proceeding from there, to deduce the actions from the properties of the substance. I have suggested instead that 'what endures' (what a substance does, how or what it is) is precisely what is at stake in these experiments. The six different boxes of Figure 1 then do not refer to 'properties' of methadone, nor to a variety of accounts of these properties. They are indeterminate 'effects' or 'performances' of actants ('particulars' of the dispositif). To escape from a social constructivist and essentialist description of experiments and accounts, I focussed on 'performance' and 'action'. I described the experiments as enactments of alternatives to a traditional theory of action. Each experiment tries out a specific hypothesis about what occurs after 'performance'. In Dole and Nyswander's experiment, methadone acts as a dramatic actor that 'blocks' drug craving; in SainteAnne's experiment, methadone acts merely as a silent intermediary for the actions of the psychiatrist. Methadone is 'substantiated' differently in each dispositif. Methadone is not, to use the ethnomethodological term, always already there, found not constructed. Garfinkel proposed the metaphor of the 'potter's object'. For him, the 'potter's object' insists on the 'intertwining' of worldly objects and embodied practices. The scientific object takes 'shape' in and as of the way it is worked. In the same way, methadone in each trial is performed through different practices; it varies as these practices vary. However, the 'intertwining' of the 'potter's object' is a weak metaphor for the radical transformation undergone by methadone from one trial to the next. I have tried to show that the substance is not simply 'intertwined' with other elements. Each trial posed again as an empirical question 'what is substance?', 'what is the difference between methadone and heroin?'; and, in each one, the actants, the mediating dispositif(which could not as yet be distinguished as either natural, technical, social) performed, folded at the same time the substance, its boundaries, its
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architecture, its theoretical context ... This particular form of constructivism has been summarized by Bruno Latour in the following terms: ... [This is] a specialform of constructivism since it overcomesits own The artificiality the laboratory of does not negateits validity construction. and truth;its obvious immanenceis actuallythe source of its downright transcendence.74 In the end only, the (social, natural, technical) elements are distinct enough to be said to be 'intertwined'. But by that time, the show is over: the crucial event of the performance (of actants in a dispositif)has already ended. Defining methadone can only be done in reference to the specific dispositifsengaged each time in its achievement. It requires that one focus on the moment ofindetermination when techniques are 'mediating actants'. It requires that one be attentive to the 'particulars' (the details, the devices): if we disregarded them, methadone would seem to be everywhere the same again. The resulting analysis of methadone at two different points in history is not a linear history of an entity, it is not simply the work of aligning and tracing references to one substance. In these experiments, experimenters do not focus on an entity, methadone. Their attention is elsewhere: they create new differencesbetween the effects of methadone and heroin. The history of methadone is one of tentative constructions of differences, not once and for all, but afresh in different dispositifs.The experimenters' reports record their focus, not on pre-given entities, but on the tentative performance of a significant difference. Methadone is this, the tentative performance of an adjustment,not an entity progressively discovered. The reports I have used were themselves one of these 'particulars' that adjusted and stabilized the differences between heroin and methadone in America and in France. In referring to them and teasing out the nature of their difference, this text adds to the dispositifthat performs two methadones, two 'substantiations' in America and in France. Notes
This paperis based on a chapterfrommy PhD thesis, Surprised Methadone: experiments by de in substitution (tcole NationaleSuperieure Paris, 1999), co-fundedby a grantfromthe de 'Fondation FrenchMinistryof Researchand the Synthelabo pour le developpement la For connaissance'. theircommentson earlierdraftsof this paper,I wouldlike to thank MarcBerg, GerardDe Vries,Nicolas Dodier, BrunoLatour,AntoineHennion,Isabelle Stengers,Lucy Suchman,the 'ScienceDynamics'discussiongroupof the Universityof reviewers. and Amsterdam, four anonymous Maintenance: see on 1. For a classicvariation this argument, DorothyNelkin, Methadone Fix A Technological (NewYork: 1973). Nelkin introducesmethadone GeorgeBraziller, as havingthe same physicaleffectsas heroin,and being heralded'for society'as the crime. to breakthrough reducedrug-related long-awaited 'A 2. This firsttrialwas reportedin VincentP. Dole and MarieNyswander, Medical TrialWith Methadone A for Treatment Diacetylmorphine (Heroin)Addiction: Clinical Vol. Medical Association, 193 (23 August 1965), of Journal theAmerican Hydrochloride', in 646-50 [80-84 in the issue (No. 8) pagination]; reprinted HowardSchafferand in Brunner/ Contributions theAddictions Milton EarlBurglass(eds), Classic (NewYork:
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3.
4.
5. 6.
7. 8.
9.
10.
11.
12. 13.
Mazel, 1981), 401-11. This report is referred to in the text as [D&N], with page numbers from its original publication in the 1965 Volume of JAMA, using the volume pagination (646-50). The report was published as Pierre Deniker, Henri L6o, Edouard Zarifian and Henri Vol. I Cuche, 'A propos d'une experience francaise de la methadone', L'Encephale, (1975), 75-91. This report will be referred to in the text as [S-A]; the translations are mine. Historians of pharmaceutical practice and the pharmaceutical industry are numerous; historical appendixes to manuals of pharmacology are standard; however, attempts at describing not the different uses or medical practices around the drug but what exactly varies when a substance is described as doing different actions in different times and places, are quite rare. This has been noted by Philippe Pignarre, in Qu'est-cequ'un medicament?Un objetetrange entrescience,marche et sociiet (Paris: La Decouverte, 1997). Pignarre adds that the rarity of histories of drugs has to do with the fact that substances are often taken to be just what does not have a history, just what does not vary. On the peculiar historicity of objects, see also Lorraine Daston Biographyof Scientific Objects(Chicago, IL: The University of Chicago Press, 2000). Roy Porter and Mikulas Teich (eds), Drugs and Narcotics in History (Cambridge: Cambridge University Press, 1995). One classical historical work that fits into the social constructivist pole of this dualist scheme is Virginia Berridge and Griffith Edwards, Opium and the People:Opium Use in Nineteenth-centuryEngland (London: Allen Lane/St Martin's Press, 1981). Andreas-Holger Maehle, 'Pharmacological Experimentation with Opium in the Eighteenth Century', in Porter & Teich (eds), op. cit. note 5, 52-76. More about this problem below. For now, I refer to ethnomethodologists who criticized this notion of 'objects': see, for instance, Dusan Bjelic's analysis of what he calls 'Galilean objects', in D. Bjelic, 'An Ethnomethodological Clarification of Husserl's Concepts of "Regressive Inquiry" and Galilean Physics by Means of "Discovering Praxioms"', Human Studies,Vol. 18 (1995), 189-225. This object is like the boy that a Bosnian woman intends to adopt and who, according to the ritual for adoption, is pushed and pulled through her skirts. The 'object', like the boy, has total amnesia about what he saw under his adoptive mother's skirts. Such a view assumes a world always already there, and implies a certain form of truth-building (and thus a 'discovering' scientific work): see Harold Garfinkel, Michael Lynch and Eric Livingston, 'The Work of Discovering Science Construed with Material from the Optically Discovered Pulsar', Philosophyof the Social Sciences,Vol. 11 (1981), 131-58. Using the term 'propensity', the student of Chinese philosophy, Francois Jullien, proposes that objects are not just represented in different ways but actually 'are' different objects: F. Jullien, La propensiondes choses:pour une histoirede l'efficaciteen Chine (Paris: Seuil, 1992). Caroline Jean Acker, 'From All Purpose Anodyne to Marker of Deviance: Physicians' Attitudes towards Opiates in the US from 1890 to 1940', in Porter & Teich (eds), op. cit. note 5, 114-32. I use here the term 'dispositif in the sense developed by Michel Foucault in Surveilleret Punir: Naissance de la prison (Paris: Gallimard, 1975). This word has no equivalent in English. The closest term is perhaps 'topical contextures', as used by Michael Lynch, 'Laboratory Space and the Technological Complex: An Investigation of Topical Contextures', Science in Context,Vol. 4, No. 1 (Spring 1991), 51-78. I also use such terms as 'settings' and 'frames', which have everyday English currency. The term 'dispositif is further defined in the discussion below of literature on action. For an exploration of 'modern' discourses on humans versusthings, see Bruno Latour, WeHave Never Been Modern (Cambridge, MA: Harvard University Press, 1993). See, for example, the classic Howard Becker, Outsiders:Studies in the Sociologyof Deviance (NewYork: Free Press of Glencoe, 1963). Or, more recently: Patricia Adler, Wheelingand Dealing: An Ethnographyof an Upper-Level Drug Dealing and Smuggling Community (New York: Columbia University Press, 1985); Marsha Rosenbaum, Women
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Social Studies of Science 32/1 on Heroin (New Brunswick, NJ: Rutgers University Press, 1981). Works in other traditions that share some of the goals of symbolic interactionism include: Michael Agar, Ripping and Running:A Formal Ethnographyof Urban HeroinAddicts (NewYork: Seminar Press, 1973); Philippe Bourgois, In Search of Respect:Selling Crack in El Barrio (Cambridge: Cambridge University Press, 1995). For a full review of American and European ethnographies on drug use and treatments, see Albert Ogien, 'Situation de la recherche sur les drogues en Amirique et en Europe', in Alain Ehrenberg (ed.), Penser la drogue,Penserles Drogues- Etat des lieux (Paris: Editions Descartes, 1992), Vol. 1, 49-86. On the non-deterministic goal of symbolic interactionism, see Herbert Blumer, and Method (Berkeley: University of California Press, SymbolicInteractionism: Perspective 1969). Blumer distinguishes between symbolic (which involve interpretation) and non-symbolic (reflex) responses. His definition of the human agent is central to this strategy: 'With the mechanism of self-interaction the human being ceases to be a responding organism whose behavior is a product of what plays upon him from the outside, the inside or both. Instead he acts towards this world, interpreting what confronts him and organizing his action on the basis of this interpretation' (ibid., 63). In the great diversity of works I encapsulate here under 'ethnographies of drug use', this anti-deterministic goal is achieved in different manners. For example, Becker, in Outsiders(1963, op. cit. note 13, 3), rejects the commonsense idea that the deviant acts occur because there is something inherent about the persons who commit them that makes it necessary, inevitable that they should. Of course, the goal of de-pathologizing drug addiction was/is not the monopoly of symbolic interactionists: see, for example, the often-cited work, inspired by anti-psychiatry, by Stanton Peele, DiseasingAmerica: AddictionTreatment of Control(Lexington, MA: Lexington Books, 1990). out I thus draw on classical studies of science, such as: H.M. Collins, 'The Seven Sexes: A Study in the Sociology of a Phenomenon, or the Replication of Experiments in Physics', Sociology,Vol. 9 (1975), 205-24; Garfinkel, Lynch & Livingston, op. cit. note 8. For these diverse authors too, the phenomenon could not be detached from the specific experimental conditions. What each meant by 'conditions' differed. For Garfinkel, it was (among other things) the irreproducible present in which the phenomenon was 'seen'; the final object will carry the traces of this moment in time. For Collins, reproducing an experiment required the 'enculturation' of the novice experimenter. For many in the field, this point was the occasion for an 'empirical turn', and was influenced by ethnomethodolgy. See, for example, Annemarie Mol, 'What is New? Doppler and its Others: An Empirical Philosophy of Investigations', in Ilana L6wy et al. (eds), Medicine and Change: Studies in Medical Innovations (Paris: Editions INSERM, 1993), 107-25, and Andrew Pickering, The Mangle ofPractice: Time,Agency, and Science (Chicago, IL: The University of Chicago Press, 1995). More recently, see Karin Knorr Cetina, EpistemicCultures:How the SciencesMake Knowledge(Cambridge, MA: Harvard University Press, 1999). Annemarie Mol and Marc Berg, 'Differences in Medicine: An Introduction', in M. Berg and A. Mol (eds), Differencesin Medicine: UnravelingPractices,Techniques and Bodies (Durham, NC & London: Duke University Press, 1998), 1-12, at 6. In this sense, this argument might be distinguished from the 'strong programme', where the content of science would be 'also' social: for the classic original statement of the latter position, see David Bloor, Knowledgeand Social Imagery (London: Routledge & Kegan Paul, 1976; Chicago, IL: The University of Chicago Press, 2nd rev. edn, 1991). In contrast, this argument claims that the social cannot be used to explain science, since science is what is constructed through scientific practices, along with 'nature'. For instance, in a study of German treatment programmes for transsexuals, Stefan Hirschauer shows that different practices perform different 'sexes'. And that each one is a contingent accomplishment.
14.
15.
16.
17.
18.
Gomart: Methadone: Six Effects in Search of a Substance If one asks what each of these sexes really consists of, the answers will refer to interactive accomplishments, to loops in which meanings are constructed, and to differentially arranged materials of skin, matter, tissue and vessels. Each method [psychiatric, endocrinological, surgical] composes its sex by mobilizing the specific internal environment of its own procedure. So the differentiating methods are relatively independent of one another.
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Hirschauer's account is populated with computer programs, test tubes, scalpels, body parts which localize and specify the 'sex' performed by each method respectively: see S. Hirschauer, 'Performing Sexes and Genders in Medical Practices', in Berg & Mol (eds), Differencesin Medicine, op. cit. note 16, 13-27, quote at 23. Other contributions to Differencesin Medicine, in particular Marc Berg's, Charis Cussins', Isabelle Baszanger's and Annemarie Mol's, are also notable examples of this approach. For another recent statement on 'performance', see Michel Gallon and Bruno Latour,' "Tu ne Calculeras pas!" Ou comment symmetriser le don et le capital', Revue de Mauss, Vol. 9 (1997), 45-70. On 'framing', a similar term, see Michel Gallon's Introductory Chapter to his The Laws of the Markets (Oxford, UK: Blackwell, 1998). 19. Just as the autonomy of facts is constructed through experimental techniques so the specificity (what makes them unique) of objects is obtained in relation to other actants. In other words, specificities of the object emerge as relevant in the course of action, and only in relation to other pertinent elements of the setting. To elaborate on Latour's famous example of the gun, the gun is 'light' only when the skilled shooter lifts his arm to aim: see Bruno Latour, 'On Technical Mediation: Philosophy, Sociology, Genealogy', CommonKnowledge, Vol. 3, No. 2 (1994), 29-64. The very capacity of certain entities to act in unexpected ways - transforming, for instance, the project of the designer - is emergent in the setting. 'Resistance' describes these entities as both (1) emergent in relation to, in reaction to the dispositif,and (2) as never reducible to the sum of the forces which went into their production. To use a well-known example, things do not simply implement the designers' plans but prolong and deviatefrom, in unexpected ways, the action which was delegated to them. 20. As I will show in a specific case below, until this point, ethnographies of drug use are useful despite the fact that they do not address head-on the questions of 'Who acts? What endures? What is action?'. Because they describe the settings of drug use, their techniques of use and the modes of life of users, they are an essential reference in reconstituting the 'dispositif which 'performs' a patient and a drug. In this sense, a diversity of works can be called upon in the literature on drug use. A few classics from different traditions are: Patrick Biernacki, Pathways of Addiction (Philadelphia, PA: Temple University Press, 1986); Norman Zinberg, Drug, Set and Setting (New Haven, CT: Yale University Press, 1974); Ed Preble, 'Taking Care of Business', International Journal of Addictions,Vol. 4 (1969), 1-24; and, in France, Frederic Bachman and Anne Coppel, Le Dragon Domestique(Paris: Albin Michel, 1989). 21. For authors influenced by actor-network theory (ANT), this work on an alternative theory of action has allowed original descriptions of the emergence of the capacity to act. Agency is not either inherent or corrupted. It can be occasioned by a technological setting. For example, Charis Cussins' work on 'ontological choreography' shows that techniques of objectification 'require the [subject's] participation', and that agency (or 'trails of activity') is an achievement which requires objectification. Technology does not have to be seen as obliterating the agency of the subject; rather, the focus should be on what others have called the 'co-construction of subject and technology'. See Charis Cussins, 'Ontological Choreography: Agency through Objectification in Infertility Clinics', Social Studies of Science,Vol. 26, No. 3 (August 1996), 575-610; C. Cussins, 'Ontological Choreography: Agency for Women Patients in an Infertility Clinic', in Berg & Mol (eds), op. cit. note 16, 166-201. Similarly, in previous joint work with Antoine Hennion, I have described subjects as ... ... 'attachments', where action is a return gift from the dispositifto the beings who pass through it. The capacities of the subject then are not essential, but
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Social Studies of Science 32/1 are effects granted by this dispositif.The subject, however, is not passive in this achievement: he/she prepares him/herself to be overcome by the event, the pleasure of the drug or of the music. The generosity of the setting (in granting action) to a subject depends on his/her preparation. The dichotomies of passive/active, determined/constructed, are undone in this description of the preparations or 'conditioning' which the subject both tentatively sets up and submits to. The pleasure of cocaine or of Bach's partitas for the amateur requires that she meticulously establish the conditions: active work must be done in order to be moved. Ignoring the mutual exclusion of passion and passivity imposed by theory of action, the actor might pass through a series of states (being open, patient, receptive, sensitive). These models of acting/being weave together what had seemed to be polar opposites - passivity and activity, determining and determined, collective and individual, intention and causality. See Emilie Gomart and Antoine Hennion, 'A Sociology of Attachment: Music Amateurs, Drug Users', in John Law and John Hassard (eds), Actor NetworkTheory and After (Oxford & Malden, MA: Blackwell, 1999) 222-47, quote at 227. ANT authors have introduced the term 'actants' to load as little as possible a priori the entities involved in the action: see Michel Gallon and John Law, 'Agency and the Vol. 94, No. 2 (1995), 481-508; Bruno Hybrid Collectif, The South Atlantic Quarterly, Latour, Pandora'sHope: Essays in the Reality of Science Studies (Cambridge, MA: Harvard University Press, 1999), esp. 122-23 and 141. Julien Algirdas and Joseph Courtes Greimas, Semiotique:dictionnaireraisonnede la thiorie du langage, tome 2 (Paris: Hachette, 1986). Latour, Pandora'sHope (1999), op. cit. note 22, 152. To emphasize that the event does not have the structure expected by the prevalent definition of drug action, semioticians prefer to speak not of 'action', but of the 'performance' of a substance. The alternative definition of action described above is well summed up in this definition. For semioticians, 'performance' implies that at the beginning there is a collection of effects about which it is impossible as yet to decide 'who acts?'. See also Bruno Latour, 'Pasteur on Lactic Acid Yeast: A Partial Semiotic Analysis', Configurations, Vol. 1 (1992), 129-45; there, Latour writes similarly: '[Performance] precedes the definition of the competence [e.g. substance] that will later be made the sole cause of those very performances' (136). William James has also been used as a resource by several authors influenced by, or participating in elaborating, ANT: see, for example, Vincianne de Desprets, Ces imotions qui nousfabriquent:pour une ethnopsychiatrie l'authenticiti (Paris: Les empecheurs de penser en rond, 1999); also Latour (1999), op. cit. note 22. Though Michel Gallon and Bruno Latour have long been occupied with describing different 'modes of articulation' (or action) between, for example (in Latour's case), science vs art vs religion vs law, there has been less attention to different modes of action within science. In adopting this as a goal, I pick up the thread of works on multiplicity in medicine (in particular, by Annemarie Mol, op. cit. note 15) as well as laboratory practice by Karin Knorr Cetina (op. cit. note 15) and Michael Lynch (op. cit. note 11). In this section, page numbers in [square brackets] refer to quotations from Becker, Outsiders(1963), op. cit. note 13. On deviant behaviour in general, Becker writes: [Scientific research] has accepted the commonsense premise that there is something inherently deviant (qualitatively distinct) about acts that break (or seem to break) social rules. It has also accepted the commonsense view that the deviant act occurs because some characteristic of the person who commits it makes it necessary or inevitable that he should. [3] Deviance is not a quality that lies in behaviour itself, but in the interaction between the person who commits the act and those who respond to it. [14]
22.
23. 24.
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26.
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27. See Howard Becker, 'History, Culture and Subjective Experience: An Exploration of the Social Bases of Drug-Induced Experiences', Journal of Health and Social Behavior, Vol. 8 (1967), 163-76, reprinted in Shaffer & Burglass (eds), op. cit. note 2, 219-40, quotations at 222 and 239. The limits of the symbolic interactionist 'take' on objects has also been criticized elsewhere: see, for example, Latour (1993), op. cit. note 12, esp. 136ff, and Antoine Hennion, La passion musicale, une sociologiede la midiation (Paris: Metailie, 1993), esp. 158ff. 28. As Bruno Latour explains, taking texts to stand for the reality of these experiments has both advantages and disadvantages. A disadvantage is that texts might exclude the question of the referent (the object 'methadone' itself) which I explicitly want to tackle here. (However, in his 'A Relativistic Account of Einstein's Relativity', Social Studies of Science,Vol. 18, No. 1 [February 1988], 3-44, Latour has suggested that this need not be the case.) An advantage is that the texts, when analysed in a semiotic fashion, allow the analyst to take the narrative that unfolds in the text as an event. The text is not taken to refer to a world out there, but to detour just the problem of the correspondence between the text and the world. 29. David Courtwright, 'The Prepared Mind: The Story of Marie Nyswander', Addiction, Vol. 92 (1997), 257-65, quotes at 257. 30. Marie Nyswander, TheAddict as Patient (NewYork: Grune & Stratton, 1956). 31. Courtwright, op. cit. note 29, 264. 32. The experimenters worked in a larger debate on (penitentiary versusmedical) techniques for treating addiction. In the mid-1960s, a fraction of the American Medical Association had just started to argue convincingly for medical control of treatment of addicts, and to propose medical explanations of drug use. Until then, addiction treatment had been coercive, and had taken place in penitentiary-style facilities, such as Lexington (see Nelkin, op. cit. note 1, Chapter 1, 12-36). Medical treatment was an attempt to formulate a liberal alternative to these procedures. Its aim was to show that addicts who had until then been (inefficiently) treated with coercive means in prisonlike settings could be transformed through non-coercive (chemical) means into good citizens and ordinary patients. As it turned out, the argument did not satisfy liberals but this development came later - as addiction was re-defined in the debate as a social problem, not a social crime. Methadone was seen by some as a way to do away with individuals in difficulty rather than as an attempt to soothe and care for them (ibid., Chapter 2, 37-41). For instance, by the late 1960s, certain politicized Black groups vehemently criticized methadone treatment. They considered methadone patients unfit for militant political action because their ties to the methadone-dispensing institution made them too sensitive to exterior control. Methadone was 'the White man's opiate': see James Walters, 'Taking Care of Business: Updated', in Bill Hanson et al. (eds) Life with Heroin:Voices from the Inner City (Lexington, MA: Lexington Books, 1985), 31-48. Other critics declared that it was a 'short-sighted, patchwork treatment based on the principle of least effort': see, for example, Henry Lennard (ed.), Mystificationand Drug Abuse (San Francisco, CA: Jossey-Bass, 1971). Despite scepticism and opposition, by 1971 in New York 17,000 addicts were receiving methadone on a daily basis. Many saw methadone maintenance as the long-awaited 'breakthrough in the treatment of drug addiction' (Nelkin, op. cit. note 1, 32). 33. This argument closely follows the one deployed by Latour, using semiotic techniques to analyse Pasteur's writings on lactic acid: see Latour (1999), op. cit. note 22; Latour (1992), op. cit. note 24. 34. As mentioned above, 'resistances' are: (1) the emergent quality of all properties of things; and (2) to one emergent quality in particular - that things do not simply obey their designers' plans, but also transform and deform them in unexpected ways. Here I insist on the first definition. 35. This does not, of course, mean that methadone would not do anything at all. 36. For a discussion of the US context, and of American political controversies over methadone treatments at the end of the 1960s, see Nelkin, op. cit. note 1, Chapter 1, 12-36, and Chapter 3, 72-94.
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37. For an epistemological history of pharmacology, see Acker, op. cit. note 10. My rough sketch of a history is based on her text; however, the theoretical extrapolations here (an assimilation of pharmacological thinking about drugs to a classical theory of action and substance) are entirely my own. 38. This anecdote is mentioned in Caroline Jean Acker, 'Addiction and the Laboratory: The Work of the National Research Council's Committee on Drug Addiction 1929-1939', Isis, Vol. 86 (1995), 167-93, at 173. 39. The beginning of philosophical reflection has been problematized by post-modern philosophers, some of whom made this beginning an empirical question. For an analysis of Deleuze's critique, see Frangois Zourabichvili, Deleuze, une philosophiede l'evenement(Paris: Presses Universitaires de France, 1994; 2nd edn, 1996). 40. Acker, op. cit. note 38, 173. 41. Here again, I follow for the history, Acker, ibid., 188. 42. If the subject was cross-tolerant to the new drug, this was an additional and conclusive sign that the substance was addictive. Withdrawal, cross-tolerance and addiction have been defined in multiple manners over time. To avoid confusion, however, I will offer the following partial, time-bound definitions. Withdrawal refers to the 'physical' syndrome induced when the administration of an opiate is suddenly interrupted. It contrasts with 'psychological' withdrawal until recently attributed to all other illegally used drugs, like amphetamines and cocaine. In recent years, neurobiologists have suggested that the 'physical' and 'psychological' syndromes both involve a neurobiological mechanism. Tolerance, simply put, refers to the necessity of increasing doses in order to achieve a similar effect of the drug. Cross-tolerance refers to the fact that once this increase has begun with one drug, other drugs can take the delay. Cross-tolerance has been used to demonstrate that different substances are similarly addictive. I will not try to define 'addiction': in each section, I attempt to make clear what, at that point, is the posited relation between drug and drug user. For a contemporary summary of neurobiological explanations of drug addiction, see for example, Jean-Pol Tassin, 'Interets des recherches pharmacologiques pour la clinique' (manuscript, INSERM U. 114, 1993). Les 43. Pierre Deniker, Psychopharmacologie. midicamentset drogues (Paris: psychotropes Ellipses, 1987), 38-39 (my translation). 44. However, one difference should be delineated between the previous uses of substitution and this substitution treatment: if substances had previously been tested through this experimental strategy of substitution, no patient had ever been treated by substitution. Dole and Nyswander's innovation is to have taken a strategy designed to describe the action of a substance without referring to its source (structure), and to have used it to describe - not the action of substance - but the complex phenomenon of addiction. They modelize addiction, 'hunger' and 'tolerance' without (and this is the advantage of the strategy of substitution) having to precisely describe, let alone to prove the existence of, the metabolic mechanisms at the root of addiction. Just as this strategy had allowed the pharmacologists to describe drug action without a source, with substitution, they become capable of treating a phenomenon without being overly concerned by its cause. Despite the immense success of their treatment (in terms of the number of methadone centres opened after publication of their work), Dole and Nyswander's 'metabolic' hypothesis never stopped being controversial: see, for example, de William Lowenstein, La mithadone et les traitements substitution(Paris: Doin, 1995), for a recent French take on Dole. and Intervening:Introductory 45. See, for example, Ian Hacking, Representing Topicsin the Philosophyof Natural Science (Cambridge: Cambridge University Press, 1983). See also Andrew Pickering (ed.), Science as Practiceand Culture(Chicago, IL: The University of Chicago Press, 1992). 46. But, of course, it still has a source - that is, it still takes as its model human agency. 47. David Lapoujade uses the indeterminate phrase in French, 'il pleut', to describe the emergence of the subject. There is a moment, he writes, in which 'he thinks' should be heard, not as the confirmation of an ego, but as the passage of a 'current of thought'.
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48. 49.
50.
51. 52.
53.
54. 55. 56. 57.
58.
See D. Lapoujade, WilliamJames: empirismeet pragmatisme(Paris: Presses Universitaires de France, 1997), 29. Latour (1992), op. cit. note 24, 136. Dole himself had moderated his claims in 1968: Vincent Dole, Marie Nyswander and Alan Warner, 'Successful Treatment of 750 Criminal Addicts', Journal of the American Medical Association,Vol. 206, No. 12 (16 December 1968), 2708-11; reprinted in Shaffer & Burglass (eds), op. cit. note 2, 412-20. Methadone was then tried out at Sainte-Anne Hospital, but also at Fernand-Widal, another Parisian hospital: see E. Fournier, A. Gorceik, P. Bourdon, C. Alva and J. Dugarin, 'Les toxicomanies anciennes aux opiaces', Annales de la MedecineInterne, Vol. 125 (1974), 447-52. Bruno Latour, Science in Action (Cambridge: Cambridge University Press, 1987), 227-37. 'Malleability' does not suggest that an object has a limited set of capacities already 'in it', of which experimenters 'see' or 'use' only one. Instead, the argument is not about potentialization, but 'propension', and about how the experimenter, through meddling with the dispositif,can participate in creating properties, new ones which had not been there before. On 'propension', see Francois Jullien, La Propensiondes Choses:Pour une histoirede l'efficaciti en Chine (Paris: Seuil, 1992). I only describe a few of the transformations operated. Another set could have been described: those operated by the INSERM Commission, a committee designated by the Minister of Health in the early 1970s, included scientists from Sainte-Anne, and was in charge of making French methadone 'safer' than the American methadone. This involved transforming what they called the 'form' and 'mode of administration' of methadone. Methadone had been a pill which the American user could hide in his cheek and sell on the black market. French methadone was a syrup which had to be drunk in front of a nurse. The syrup also made methadone 'difficult to inject'. Such a transformation was not just a change 'around' methadone 'itself': it participated in making methadone a medication, safe, legitimate, and thus facilitated certain ontologies rather than others. Unexpectedly, these transformations of 'form' are also nonessentialist experiments with methadone. For the analysis of the transformation of in 'form', see my PhD thesis: Emilie Gomart, Surprisedby Methadone:experiments substitution(tcole Nationale Superieure de Paris, 1999). Deniker's Service was 'General Psychiatry' ('Service hospitalo-universitaire santi de mentale et de Therapeutique'), and did not specialize in addiction. See Jean Thuillier, La rivolutionsdes Tranquillisants (Paris: Opera Mundi, 1981). Henri Ey proposed an 'organodynamisme' much criticized by Jacques Lacan, who also lectured at Sainte-Anne in the 1950s: see Thuillier, op. cit. note 55, 28-32 and 195-99. According to Thuillier (ibid., 27-28), progress was defined as the transformation of the toolkit of the psychiatrists in state mental hospitals. State hospitals, as representatives of the state, were suspected of striving to make docile citizens, whereas their therapeutic mission, according to certain Lacanian analysts, should have made them work to free the individual. This freedom might even be radical and subversive to the state, according to Marie-Claude George andYvette Tourne, Le secteurpsychiatrique(Paris: Que sais-je?/PUF, 1994). Traditional psychiatric techniques (electric and insulin 'shock therapies' which were so violent that when they shocked the patient they also shocked and exhausted the staff responsible for the procedure) were replaced by the more 'efficient' and 'bearable' psychotropic drugs. The neighbourhood of the Sainte-Anne hospital, which until the middle of this century had been notorious for the terrifying shrieks heard behind the thick tall walls, had since the introduction of tranquilizers become 'one of the most peaceful neighbourhoods of Paris' (Thuiller, op. cit. note 55, 44, 201-4, 310). One central reason for this rejection of psychotropic medication was that they did not believe that the addict was psychopathological or sick: a prescription would not only wrongly designate the user as sick - it risked making him sick. Methadone began, then,
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Social Studies of Science 32/1 in France as a tool of just those psychiatrists who were isolated from the growing psychoanalytically-oriented 'specialized' field of addiction treatment. It remained an experimental practice, authorized under strict conditions by decree, and for a strict number of patients (25 patients per centre, only two centres doing it - and both trying to prescribe to even less than 25). With the advent of the AIDS epidemic, the harm-reduction promoters devised a new treatment with methadone, which defined yet another way of 'doing' methadone, with its own very specific dispositif.For a description of the state of the art of French methadone treatment in the late 1980s, see Francoise Lert and Frederic Fombonne, La toxicomanie:vers une evaluation des traitements(Paris: La Documentation Francaise, 1989); for an analysis of experimental treatments developed during the 1990s, see Gomart (1999), op. cit. note 53. Dole and Nyswander's report [D&N] had not described the chemical structure, nor the pharmacological actions of methadone. I have chosen in this paper not to develop a normative analysis of the different treatments, the topic of action being important to settle before such analyses are taken up. For an attempt at such a treatment, see Emilie Gomart, 'Elogeof Methadone', in Marc Berg and Madeleine Akrich (eds), Bodies on Trial:Performances and Politicsin Medicine and Biology, Special Issue of Body and Society (in preparation). The Sainte-Anne report [S-A: 89] designates their techniques of selection of patients as important intermediaries, the 'bridge', that performed methadone. These terms 'intermediaries' and 'bridge' are borrowed from William James, Psychology:The Briefer Course (NewYork: Henry Holt & Co., 1910), 67-76 and 92-122. Following James, my aim is to describe the emergence of things in the making, rather than a world already full with distinct entities. These terms are taken from James' argument against 'saltationist', and promoting 'ambulatory', modes of knowledge-making. Rather than jumping across a gap between subject and object of knowledge, he recommends us to take seriously the 'particulars', the 'intermediary series' through which one 'deambulates'. He explains that objects seem to be pre-given entities only because we forget these intermediaries and retain only the general schema of things. Latour (1988), op. cit. note 28, 6. Interview by author with Henri Loo (Paris, January 1994). Antoine Hennion makes a difference between intermediaries and mediators: for him, intermediaries are instruments used by humans to realize their plans but which in no way transform, add to, these plans; in contrast, mediators as they are mobilized to accomplish a task always do more than what was expected of them. In the end, the task performed is not exactly the one which had been assigned to the object. (It should be noted that Hennion's use of 'intermediaries' has nothing to do with my own, drawn from a Jamesian vocabulary.) See Hennion, La passion musicale, op. cit. note 28. To use Garfinkel and his co-authors' expression in a different sense: see Garfinkel, Lynch & Livingston, op. cit. note 8. One well-known instance of such experimental uses of drugs was 'narco-analysis'. Short-acting barbiturates (usually used for anesthesia) were administered intravenously. This caused a lowering of vigilance, psychological and neurological modifications and, it was claimed, could be useful for 'the exploration of the subconscious'. A combination of barbiturates and amphetamines was sometimes used to provoke both a lowering of vigilance and an acceleration of thought and speech processes. See Deniker, op. Psychopharmacologie, cit. note 43, esp. 64. Deniker, ibid., 60 (my translation). Thus Deniker writes (ibid., 64-65, my translation, his emphasis): In the melancholicstate the subnarcosis barbiturate produces an attenuation of symptoms. This can be such that the patient can feel himself to be 'cured' as long as the action of the barbiturate lasts. In cases where inhibition dominates, the contact until then difficult becomes possible and the patient expresses depressive themes, sometimes delirious, which had been impossible for him to communicate. The amphetamine trial on the contrary accentuates
59.
60. 61.
62.
63. 64. 65.
66. 67.
68. 69.
Gomart: Methadone: Six Effects in Search of a Substance the melancholic symptomatology, which is particularly interesting in light forms, where the diagnostic is doubtful, and where the accentuation of the symptoms will ensure the diagnostic and allow the start of the treatment. For manias, subnarcosis with barbiturates reduces temporarily the agitation and hyperactivity, making the interrogation of the patient easier.... In certain cases, the amphetamine trial can even provoke a sudden inversion of the expansive moods into a depressive anxiety with appearance of melancholy themes. In schizophrenic psychoses,the use of pharmacodynamic trials is also of great interest. Lifts the inhibition which dominates certain forms and allows the exteriorization of delirious ideas until then hidden.... Most often, amphetamines make latent schizophrenic symptoms appear ... which are of great diagnostic value since these appear only with schizophrenics.
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70. Unlike Dole's methadone, at Sainte-Anne methadone does not act on addiction itself or on its cause. For Dole, methadone soothed the metabolic disequilibrium which was the cause of relapses and of the intractability of drug craving. At Sainte-Anne, the deficitary syndrome upon which methadone acts is not the cause of addiction but rather a result of drug use. It is a symptom of drug use. 71. In interview in 1994 (loc. cit. note 64), Henri L6o said: Loo: It's not methadone that makes him return to a normal life, it's the personality that's behind it all. The 'real addict' only became marginalized because he spent too much time searching for the drug. If you give him the opiate, pffft! ... [the problem disappears]. The real addict when you give him his opiate, becomes a good father, good husband and employee.... EG: There's a whole diagnostics of the personality involved. Loo: That's very good, what you're saying. A diagnostic of the personality and of the environmental factors that precipitated... 72. Henri L6o, Xavier Laqueille, Pascal Remi, Frank Bayle and Jean-Pierre Olie, 'Les traitements de substitution des heroinomanes par la methadone. Interet, limites et pratiques en France' (Paris: Service hospital-universitaire de sante mentale et de therapeutique de Sainte-Anne, 1994). 73. The exact rate of psychopathology among users is today a topic of heated debate: see Anne Coppel, 'Peut-on soigner les toxicomanes? Les enseignements de l'histoire', in Jean-Marie Guffens (ed.), Toxicomanie, Hepatites, S.I.D.A. (Paris: Les empecheurs de penser en rond, 1994), 43-46. 74. Latour (1992), op. cit. note 24, 141.
Emilie Gomart is a Postdoctoral Researcher at the Political Science Department of the University of Amsterdam. This paper is based on her PhD thesis, an ethnography of methadone maintenance, submitted in 1999 at the Ecole Nationale Superieure des Mines de Paris. Her current work, an ethnography of designers engaged in policy-making in the Netherlands, explores the politics which their images and drawing techniques make possible. Address: Department of Political Science, University of Amsterdam, 237 Ouderzijds Achterburgwal, 1012 DL Amsterdam, the Netherlands; fax: +31 183 500 709; email: gomart@pscw.uva.nl

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Methadone: Six Effects in Search of a Substance Author(s): Emilie Gomart Source: Social Studies of Science, Vol. 32, No.

Methadone: Six Effects in Search of a Substance

Social Studies of Science 32/1

Gomart: Methadone: Six Effects in Search of a Substance

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Gomart: Methadone: Six Effects in Search of a Substance

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Gomart: Methadone: Six Effects in Search of a Substance

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Gomart: Methadone: Six Effects in Search of a Substance

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Gomart: Methadone: Six Effects in Search of a Substance

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1 FIGURE Six Effects of Methadone Treatment?

Gomart: Methadone: Six Effects in Search of a Substance

Six Methadone: Effectsin Searchof a Substance Gomart: Division of ProgramInto ThreePhases

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Gomart: Methadone: Six Effects in Search of a Substance

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action) which pharmacolo-

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Gomart: Methadone: Six Effects in Search of a Substance

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Gomart: Methadone: Six Effects in Search of a Substance

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Gomart: Methadone: Six Effects in Search of a Substance

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psychotic personality ...

unbalancedpsychopathological personality... 'addictive'personality,where the main pathologicaltrait is summarized

Gomart: Methadone: Six Effects in Search of a Substance

relationto personality, shown that successeswere those of psychotic has

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Gomart: Methadone: Six Effects in Search of a Substance

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Gomart: Methadone: Six Effects in Search of a Substance

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Gomart: Methadone: Six Effects in Search of a Substance

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Gomart: Methadone: Six Effects in Search of a Substance

Gomart: Methadone: Six Effects in Search of a Substance

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Gomart: Methadone: Six Effects in Search of a Substance

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