Withdrawal From Injecting Heroin Use PDF

Critical Public Health
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Withdrawal from injecting heroin use: Thematizing

the body
Glenda Y. Koutroulis
To cite this article: Glenda Y. Koutroulis (1998) Withdrawal from injecting heroin use:
Thematizing the body, Critical Public Health, 8:3, 207-224, DOI: 10.1080/09581599808402908
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Critical Public Health, Vol. 8, No. 3, 1998 207
Withdrawal from injecting heroin use:

thematizing the body
G L E N D A Y . KOUTROULIS
Downloaded by [b-on: Biblioteca do conhecimento online UBI] at 04:19 21 November 2015
Turning Point Alcohol and Drug Centre, Fitzroy, Victoria, Australia
ABSTRACT Much of the drug research literature has concerned itself with quantifjring aspects
of drug use and drug users lives, paying little attention to the social processes that underlie drug
use and withdrawal therefrom. This paper highlights the value of the sociology of the body for
understanding the issue of withdrawal from injecting heroin use. Based on interviews with nine
women and seven men, the approach involves focusing on these clients accounts of their
experiences of (now-methadone) withdrawal from heroin, tracing the social processes that invoke
them to thematize the body as they position themselves as dirty or clean, and resist
construction of the self as junkie or slave.
Introduction
Despite the large body of literature surrounding drug use there is little that
conveys a sense of a persons embodied experience of drug use and withdrawal
therefrom. This could be explained by the selective character of the research.
What is significant about the drug and alcohol research literature is its
intellectual provincialism and isolation and a peculiar repetitiveness. This
repetitiveness relates to bias in the literature reviews2 and that extends to
research methodology2i3and reporting of findings.2 Such representations of
knowledge have gained their plausibility and normative status from assump-
tions about what is important to know and the superiority of certain forms of
kn~wledge.~
The narrow terms in which drug and alcohol research is defined3 and the
overshadowing of drug-related sociological research by medicine and psy-
chology5 was highlighted in a special issue of the Australian journal Drug and
Alcohol Review, dedicated to social sciences and the addictions. This edition
testifies not only to the past pre-eminence of quantitatively oriented works, but
to the continuing diminution of the contribution of qualitative social scientific
research particularly with regard to that which seeks to understand subjective
meaning^.^ This is not to say that there is no qualitative research of this kind,
just that comparatively it is thin on the ground, and has difficulty being heard
when policy, funding and treatment decisions are made.
~
Correspondence to: Dr Glenda Koutroulis, 75 Henry Street, Windsor, Victoria 3 181, Australia.
0958-1 596/98/030207-18 0 1998 Carfax Publishing Ltd

208 G. Y.Koutroulis
One of the hallmarks of drug use as a field of inquiry is its multidisciplinary

nature.6 This offers the opportunity to promote scientific research as an interdis-
ciplinary exchange, which would enable a problem to be approached from
different points of view.7 Such an exchange has the potential of generating a
rich, exciting discourse feeding into the knowledge base of drug use. Interdisci-
plinary exchanges, though, can mean a group of individuals talking loudly past
each other and not hearing what the other says.6 Rogalski* provides a poignant,
colourhl account of her work as a clinical psychologist in an interdisciplinary
drug and alcohol centre. She reports that the puffery, self-interest, aggrandize-
ment and bloated sense of self of some of her work colleagues in management
positions clouds sobriety in collection and assessment of data, hampering
effective interdisciplinary research. This description resonates with my own
experience.
Scenarios like Rogalskis have crucial implications for choice of methods
which are clearly shaped by wider social b i a ~ e s They
.~ are also an example of
why certain theories of addiction continue to predominate at the expense
of alternative theories, guiding research in certain, not necessarily helpful,
directions, and guiding treatment toward utilizing chemical options over other
styles of treatment.8J9America has been described as the western prototype of a
preoccupation with focusing on the addict, addiction and chemical substances
with a movement away from cultural psycho dynamic^.^ My own experience of
working in an Australian drug and alcohol centre suggests a similar phenom-
enon at work. It was my observation that an emphasis upon chemical treatment
modalities prevailed, more recently in the form of the rather fashionable concern
with alternative pharmacotherapy treatment. Such persistence toward chemical
treatments emanates from what Stein calls officially sanctioned theories of
chemical addictions and management strategies rationalized through medical
science. In Steins view, these theories are psychological or symbolic guides to
the normative structure of contemporary society.
Normative conventions hold much symbolic power, and there is a tendency
to treat as a heretic someone who questions accepted beliefs about addictions
treatment. As well as personal ramifications, any bias (sex, disciplinary or
methodological) is likely to have implications for the way drug use issues are
addressed and drug use inquiry advanced, and for clinical practice. The knowl-
edge on which clinical practice is predicated, the attitudes of practitioners and
the way in which clinical services are constructed are shaped by knowledge
emanating from sources such as the drug literature. One possible outcome
(to use a term familiar to those who work in the drug and alcohol field) of the
narrowness of research thus far is a general intellectual impoverishment of
the field (p. 356)3. The publishing of Rogalskis brief but scathing account
of her interdisciplinary experience, though, poses an epistemological challenge
about who is the knower and what can be known serving to (re)define what
counts as acceptable knowledge in this field of study.
As the foregoing implies, there are limitations to what is imbued with
significance in the drug and alcohol research and treatment arena. In this section
Withdrawal from injecting heroin use 209
I reflect on literature specific to withdrawal. While there exist numerous

discussions about withdrawal I will proceed directly to Rumbold, Frank and
Peads annotated bibliography of opiate withdrawal to help provide initial
bearings for how withdrawal tends to be conceptualized and to substantiate my
claim regarding how drug research literature is represented. I focus on this
document because it was suggested by my work colleagues as a very useful
source when I began researching in the drug and alcohol field some two to three
years ago. In their annotated bibliography, Rumbold et al. propose that all
literature that was relevant to the treatment of withdrawal from ... opioids was
included, except animal research ... [and] the large and more general areas of
literature which relate to withdrawal, such as anxiety and sleep dis-
order, ... [and] neonatal withdrawal (p. 3). T h e literature reported in the
annotated bibliography was used, in combination with expert opinion, to
develop treatment guidelines for alcohol and drug withdrawal (p. 3) . Topics
included the nature of withdrawal encompassing symptoms and physiological/
pathological response to opioid withdrawal, treatment for opiate dependence,
pharmacotherapy, and the settings in which withdrawal takes place. However
benevolent the research activities of Rumbold et al. might be, I suggest that the
document emphasizes the discipline and individual interests of these authors,
supporting the claim of Brett et al., amongst others, that bias in literature
reviews and compilations is alive and Social research, including explicit
reference to gender and class, for example, was excluded from the document,
neither noted for its absence nor addressed as warranting attention with
regard to future research. This suggests the possibility that these authors do not
see any of the aforementioned factors as relevant to the development of
treatment guidelines, or that they d o not see because of their own disciplinary
bias. Their literature selections reinforce the disease model of addiction, which
emphasizes drug use as a disease process contained within the body of the drug
user and diverts attention from social, political and economic influences on drug
use.12
This eclipsing of social categories by researchers has also been noted by
Strang and Taylor3 who draw attention to the ignoring of age and gender
characteristics of heroin users in the UK across time. They express concern
about this oversight in light of their findings of major differences in gender and
age of addicts over two time periods.13 T h e findings of these authors support my
contention that inclusion of gender (and other social variables) in data analyses
is idiosyncratic or whimsical, dependent on personal proclivity or consciousness
of the researcher.
There are few works which explore meaning and subjective experience around
withdrawal (for one example see Blackwell14), and a cursory glance at the
literature that examines why drug users enter withdrawal treatment shows that
the most obvious feature of much of the research is the way in which the data
have been classified and collected, much as if this is the routine, normal way.
Murphy and Bentall, for example, utilized a 30 item motivation scale to
question 107 heroin users within the first two days of an attempt to withdraw.I5
210 G. Y.Koutroulis
These items were then factor analysed. Three studies l 8 utilized a number of
questionnaires to find out why drug users sought help. One questionnaire,
employed by all three studies, itemized 54 possible reasons for coming for
treatment, asking respondents if they had experienced any of the listed reasons
and if so, whether this was an important reason for coming for treatment. Items
spanned such topics as: the availability of drugs, subjective experience of the
dependence on drugs, the physical health implications of drug misuse, problems
experienced in relation to money, accommodation, employment and the legal
system, appraisal of own emotional state, and relationships. Oppenheimer et al.

conclude that it does seem to be a combination of trigger events and a
subjective re-evaluation of the meaning of these events that precede help-
seeking17 (p. 645).
How do these authors know, through respondents standardized responses to
highly structured questions, that a subjective re-evaluation of the meaning of
trigger events that precede help-seeking has taken place? Mishler takes the view
that instruments, where questions have been standardized and the technology of
coding and statistical analysis is used to make sense of the data, have the effect
of suppressing discourse and obscuring, even quashing the social and personal
contexts of meaning-expressing and meaning-understanding. l9 Thus, the con-
clusion of Oppenheimer et al., I argue, is debatable. From a poststructuralist
stance, Reekie points out that without attention to language and the processes
by which meanings and categories are constituted, we perpetuate conventional
and over-simplified understandings of the world, rather than opening up new
interpretative possibilities (p. 462). A case, therefore, can be made for some
displacement of what has come to be the traditional, customary well-worn way
of tackling research around withdrawal treatment. The replacing of quantitative
instruments with a more sustained focus on client experience and the discourses
through which clients are positioned, then, would promise illumination of
neglected aspects of withdrawal and the many ways withdrawal is experienced
and managed within given social structures. Social categories that include age,
class and gender are tied to how we experience our bodies. Contributions that
focus on the body and embodied experience could bring us closer to those
whom we are trying to study.21
This paper is an empirical contribution to drub research about withdrawal. I
focus on the meaning and significance of injecting heroin use within the context
of withdrawal as experienced in everyday life. This is understood within some
cultural interpretations of heroin use and withdrawal from heroin. My aim is to
contribute to the development of an understanding of the embodied experience
of heroin use and of heroin withdrawal and how this might influence clinical
practice around withdrawal. I do this by producing a record of interviews with
injecting heroin users about their impetus for withdrawal that are treated as a
narrative account embedded in complex issues of subjectivity; and through
providing a distinctive analysis of the withdrawal accounts by interfacing these
data with the sociology of the body perspective. This approach has an agenda
of fleshing out relations among subjectivity, embodied experience and the social
Withdrawal from injecting heroin use 21 1
factors that mediate the withdrawal experience that has the potential of altering
the shape of withdrawal knowledge. Having begun this introduction by touching
on some of the main themes that run throughout the drug withdrawal literature
I will conclude by providing a brief description of the sociology of the body
perspective on which I draw within this paper.
Sociology of the body

The view of the body I take here follows that of Turner who assumes the
existence of an organic body that is relational, and socially and culturally
elaborated.22The elaboration of the body is part of what Shilling calls a body
project where the body is in a continual process of becoming, something that
needs to be worked at and is integral to self-id en tit^.'^ The most common
example of the body as a project is the attention that is given to healthy bodies.
This attention is focused on individual responsibility for health rather than on
threats to health by global dangers. Individuals are urged to be diligent about
the application of self-care regimes which include eating the right foods and not
smoking.23
Implicit in the body project is a notion of reflexivity and an acknowledgment
of the body as a symbol. From a structuralist perspective the body communi-
cates social organization which is expressed in body symbolism. The body, a
metaphor of society, both expresses and mediates the social situation at any
given point in time.24 An example of how social organization is expressed in
body symbolism comes from C o ~ r t w r i g h t description
s~~ of the etymology of the
word junkie. In its original, literal sense junkie meant junkman. T o explain,
junkmen were those New York City addicts who in the early 1920s supported
themselves by retrieving scrap metal from industrial dumps which they then sold
to a dealer. Co~rtwright~ believes that symbolically the term captures the shift
in the locus of addiction from the nineteenth century offices and parlours of
middlehpper class women, to the urban desolation of the 1940s lower class
male.
The body as a project and as a carrier of social messages requires a conscious-
ness and concern about body look and management. The extent to which the
body is a project is likely to vary across classes and among individuals but
the experience is inevitably embodied.23Social divisions become embodied and
there are differences in embodiment between men and women.26 Societies
produce certain kinds of bodies, and normality is the controlling principle so
that corporeal existence is a form of life and a ~ondition.~ In American society,
as in Australian society, the culturally and politically correct body is the
beautiful, strong, and healthy body (p. 25)2R.I would add the non (visibly)
drugged body to this list. Normality and deviations therefrom have an impact on
experiences of bodily pleasure and ~ell-being.~ In a discussion of moral
socialization, Haug notes the tensions inherent in body functions and pleasure.
On the one hand, integration into social groups depends on behaviour centred
on the body and its normality; on the other, there is the issue of body well-being
212 G. Y.Koutroulis
and enjoyment.29In sum, the literature suggests that through the body meaning
is expressed. It follows, then, that how heroin use, or withdrawal from it, is
experienced is dependent on the social ascription of meaning.
Setting
This study was carried out at a public non-residential alcohol and drug centre
located in an inner suburb of Melbourne, Australia. T h e location of this centre
was more eloquently described by one participant as being right in the heart of
Smacksville. Drug users come to the centre for withdrawal treatment and
other interventions, after a lengthy series of assessment procedures. T h e initial
assessment occurs when the drug or alcohol user first requests treatment, and
this may take place over the telephone. Provided certain criteria are met, for
example, the exclusion of some medical and psychiatric disorders, then the
client is invited to attend a more general assessment. At this assessment a
detailed psychosocial history is recorded. This is followed by a medical examin-
ation and the conducting of medical tests. For some, interventions (counselling,
and prescription drugs such as Valium and Doloxene) may begin at this
assessment. For others, interventions are initiated at subsequent withdrawal
appointments. The assessment determines the clients acceptance into the
withdrawal programme; if accepted, the person signs a contract agreeing to
the conditions of the withdrawal programme and so becomes a client.
Method
Fieldwork took place over a three month period during 1996. This involved
tape-recorded, semi-structured interviews with 16 clients who, following a
detailed explanation of the project and an assurance of confidentiality, agreed to
participate in the study. There were seven men (aged from 24 to 31 years) and
nine women (aged from 21 to 37 years). All were Melbourne residents
and Anglo-Australian in origin. Pseudonyms have been used throughout the
data analysis to protect client identity. Fourteen clients were injecting heroin
users, one was an alcohol user and one was primarily a cannabis user, although
this person was also an occasional heroin user. It is the accounts of the heroin
users that are represented here. I have used italics to distinguish the voice of the
research participants in an endeavour to signal their text as the primary
data.
The first interview, generally of 20 to 30 minutes duration, took place
following the clients agreement to participate. This interview explored the main
reasons influencing the clients decision to seek entry into the withdrawal
programme and how she or he anticipated that treatment might address these
issues. A second and third follow-up interview was conducted where possible.
When these follow-up interviews did occur, they were conducted with a slightly
different schedule of questions, but the focus was directed toward what the
client felt she or he might have achieved by participating in the withdrawal
programme. T e n of the 16 participants were interviewed twice and one was

interviewed three times. A second interview was conducted with one man and
two women at the time they presented for a second appointment with pro-
gramme staff. Others (three men and five women) participated in a second
interview after they had dropped out of the programme but then returned to
re-start in the programme at a later date (kick-starters). This interview focused
on why the client decided not to continue with the initial withdrawal pro-
gramme. Of these kick-starters one woman completed the treatment programme
and was interviewed on a third occasion. Here she was asked evaluative
questions about the programme.
The interview material was transcribed into hard copy form. Through analysis
of words, complex representations of social relations were given meaning. T h e
style of analysis employed is well described elsewhere 7 3 and generally involved
noting themes and underlying similarities and differences in a text. Interpretive
devices such as metaphors were used to link different thematic elements of the
text to explain the representation of ideas or taken-for-granted knowledge
brought to the experience and displayed in the talk. Essentially, the text was
decoded.
Results
In what follows I shall examine some dominant features of the body themes that
emerged from the withdrawal narratives; and offer my own analysis of these
accounts. These narratives and the accompanying analysis highlight the role that
bodily experience has in shaping identity. I begin by introducing heroin users
talk and discussing symbolic meanings of this talk. Next, I examine how these
heroin users make sense of their withdrawal experience in the context of junkie
and as slave. Finally, I consider the subjective experience of withdrawal as a
gendered embodiment of social life.
I have to be clean
It is through illicit drug use that a person acquires certain meanings and
becomes a vehicle of signs, indeed a sign in their own right. T h e heroin user is
spoken of as dirty, junkie, scummy, untrustworthy. They may look dirty
on the outside, or even clean on the outside, but be dirty on the inside. Drug
users are constructed as dirty when their urine is found to contain evidence of
illicit drugs; they are clean when their urine indicates this to be so. These
categories of clean and dirty are an expression of symbolic systems.24
T o voice their own (im)purity through describing themselves as clean or dirty
is part of the common parlance of drug users, and this came through in a
number of interviews. T o get clean; stay clean as long as possible; clean u p
altogether; ty to get clean again, show that clean is a milestone to the pathway
of withdrawal. These, and the comment: I have to be clean .. . for practical reasons,
demonstrate how non-drug use is re-named or overlaid by the notion of
214 G. Y.Koutroulis
cleanliness, a value through which the drug user is interpellated as one who
must keep his or her insides clean. This is required not only for the subjective
self but for reparation of the social fabric in which the drug users life is
entwined to take place.
Heroin is surrounded by prohibitions, moral regulations and more recently
with the advent of AIDS, rules of hygiene. The layers of meaning built up
around heroin, and through heroin use, as well as the myths and fantasies that
accompany it, seem to form part of a dynamic of socialization which is
understood as a relation of crossing boundaries; moving from outside the body

inwards, heroin is lived from inside the body outwards, including in its associ-
ation with urine: heroin, when inside the body, becomes dirt. This magical
reconstitution of heroin can be understood within K u b i e ~ framework
~ of the
body as a dirt factory, thus explaining the reference to the (human) container as
dirty or even junk.
The subject: Dirty, scummy, little junkies

Injecting heroin users produce themselves as particular beings through the
appropriation of specific characteristics-dirty, junkie, criminal and so on. Some
users make clear distinctions between user (self) and junkie (other). In several
of the interviews, the concern is to produce an appearance that conveys
particular meanings relating to the self as a person. The hope, in so doing, is to
show the possession of qualities that stand in contrast with the construction of
the self as a junkie. Looking at the expressions used here-Living the life of a
junkie; I dont want to be a junkie; You cant trust a junkie; Dirty, scummy little
junkies-the theme being addressed, or rather the problem being manufactured,
is equated with a negative association of the body, the self. This becomes
apparent when we explore the use of junkie as a metaphor. The use of junkie
in popular discourse reinforces the notion that drug users are worthless. It
amounts to saying, first of all, that a person is (worthless) rubbish. Second, to
describe a person as junk(ie) incites imagery of a heroin vessel, a courier, a
container of evil. This metaphor fits well with Steins view that drug users serve
as the vessels for a collective social evil, an evil which is displaced and projected
on to them to distract from more frightening social worries such as indifference
and the threat of nuclear war.
The process by which the person becomes drug user is a system of signs; in
Shillings terms, the references are to what she or he is to become.23The
transformation becomes evident as quantitatively and objectively verifiable as
the point is reached where drug use is clearly visible. This bodily process is
firmly entwined in the social context, fixed to the meanings through which drug
user is made. Within this social context the status of junkie is attained. In his
popular book Junky, William S. bur rough^'^ tells of his experiences as an
injecting drug user. In the context of Burroughss experiences, the drug is junk,
and junk is a way of life. Being a person who uses junk, then, becomes being a
junkie.
Withdrawalfrom injecting heroin use 215
Hospitalized for several hours because of an overdose, Beth portrays the

positioning of herself as junkie: I was just called a (polite) junkie at the hospi-
tal ... but I never saw myself as one ... . I just see myself as a person. Her
disassociation of this status can be understood as a moment of resistance.
Alongside Beths resistance to associations with junkie stand all black well'^^^
study participants who shared a similar distaste for the junkie role model. Even
so, about half had at some time applied the label to themselves although not
with any sense of seriousness or permanency. Blackwell does not, however,
forward the idea that this lack of seriousness may have constituted a form of
resistance to the idea of self as junkie.
Resistance to such negative associations is not necessarily easy. It is possible,
though, that a mending of the junkie-person rupture can be facilitated by what
takes place within helping agencies. For example, Joan described attending the
alcohol and drug centre as: empowering to the users. She explained: It doesnz
make them feel degraded and that they are these dirty, scummy little junkies coming
in.
The subjective experience of junkie is important. Subjectively, the previous
story teller experiences the association with being a junkie as a source of
degradation. For some, however, junkie is a lived experience in another sense;
in practical terms, it is, as bur rough^^^ so well conveys, a way of life, and an
obstacle to a certain quality of life. One person was to remark: Living the life of
a junkie, dying and having a really scattered life, I dont want any of those.
In the above accounts, there is an expression of a moral distinction between
drug user and junkie, in much the same way that distinctions are made
between drug user and misuser/abuser. This is interesting in the light of
Dallys concerns with drug use language, or what she refers to as
. ~ ~ calls Drugspeak a language which is tied to politics, and
D r u g ~ p e a k Dally
which is used as a tool of manipulation that has the effect of obscuring
meaning. She proposes that the term drug user is preferable (neutral) to drug
abuser/mi~user.~ I believe, however, that Dallys view overlooks the hierarchi-
cal morality and infrastructure which is associated with, and assigned to, the
use of drugs and its concomitant language. What all of these terms have in
common, I argue, is a moral judgement surrounding a drug lifestyle. Thus,
both drug and user are not unproblematic terms; user, like abuser/misuser
has distinct meanings and in Australian popular culture one of those meanings
is taking without giving back-a way of life that is often linked with one who
uses drugs.
The subject: slave

Rogalsk? chronicles the political processes surrounding drug use in America
from the 1700s until recent times. She connects political power and regulatory
structures to market place conditions (including slavery) that influenced the
drug trade and obscured the real intention ... to regulate the person (p. 40-
41). It could be argued that these clients who have constructed themselves as
216 G. Y. Koutroulis
slaves have interpreted their drug use through what Bell calls a subtle conceptual
framework whereby the drug (heroin) is seen as the causal agent in the
p r ~ b l e m . ~T h e drug is conceptualized as an evil essence that has invaded
the person. Thus, American theories of drug and alcohol abuse convey the belief
that the essence of the abuse lies in the chemical substance rather than in
personal or social factors. This ignores the social relations in which drug use
takes place, that is, the drug is isolated from its context of use and is cast as the
demon, the menace, the problem.
T o be a slave is to occupy a hallowed space as the object of another;

participation in the reinforcement of a subordinate status can be called slavish
b e h a ~ i o u r Drug-taking
.~~ does not automatically place someone in the position
of slave, So, how do drug users construct themselves as slaves? Blackwel13
reports that a slave-like sense is more likely professed by those who are
powerfully compelled to heroin and other opiate narcotic use than b y those
whose compulsion is less powerhl. In the present study, slave language
showed up in a number of the interviews. I have used excerpts from these
interviews to illustrate what informs a slave identity. Although differences are
apparent in the choice and frequency of this slave language, the excerpts are all
remarkable for these drug users recognition of their position as slave and for
their expression of resistance which, through the desire for withdrawal, is
directed against the dictates of the body. In the following account, Jims sense
of being a slave is linked with multiple elements (feelings, money, control).
(J =Jim; I = interviewer).
J: If we didnt get it [smack] wed stop for a day and then if we didnt get
it the day after that Id start feeling really horrible and shitty; ... then I
realized I had to get a grip because it was costing me a lot of money. Like
I want to control the drug not the drug control me ... . Money was another
big factor, like Im in debt a bit.
I: So youve got the financial side of things ...
J: Yeah, I dont want to be a slave.
I: Controlling you?
J: Yeah, I want to be the master not the slave.
T h e stories clients told explaining why they wanted to withdraw were linked
with loss of control and revolved almost without exception around finances.
Eland-Goossensen et al. have written that a sure sign of losing control of drug
use is when the user ceases to decide the amount of use but is limited by the
available money. T h e image of slave allows us to grasp the relation of
structural domination within which the heroin user is subordinated to the drug,
and at the same time to portray the heroin user as active, albeit in the context
of given constraints. T o Jim, heroin has lost its function of pure pleasure in
which its usefulness was defined in relation to how it made him feel. Instead, it
has become a symbol of domination, and of potency not only in its pharmaco-
logical characteristics but in its association with his lack of money.
While it could be argued that all heroin users demonstrate assent to their
rejection of the dominant order through their use of this illicit substance, at the
same time, for these users, the illicit substance became the agent of domination.
The bodily pleasure involved in using heroin was undermined by the effort and
money involved in attaining it, and the subordinating character of this process
whereby these injecting heroin users felt themselves to be slaves.
The view of most clients, embodied in Scotts words-1 think it would be good
just to at least feel free fiom the drug for a while-is that withdrawal offers
momentary freedom. Scott, like many others, does not, however, abandon the
idea of being permanently free from the drug. Freedom constitutes a capacity
to step outside heroin use in any instance of withdrawal.
These study participants, to remember, have come to a treatment centre for
help with addressing their drug use because they feel unable to self-limit their
use. In the above accounts the controlledregulated use theme is not entirely
absent, it is implicit and the idea of controlling the drug is expressed in some
way. For now, though, a lack of control seems apparent.
Historically, loss of control over consumption has symptomized dependence
since drug use first came to be considered a disease rather than a vice.I4 The
uncontrolled heavy regular user, however, does not equate with the out-of-con-
trol user; those who are dependent can exhibit control and those who are not
dependent can experience loss of control in a single incident of buying heroin
with money put aside for other purpose^.'^ Eland-Goossensen et al.39 provide
the metaphor of a downward spiral to project the image of a drug user who
reports negative effects of heroin use, perceived as beyond individual control.
They draw on the metaphor of controlled descent to describe those who regulate
their drug use for purposes such as preventing destructive behaviour. This latter
metaphor encapsulates both B l a ~ k w e l l s and
~ ~ Moores4
~~ findings that some
injecting drug users are quite able to self-regulate their use: There is the
suspension of control of injecting drug use when on holiday, then there is the
reinstatement of control to accommodate work and study. Before proceeding, I
shall make a final point about the controlled descent metaphor. The term
descent is synonymous with downward path. The suggestion from both these
metaphors, then, is downward mobility, that drug use, whether controlled or
not, is inevitably associated with a decline of one sort or another; they simply
differ in the way in which the path is descended-spirallinq or controlled.
Implicit in the decision to refuse the position of objecthlave is a change in our
own b e h a ~ i o u rThe
. ~ ~ next account is the response of Zoe who, on her second
presentation for withdrawal, was asked the main reason why she had originally
entered the withdrawal programme:
I was realizing that I was becoming the slave and it was becoming the master
and I dont like those sort of relationships, so yeah, thats the main reason
why.
Zoes use of the term slave allows her to describe the behaviour of herself-a
heroin user-in a way that showed her to be both subordinate and active; she
is subordinate to the master, explicitly named as the drug, yet through entering
a withdrawal programme she is working actively toward displacing the position-
ing of herself within the master-slave relationship.
I do want to stop [using heroin] ... I want to get off ... I just want to clean
up altogether, implored Joan at her first interview. Seven weeks later
having: stayed clean for 21 days, Joan remarks: at the moment its
maintaining itself in a controlled manner.

Having rethought her usage, she adds:
Also I think I dont want it totally out of my lije, I still get a lot of pleasure
from it. But I do have a control problem with it. Its a battle to maintain it
just as a recreational pleasure and not let it swallow nze up ... . It does get
to a point where all of a sudden Im using e v e y day again and then Ill
decide I cant afford this, Im in debt up to my eyeballs, Ive got to stop using
and I have to come in here again. ... I suppose I do have an addiction
though I dont know. What else could there be?
In the words of medicine, Joan does have an addiction or dependency. Joans
question, though, suggests an awareness of the narrow repertoire available to her
to help explain her experience. Her references to having difficulties controlling
her heroin use, not letting heroin swallow her, and not being able to afford to
use every day, make visible the slavish relation whereby through addiction or
structural domination, Joan constructs herself as subordinated to heroin. At the
same time, her entrance into a treatment centre portrays her as actively stepping
outside this relation to have control(1ed use).
Subjective experience
There is a widespread belief, says Stein, in the inherent powerfulness of drugs
that it leads to reasonings like she is not really herself, it is the drug speaking.
Such reasonings define the acts of the drug user as ego-alien. This conveys a
notion of a split subjectivity (self and other) which comes through in Black-
wells30account of a man who toward the end of one using episode thought that
he was taking on an alien identity. These themes of disruption to the self
through injecting drug use come through in other ways. B l a ~ k w e l has l ~ ~written
that 19 of her 51 participants found themselves in a situation whereby they
wanted to self-regulate their opiate use to improve health, psychological well-
being and general appearance. Moores4 analysis of dependence gives insight
into some aspects of the emotional life associated with injecting drug use. He
tells of the tension, edginess, ugly arguments and emotional outbursts related to
coming down. And, a withdrawal from speed experienced by two of his study
participants (Vinnie and Laura) was marked with depression, extreme agitation,
mood swings, lethargy, irritability and paranoia.
In this section I describe some of the subjective, bodily existence of injecting
Withdrawal from injecting heroin use 219
heroin users. Heroin is thought of as something added to the person-some-

thing that can be felt as disrupting an essence, the character, the emotions, the
physical being, even eclipsing the self-both buttressing and emphasizing sub-
jective experience. In a cross-sectional analysis of the interviews with men and
women I found many points of similarity between their stories and this is
represented in the themes. I also found some points of difference between the
stories of these men and women; one difference manifests in the way in which
the subjective experience of heroin use is expressed. Reducing heroin use
(coming down) threatens body stability. The interviews speak of the emotional
and corporeal experience: women, more often than not, discussed the feeling in
terms of emotions-usually expressed negatively and as out of control; whereas
the men tended to discuss the feeling in terms of a bodily or corporeal
sensation-usually expressed negatively as a sickness.
Emotions are gendered, and therefore womens expression of emotions is
evaluated differently from mens expression of emotion^.^"^^ Understanding the
expression of feeling or emotion lies in understanding the social relations in
which such feelings and emotions are embedded.41First I turn to explore how
these womens expression of the self pertains to their emotions:
Judy: Ijust feel miserable, I rn not a person any more ... . Most of my friends
are straight-thank God I dont move in a circle of junkies or anything ... .
And having a girlfriend ringing me up in tears and saying to me: Wheres
Judy gone? ... Where is she?
When asked by the interviewer to prioritize her reasons for wanting to withdraw,
Judy said:
... getting me back ... . Having all my old energy and, you know, being
vivacious, ... being clever and stuff. And now Im just not until I have a hit
and then ... Im stoned and thats not the real me either ... . I dont want
to substitute for anything ... . I want to get a sense of myself back. Not just
a sense of myself, I want to get myself back because it is just such an insidious
drug it just takes you over.
Emotions are constructed with reference to the evaluation of other^.^',^* In
Judys self-reflection, and in subsequent appraisals and evaluations of her
behaviour by her friend, misery is constructed.
Judys story carries with it an awareness that heroin use threatens her sense of
self, even displaces the self. Her embodied experience (as a heroin user) is one
of otherness inhibiting her energy, vivacity and abilities, preventing her from
accomplishing her goals. The real or true self can only be realized with
the assertion of independence from heroin use. This expectation is further
illustrated in another womans reflections:
Zoe: I want to see the old me sort of showing through a bit because you forget
that there is another person underneath there, and I just want to see
her ... without being clouded by drugs. Emotionally I just cant cope with
being on heroin all the time because I dont give my real emotions a chance
to peep out of the clouds. And when they do, they really do, they storm
down ... . A couple of times lately when Ive had it ... Ive got cranky on
it ... . I just thought Oh God, whats the point?
Zoe, as a drugged subject, experiences the self as eclipsed by a cloud brought
about through drug use which prevents expression of her real emotions. When
expressed, there is a sense that they are regarded as out of control. Relief from
the (storm of) emotions is constructed at the point of freedom from heroin use,
and is grounded in the recognition that there is another (more desirable) self to
be recalled.
For others, heroin use was also linked with control or stability of emotions:
Judy: M y temper has been completely out of control.
Anna: Coming down all the time means that Im not emotionally stable
enough to do anything.
So debilitating is Annas experience of emotions, she finds herself immobilized.
Following, there is a more globalized sense of bodily debilitation and a recogni-
tion of a decline in the symbolic value of the body:
Beth: M y looks are going down the gurgler a bit, ... [my] skin is not
wonderful, ... [Im] not dealing [with] anxiety; ... I dont think my body
can take it much longer.
While noting the array of themes (e.g. looks, feelings) there is a generalized
relationship and a preconstructed social recognition of a standard by which the
self is measured. Heroin use is unbecoming, impeding Beths chances of
achieving the standard. Similarly, Bla~kwell~ makes reference to one woman, a
photographic model, who expresses worry that her unhealthy lifestyle (associ-
ated with opiate use) might adversely affect her appearance. These examples of
concern about decline in the symbolic value of the body through injecting drug
use contrast with some other findings. Dorn and for example, assert
that for many groups of injecting drug users, looking somewhat wrecked is
viewed as more attractive. They invoke the term lookism and import a theory
of intersubjectivity to claim that in the cultures of many groups of injecting drug
users, damage to appearance and to health is worn with pride.
I now turn to explore how the men interviewed expressed their subjective
experience of heroin use. Heroin use brings an awareness of the body. Through
this use there is a noticeable change in bodily state signalling a disruption or
dysfunction that warrants attention. While health might not be the prime motive
for seeking withdrawal services for these men or women, it is a prompt and a
strong theme in many of their stories. What is of interest is that in these mens
stories there is an absence of emotional expression and a (re)focus on corporeal
sensation:
Eddy: I like using heroin, its a pretty enjoyable experience,
... [but] Z use too much; my livers starting to hurt and Z dont eat enough.
Nelson: Waking up e v e y morning knowing Z have to get on, Z have to score
that day otherwise Ill be sick.
Bill: Everyday Z had to ... have a taste or go and score. ... [Otherwise]
youre feeling like grinding down a bit getting into lunch time and a bit
further on your bones are aching and youre feeling a bit sluggv and stuff:
Peter: Youre in a constant cycle of being sick all the time ... . You go for
a few days not using and you use or whatever and then youre sick again for
a few days and this constant up and down cycle.
What is brought to light is a complex interplay of relations: heroin use marks

identity and produces the wrecked, wracked body: it says, this is what I am as
a heroin user. Through heroin use these four men became strongly focused on
somatics. The embodied experience of heroin use takes place in questions of
bodily concern (liver, bones, feeling sick). The process whereby the biological
becomes social is articulated as a negative relationship between heroin use and
its infringement upon health.
Thus, the subjective bodily experience of this group of heroin users wanting
to withdraw is expressed negatively. For these men, the subjective experience of
heroin use is enacted through bodily sensation and feeling that brings the self
into awareness; for these women, the subjective experience of heroin use is
enacted through emotional expression and a displacement of the self. This
gendered experience is more or less as follows: physical strength and emotional
stability are stated to be products of men and are related to self-control and
self-discipline, while emotional expression-of a particular kind, quality and
(in)stability-is considered to belong in the realm of women. This is borne out
here: men become concerned as their physicality is threatened; women construct
themselves as out of control owing to their emotions, and in negative self-
definition. At the same time, the hope remains that to relinquish heroin use will
produce the other self, the real self. Intersubjectively, or through the gaze of
the other, the emergence of the real self will enable the construction of a
positive self-definition.
Discussion
From the above accounts, the experience of withdrawal can be understood as a
process of becoming withdrawn, becoming clean,perhaps even more a (lifes)
project than a process. This resembles Shillingsz3description of body projects
(for example dieting) as requiring constant work. The accomplishment of the
project is tied in with the individuals ~elf-identity.~~
The data presented show
the extent of the work and the vigilance required for a heroin user, through
withdrawal, to (re)shape his or her body to a point where the body, as a social
222 G. Y.Koutroulis
symbol, is linked with a positive self-identity. The most common example here
of withdrawal as a body project can be found in the attention given to the effort
not to become junk. The expression junkie recognizes the body as making a
personal statement about who and what she or he is; drug use and withdrawal
therefrom are tethered to expressions of self-identity and lifestyle: from dirty,
scummy junkie to clean and in control.
The (drugged) body is implicated in a system of domination and subordina-
tion. I have shown the body as a basis of oppression through, for example, its
location as a site for the construction of the junkie, and the slave. In addition
to the appearance of the body in these narrative accounts they also highlight the
social location to which the drugged body is subject. As importantly, however,
these accounts are a demonstration of the body as a phenomenon of options
and choices (p. 3)23 where drug users can exert control over their bodies by
injecting drugs or not injecting drugs.
Withdrawal is entertained at moments when the body (which otherwise has
receded from direct experience) becomes a focus of negative qualities.44 How
men and women reflect upon, and live their bodies might be seen as one of the
defining features of their experience of withdrawal.
Sociology of the body enables a clear understanding of the relationship
between heroin use and identity, so permitting such observations as the trans-
formation from person to junk(ie); and the importance of self-identity, or the
experience of the self, to well-being. The problem with the typical approach of
the structured, standardized questionnaire outlined at the beginning of this
paper is that withdrawal is examined independently of its constitution by the
embodied social actor-the drug user. I am not suggesting a disregarding of
the insights gained from the scales and instruments or for them to be cast aside.
The propensity for examining withdrawal through these quantitative measures,
though, inhibits contextual understanding of how, when and under what cir-
cumstances the body becomes thematized. For example, Sheehan et a1.I6 cite
My life is out of control as the single most frequently claimed important reason
for coming for treatment. There is no sense, however, of how respondents give
meaning to this statement; and it is unlikely that this, among a long list of other
withdrawal items appearing in the questionnaire, is viewed as identical in
meaning by all respondents. Indeed, any number of meanings is possible and
these meanings, as Reekie2 notes, are determined by the political position of the
reader of the problem. Only when there is an opportunity to analyze meaning
can control-slave-body linkages be made. T o give credence to heroin users talk
about their withdrawal experience, in the way that credence has been given to
researchers instruments examining withdrawal, can help us to understand
better the sociopolitical dimensions of this bodily process.
In this discussion of withdrawal, I have attempted to draw attention to
withdrawal as a body project, a smaller project within the vaster project of
becoming a healthy, normal body. The emphasis is on becoming with-
drawn-something constantly worked at-which is closely linked with self-regu-
lation, self-responsibility and projecting an image of the self as clean. Injecting
Withdrawalfrom injecting heroin use 223
heroin users shift in and out of withdrawal in this process of becoming

something other than a junkie or a slave.
Finally, in a sociopolitical context where addiction theories of individual
pathology and chemical remedies prevail, the opportunity for a drug user to
become anything other than an addict looks bleak. Alternative constructions of
those people who use drugs demand that those who work within the domain
of withdrawal treatment rethink the social and cultural conditions in which they
are implicated, which give rise to alienating identities such as junkie and slave.
The subjective experience of drug use and withdrawal therefrom might offer
insight to a new praxis in withdrawal treatment of drug users if it is not
discounted by those who dominate what is viewed as important in the drug and
alcohol field.
Acknowledgements
This research was supported by funding received from the Victorian Govern-
ment Department of Human Services. I am gratehl to the withdrawal research
team, particularly Peta Odgers and Allan Kellehear for their support in my
construction of this paper. Thanks are especially due to the clients who
contributed to this research. The helpful comments of Sue Goldman and the
two anonymouse referees on an earlier draft of this paper are appreciated.
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Critical Public Health

ISSN: 0958-1596 (Print) 1469-3682 (Online) Journal homepage: http://www.tandfonline.com/loi/ccph20

Withdrawal from injecting heroin use: Thematizing

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Withdrawal from injecting heroin use:

Turning Point Alcohol and Drug Centre, Fitzroy, Victoria, Australia

0958-1 596/98/030207-18 0 1998 Carfax Publishing Ltd

One of the hallmarks of drug use as a field of inquiry is its multidisciplinary

I reflect on literature specific to withdrawal. While there exist numerous

system, appraisal of own emotional state, and relationships. Oppenheimer et al.

Sociology of the body

programme. T e n of the 16 participants were interviewed twice and one was

understood as a relation of crossing boundaries; moving from outside the body

The subject: Dirty, scummy, little junkies

Hospitalized for several hours because of an overdose, Beth portrays the

The subject: slave

T o be a slave is to occupy a hallowed space as the object of another;

maintaining itself in a controlled manner.

heroin users. Heroin is thought of as something added to the person-some-

What is brought to light is a complex interplay of relations: heroin use marks

heroin users shift in and out of withdrawal in this process of becoming

process of help seeking. Br 3 Addict 1988; 83:635-647.

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