Kontroll av beroende. Substitutionsbehandlingens logik, praktik och semantik

Sammanfattning: This thesis concerns maintenance treatment with methadone or buprenorhine in Sweden. The general aim has been to contribute to an understanding of the everyday practice of maintenance treatment, how power is exercised and how clients are constructed in a local, outpatient treatment context. The study has been conducted at three clinics in the city of Gothenburg and the empirical material comprises fieldnotes from observations, individual interviews with clients and professionals, as well as two focus group interviews with members of clinic staff. In addition, textual documents used in the everyday work at the clinics have been collected. From a general social constructionist perspective, a micro-sociological approach has been applied to the data. Goffman’s interactionism is a major theoretical point of departure. Interviews, narratives and meeting talk are analysed as discourses, with special attention to accounts for decisions and rule-breaking behaviour. In addition, Foucault’s works on power and the distinction between discipline and border control occupy a central place in the analysis throughout the dissertation. The main findings are that maintenance treatment does more than provides its clients with medication to control their opiate addiction. In their own stories, the clients describe a kind of institutionalization, triggering identity transformations as well as resistance. The combination and interaction of disciplinary, pastoral and sovereign power technologies, as well as accounts for rules, rule-breaking and sanctions, contribute to the construction of institutionally anchored client categories and in the final analysis, either pitiable or blameworthy clients. The thesis exposes a number of tensions and contradictions within Swedish maintenance treatment. First, despite its attributed status of evidence-based practice for opiate addiction, it is constantly questioned and criticized as treatment approach, since it conflicts with the national goal of a drug free society. Secondly, clients experience a tension between treatment as life-saving (in relation to inclusion) and as a danger of life (in relation to exclusion). A third tension is located between the binary client positions blameworthy, manipulative addict and pitiable, worthy patient, and a fourth one is the recurring, unsolved question whether methadone and buprenorphine clients are ”cured” from their addiction or if they are still drug addicts. Fifthly, there are contradictory views on maintenance treatment as a work in itself, and treatment as a secret and an obstacle to a normal life. Finally, there are tensions between sovereign, disciplinary and pastoral power. These forms of power are based on different logics and are exercised in different ways, but meet, merge, coincide and compete in the studied clinics. These identified tensions reflect the inconsistent context of maintenance treatment and are, in turn, mirrored in and managed through the specific practice, semantics and logics of this way of controlling addiction.