[published as: Seddon, T. (2011) ‘What is a problem drug user?’ Addiction Research & Theory 19(4) 334-343]
The term ‘problem drug user’ has become a staple of the drugs research and policy industries in recent years, displacing to some extent earlier labels like ‘drug addict’. It is now common terminology in the field in the UK, as well as across the rest of the European Union and some places beyond. One obvious question to ask is: when did this happen? These things are always difficult to pinpoint exactly but we can perhaps date this shift in terminology to the year 1982, although, as we will see, its roots can be traced back much earlier than this. But has this just been a re-labelling of an old idea, a re-badging of something that remains essentially the same? Or by this shift in language has something more significant taken place? I want to explore this by posing what might seem to some readers a rather curious question: were there any problem drug users before 1982? Obviously, before 1982 there were people taking drugs who both suffered from problems of various sorts and caused them for other people. That is not my point. But, as I shall argue, in a certain and quite important sense the answer to this question may be ‘no’.
The idea that I will be exploring in this paper is at heart a philosophical one but one that I believe also has implications of a more practically-edged kind. Indeed, as Gootenberg (2009) has recently argued in an insightful piece, a focus on discourse and language is an essential component for any critical analysis of drug control. Ian Hacking calls the idea that I will be looking at ‘dynamic nominalism’ but it is perhaps better known through the title of one of his most influential essays, ‘making up people’ (Hacking, 1986; see also Hacking, 1995, 2007). I will begin the main section of this paper by outlining briefly what Hacking means by this. I will then go on to consider how the idea might be applied to the term problem drug user. In conclusion, some implications of my argument will be discussed.
A couple of points of clarification are perhaps needed here. First, I want to emphasise that I am not arguing that the language of addiction has entirely disappeared and been replaced by problem drug use. Even a cursory glance at policy documents and scholarly journals in the field tells us that that is manifestly not the case. What I am claiming, though, is that addiction has been knocked off its perch as the dominant concept and that problem drug use has rapidly risen to prominence since its (relatively) recent emergence. Second, I also want to make clear that I am not attempting to make a universal or global case. The PDU label has been more popular in some parts of the world than others. Australia is a good example of somewhere where it has had much less traction, indeed the term is scarcely used there at all. This reminds us that there is a powerful cultural and political dimension here. I write primarily from a British perspective, although the ‘rise of the PDU’ has extended much wider than that, across the rest of Europe and to some places further afield.
MAKING UP PEOPLE
Ian Hacking’s essay on ‘making up people’ has become a classic – one of those groundbreaking contributions that manages to combine great novelty and originality with a crossover appeal that seems to resonate across diverse fields and disciplines. This is not to say that it is entirely new. Its lineage can be traced back in part to some of Wittgenstein’s work in the 1950s (Wittgenstein, 1953) and it also shares some common ground with the symbolic interactionists and radical labelling theorists of the 1950s and 1960s, notably Howard Becker (1963) and Erving Goffman (see Hacking, 2004). Perhaps most obviously and explicitly, it is strongly influenced by Foucault’s dazzling contributions to questions concerning classification and categorization within the human sciences (Foucault, 1970, 1972).
In common with many classics in the social and human sciences, Hacking’s argument has been subject to some wildly varying interpretations and for this reason I want to set out here my own understanding of his thesis. He begins from a seemingly banal observation: at different times in history and in different places, human beings have created different systems for categorising their fellow humans. At any given moment in time, societies tend to think of their own categories or classes as denoting definite properties of people. So when we describe a person today as, for example, a homosexual or a high-functioning autist, we believe we are referring to an essential aspect or part of their nature, that is, to what we might think of as a real kind of person. Yet the ways in which these classification systems change over time should make us wary about this. How can they refer to real kinds or classes of people if the categories themselves keep changing? This is historical nominalism.
But by itself, this is still a relatively uninteresting observation. We could view it, for example, as indicative simply of scientific progress in a very conventional sense: as our understanding about ourselves improves, so we refine over time our scientific classification systems. But one of Hacking’s great insights is that this type of historical nominalism is only half the story; nominalism is also dynamic. Labels or names are not simply applied to people in a static way, rather, there is an interactive and dynamic process involved. He helpfully summarises:
I have long been interested in classifications of people, in how they affect the people classified, and how the effects on the people in turn change the classifications […] I coined two slogans. The first one, ‘making up people’, referred to the ways in which a new scientific classification may bring into being a new kind of person, conceived of and experienced as a way to be a person. The second, the ‘looping effect’, referred to the way in which a classification may interact with the people classified. (Hacking, 2007:285-286)
A good example he uses to illustrate this is the category of ‘homosexual’. As I have already mentioned, many people today might view this as a timeless or universal kind of person. After all, can we not trace homosexuality back to the ancient world (see Dover, 1978)? Hacking quotes an illuminating passage from a newspaper review by Foucault of Kenneth Dover’s well-known book on homosexuality in Ancient Greece:
You still find pleasant people who think that, all in all, homosexuality has always existed. They cite in evidence Cambacérès, the Duke of Crequi, Michelangelo or Timarchus. Dover offers such naïfs an excellent lesson in historical nominalism. Relations between two persons of the same sex are one thing. But to love someone of the same sex for himself, to take pleasure with him, is something else, a whole other experience, with its own objects and their values, together with the way of being a subject and the awareness that he has of himself. (Foucault, quoted in Hacking, 2007:295).
In other words, whilst same-sex acts clearly existed in Ancient Greece, the homosexual as a kind of person, as a way to be a person, did not. But this is not the end of the story for a dynamic nominalist like Hacking. The invention of the homosexual has profoundly influenced the ways in which many of the people so categorised have lived their lives and this, in turn, has refined and reshaped what is meant by the term homosexual. And these dynamic interactions continue – when we investigate kinds of people, the target is always moving (Hacking, 2007:293).
The significance of these processes is much wider than it might appear at first sight. When a new kind of person is invented, there is an impact that is not restricted just to those groups directly coming within the new classification. It alters the space within which we shape ourselves, as Hacking (1986:229) explains:
How might a dynamic nominalism affect the concept of the individual person? One answer has to do with possibility. Who we are is not only what we did, do and will do but also what we might have done and may do. Making up people changes the space of possibilities for personhood.
In this sense, we are all ‘made up’ by the range of possibilities that exist in our own time. As Hacking (1986:233) puts it, ‘we are not only what we are but what we might have been, and the possibilities for what we might have been are transformed’ by the invention of new ‘kinds’ of people. This potentially places the study of ‘making up people’ and ‘looping effects’ at the centre of intellectual enquiry into human behaviour and relations.
This is a very condensed summary of Hacking’s thesis. I will flesh it out somewhat in the rest of the paper, as I start to apply it to the problem drug user concept. I will begin in the next section by exploring where the concept has come from and setting out an outline of its genealogy, before turning directly to the matter of the making up of the problem drug user.
A GENEALOGY OF THE PROBLEM DRUG USER
New classes or categories of people, new ways to label other human beings, do not simply materialise out of thin air. They have antecedents which can be traced. As Foucault (1984) argues, this type of tracing exercise is seldom simply a matter of identifying or excavating a clear linear development from the past to the present. Rather, what he calls genealogy, a term he borrows from Nietzsche, seeks to piece together the sometimes dispersed and disparate events out of which history is formed and, along the way, to abandon the notion that the ‘origin’ is the place where the ultimate essence or truth of an object is revealed:
If the genealogist […] listens to history, he finds that there is “something altogether different” behind things: not a timeless and essential secret, but the secret that they have no essence or that their essence was fabricated in a piecemeal fashion from alien sources. (Foucault, 1984:78)
The emphasis for genealogy, in other words, is on recovering the creative work involved in inventing new ideas or concepts or classifications. They are human inventions rather than things that already exist, just lying there waiting to be found. Indeed, Hacking’s central slogan, ‘making up people’ captures this point very nicely.
The genealogy of the problem drug user concept is certainly disparate and we can trace several lines of development. Part of the difficulty here is knowing where to begin. I have no doubt that a fuller and more comprehensive genealogy remains to be written but for the purposes of my brief sketch in this paper, I want to start in the final decades of the nineteenth century. It was in this period that fears about national degeneracy became widespread across Europe (see Pick, 1989), providing the basis for the emerging eugenics movement (Garland, 1985:142-152). Central to these anxieties was the idea that a degenerate ‘residuum’ was expanding at a faster rate than the rest of the population, leading to a decline in the quality of the national stock, and this concept of the ‘residuum’ was highly influential at the turn of the century on social reformers like Charles Booth (Stedman Jones, 1971) . Concern about the ‘residuum’ abated a little after the outbreak of the Great War but returned again in the 1920s when mass unemployment revived the spectre of degenerate ‘unemployables’ weakening the population. In Britain, it was against this backdrop that the influential Wood Committee on mental deficiency conducted its work, leading to an extremely significant report published in 1929 (Macnicol, 1983). This report promoted the idea of the ‘social problem group’, essentially a revival of the residuum concept, which was to become prominent in the 1930s (Welshman, 1996). Here, then, we can see one beginning for the notion of ‘problem groups’.
The Wood Report described the social problem group as comprising the ‘lowest 10% in the social scale’. It included the insane, paupers, unemployables, criminal recidivists, epileptics, inebriates and others deemed to be ‘socially inefficient’. It recommended a strategy of segregation and sterilisation – a decimation strategy, in the most precise sense of the term – and the concept was keenly taken up by the Eugenics Society in the 1930s (Welshman, 1996:449). Articles appeared in the Eugenics Review discussing the idea (eg. Mallet, 1931; Lidbetter, 1932) and two books were also produced by prominent Society members (Lidbetter, 1933; Blacker, 1937).
The connections with what was then still called the inebriety1 field are interesting to note. Certainly, inebriates were seen as mainstays of the social problem group. But, more than this, there were strong links between the two fields of knowledge. In 1932, a member of the Council of the influential Society for the Study of Inebriety (SSI), Dr C. Brasher, produced a note for a Eugenics Society symposium on ‘Inebriety and the Social Problem Group’ (Berridge, 1990:1031). This was later published in 1937 as a chapter in the book A Social Problem Group? edited by C.P. Blacker. Blacker was a key figure in all this during this period. Not only was he General Secretary of the Eugenics Society throughout the 1930s, he was also a member of the SSI Council and this no doubt aided the crossover of the concept. So this idea of ‘problem groups’ was significant in the field of inebriety some 80 years ago.
We might think that this branch of the genealogy was sawn off long ago, as the eugenics programme has come to be seen as a particularly disreputable and discredited part of our history that has no bearing on the contemporary world. But echoes of this line of development can still be dimly heard in the drug field today, occasionally sounding above the background. In 2004, for example, a distinguished Professor of Drug Misuse Research proposed paying female problem drug users to take contraception2, an idea that might well have appealed to the Wood Committee in the 1920s had that particular technology existed then. Along similar lines, in 2006, a Scottish politician suggested putting oral contraceptives in female heroin users’ prescribed methadone3. Most recently, ‘Project Prevention’ has become a centre of controversy for offering cash incentives to women drug users to use long-term or permanent birth control4.
A decade after the flourishing of the concept of the social problem group, another line of development emerged in the 1940s, initially in the US. Researchers close to the alcohol industry began to put forward the idea of the ‘problem drinker’ as a more palatable alternative to the term ‘alcoholic’ (see Room, 1983:74)5. Joseph Hirsch’s book, The Problem Drinker, published in 1949, was one of the more prominent efforts (see also: Duryea, 1947; Duryea and Hirsch, 1948). Hirsch, at the time, was Executive Director of the Research Council on Problems of Alcohol, which had been formed in 1937 by a group of doctors and scientists, and his promotion of the term carried a considerable degree of scientific respectability as a result of his position. It also appeared in a number of sociological studies published during the same period (Riley and Marden, 1947; Riley, 1949; Straus and Bacon, 1953). But it was in the 1960s that the problem drinker concept really began to take off amongst alcohol researchers in the US, in a series of papers that sought to disaggregate the various components of alcohol-related difficulties (e.g. Clark, 1966; Knupfer, 1967), prising apart what had previously been assumed to be describable as a single entity. Don Cahalan’s 1970 book Problem Drinkers was a classic example of this new body of work.
This development was not exclusive to the US. In an insightful report, Taipale (1979) documents the use of the problem drinker concept in Finland going back to the 1950s. He identifies six different usages of the term and suggests, interestingly, that its original sense in Finland was a person who drinks on account of their problems (see also Room, 1987:1065). Taipale’s analysis is important as it highlights the malleability of the concept, that is, its potential to sustain or support multiple meanings. I will return to this point later.
In Britain, as late as the 1970s, the term alcoholic was still dominant in policy and research documents. This began to shift in the latter half of the decade. The Advisory Committee on Alcoholism, set up in 1975 and widely known as the Kessel Committee, illustrated this nicely, as Betsy Thom (1999:122) observes:
It is indicative of changing perspectives on the nature of the problem […] that the committee’s terms of reference and early discussions spoke of ‘alcoholism’ and ‘alcoholics’ while the final reports used the terms ‘problem drinking’ and ‘problem drinkers’.
As we will see, the Kessel Committee’s terminology was explicitly referred to in the report by the Advisory Council on the Misuse of Drugs in which we find what seems to be the first use in Britain of this problem language in relation to illegal drugs (ACMD, 1982:34). I will return to this report in the next section.
So, another branch in our genealogy of the problem drug user describes seepage or transfer from the alcohol field. This is a familiar story, of course. As Harry Levine (1978:144) showed over 30 years ago in his classic article ‘The Discovery of Addiction’, the addiction concept was itself first worked out for alcohol, before being applied to other substances like opium. In case we are seduced into thinking that this represents some type of general sequence or pattern, an example of a concept that travelled in the opposite direction is that of dependence. This was first coined by the World Health Organisation in the 1960s to apply to illegal drugs (WHO, 1964) but was then borrowed a decade later by Edwards and Gross (1976) in their well-known paper setting out a new ‘alcohol dependence syndrome’.
Another influence on the shift to a problem-oriented concept was the emergence in the 1970s of what became known as the new public health. This new approach was characterised by a focus on population health, the development of preventive approaches and the targeting of high-risk groups with the poorest health outcomes as part of strategies to reduce health inequalities (see Ashton and Seymour, 1988). It was driven in part by technical developments in epidemiology during this period which had been kick-started by Doll and Hill’s famous work on smoking and cancer in the 1950s and had then developed rapidly in the 1960s (see Mold, 2007).
In a useful review article, Room (1984) expertly charts how the influence of this new direction in public health began to be felt in the mid-1970s in the alcohol field. An early example was the landmark 1975 report Alcohol Control Policies in Public Health Perspective which became widely known as the ‘Purple Book’ (Bruun et al, 1975). In the context of alcohol, the implications of the new public health for alcohol policy were extremely challenging, as Room (1984) discusses, sitting particularly awkwardly alongside the economic interests of the alcohol industry, as they pointed towards the public health benefits of reducing the overall level of alcohol consumed in society.
With its focus on distributions of health outcomes, there was an obvious affinity or ‘fit’ between the new public health and notions of problem drinkers or problem drug users (Seddon, 2010:83-87; Stimson and Lart, 1991:1273). Setting this in a wider context, the connection between a problem-oriented perspective and the more general rise of risk-based forms of governance in the late twentieth century – in shorthand, the emergence of the ‘risk society’ (Beck, 1992) – is equally evident (Seddon, 2010:85; Mugford, 1993). In this sense, we might view the concept of the problem drug user as having a particular resonance in late-modern society, although, in keeping with the Foucauldian spirit of genealogy, I would resist arguing that the concept is an inevitable product of our times, just a possible one.
So what does this potted genealogy tell us? Firstly, it shows that what at first sight might appear to be a relatively new concept, can in fact be traced back to at least the 1930s and the idea of the social problem group, a notion itself linked to the even earlier term residuum. Secondly, we can see that the concept has a distinctly mixed heritage, being fabricated from quite ‘alien sources’ (Foucault, 1984:78), ranging from nineteenth-century discourses of degeneration and eugenics to contemporary neo-liberal discourses of risk and risk management. This is significant: concepts retain traces of their past and, as I hope to show, this history can sometimes illuminate otherwise perplexing features of the present (Hacking, 1991:184).
MAKING UP THE PROBLEM DRUG USER
It is against the background of this genealogy, this mixed heritage, that we should view the invention of the concept of the problem drug user in 1982 by the Advisory Council on the Misuse of Drugs (ACMD). Their report on Treatment and Rehabilitation has come to be seen as significant in many respects and historians have started to explore its origins and development (see Mars, 2005; Mold, 2008:73-78). In the report, the ACMD set out their rationale for the new term:
The individuals with whom the treatment/rehabilitation system is concerned may have various problems arising from the misuse of drugs or from drug dependency or both. These are not solely physical or psychological problems, but also social and environmental problems. A multiple drug misuser may have a range of problems, being concurrently psychologically dependent on some drugs and physiologically dependent on others, and at the same time having financial or legal problems or difficulties over housing. The response to the needs of the drug misuser therefore requires a fully multi-disciplinary approach.
This approach should be problem oriented rather than specifically client or substance labelled. It would be similar to that in the field of alcohol where the term problem drinker has been defined by the Advisory Committee on Alcoholism. Thus a problem drug taker would be any person who experiences social, psychological, physical or legal problems related to intoxication and/or regular excessive consumption and/or dependence as a consequence of his own use of drugs or other chemical substances (excluding alcohol and tobacco). (ACMD, 1982:34)
This newly-minted term was expressly and explicitly broad in its coverage. In the ACMD’s formulation, a problem drug taker could encompass not only a stereotypical heroin addict but also a teenage first-time glue sniffer getting stopped by the police when intoxicated. The purpose of this broadening of scope is made evident in the rest of their report which makes a case for a transformation of service provision, away from a narrow medical model of treatment towards a more multi-disciplinary approach.
The novelty and distinctiveness of the concept is nicely shown by comparing it with the influential World Health Organisation definition of drug dependence from a dozen years earlier:
A state, psychic and sometimes also physical, resulting from the interaction between a living organism and a drug, characterised by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence. (WHO, 1969:6)
At the heart of the WHO definition is the idea of compulsion and this is absolutely central to the language of dependence: it refers to the loss of control over drug consumption. Indeed, the notion of loss of control runs deep through the history of the addiction concept, from Jellinek half a century ago all the way back to Benjamin Rush and Thomas Trotter at the beginning of the nineteenth century (Levine, 1978). The language of problems, on the other hand, is altogether different. It refers to consequences of drug-taking irrespective of whether consumption is controlled or compulsive. Conceptually, this marks a fundamental shift.
For my purposes, the key question is this: did the problem drug taker represent a new kind of person? I do not intend to get embroiled in philosophers’ arguments about the idea of ‘human kinds’ (see: Hacking, 2002, 2007; Cooper, 2004). Hacking himself has changed his mind on this over the last 25 years. More fruitful, in my view, is to look at two types of statement that he invites us to consider (Hacking, 2007:299,303-4):
A. There were no problem drug takers in 1975; there were many in 1985.
B. In 1975, this was not a way to be a person, people did not experience themselves this way, they did not interact with their friends, their families, their employers, their counsellors, in this way; but in 1985 this was a way to be a person, to experience oneself, to live in society.
Statement A is, in many ways, patently false. Of course, in 1975 there were users of drugs like heroin who experienced a range of difficulties connected with their drug use, some of whom also caused problems for others, including through their criminality. Reading Stimson and Oppenheimer’s (1982) classic account of heroin use in the 1970s provides a vivid reminder of this. Nevertheless, at the same time, it is equally true to say that the construct ‘problem drug taker’ did not exist in 1975 but did in 1985. In stating this, I am in effect simply making the relatively uninteresting and familiar distinction between ideas and the ‘real’ objects to which they may refer (Hacking, 1999:28-30). But, following Hacking’s lead, it is the interaction between ideas and objects that I am really interested in. This leads us to statement B.
On the face of it, statement B may also look false. But I suggest that it merits closer attention. As a researcher I have interviewed many people who would be described as problem drug users, and I have read the transcripts of even more interviews conducted by collaborating colleagues – I have never tried to count all these up but it probably runs to several hundreds of people. Yet I cannot recall any of these interviewees using the PDU label to describe themselves. And so the idea of this being a new way ‘to be a person’ or ‘to experience oneself’ or ‘to live in society’ seems rather misplaced. How can we talk of interactions between a classification and the people to which it refers if those people appear not to recognise the classification?
But clearly this type of classification does have an impact. As Hacking (1999:31) observes, ‘classifications do not exist only in the empty space of language but in institutions, practices, material interactions with things and other people’. An example illustrates this very clearly. Under section 19 of the Criminal Justice Act 2003, a problem drug user appearing in an English magistrates’ court may find the usual presumption in favour of bail is reversed, if their drug-using status has been identified by a prior drug test in the police station (see Hucklesby et al, 2007). In other words, they may end up remanded in prison custody solely because they are viewed as a problem drug user. This is not a trivial impact. And it is through the awareness of this type of effect that interactions happen between the classification and the people who are classified. It influences how people categorised as problem drug users interact with their drug workers, probation officers, social workers, solicitors and so on. This, in turn, reshapes how these ‘authorities’ understand what problem drug use is and what kinds of people problem drug users are. These are Hacking’s (1995) ‘looping effects’. The fact that this group do not self-identify with the PDU label certainly makes this a different type of ‘making up people’ story from most of the examples Hacking uses but it is such a story nevertheless. My example is not chosen at random. It is in the realm of criminal justice that problem-oriented perspectives on drugs have emerged most strongly, coalescing around the idea that ‘drug-related crime’ is one of the most pressing problems we face (Seddon et al, 2008), a point to which I will return.
Another way to look at this is to understand the concept of the problem drug user as practical or governmental, in the Foucauldian sense, rather than merely descriptive (see Rose et al, 2006). In other words, it is not an idea which simply seeks to describe a particular category of people or set of behaviours, it is a term which has been actively assembled in order to enable particular strategies and practices for the government of human conduct. This helps us to understand one of the most striking features of the concept, namely, how its meaning has significantly shifted since 1982. Take, for example, the definition in the recent national drug strategy for England:
Problem drug users (PDUs) are defined as those using opiates (e.g. heroin, morphine,
codeine) and/or crack cocaine. PDUs are of particular interest because it is estimated
they account for 99 per cent of the costs to society of Class A drug misuse. (Home Office, 2008:50)
This formulation is constructed to focus on those drug users who impose the greatest burden on the rest of society. Like the ACMD’s original definition, this too is intended to shape the configuration of service provision but in an altogether different direction. Now the aim is to target the most burdensome drug users, primarily through the criminal justice system, in order to provide interventions which may reduce the costs their drug use imposes on society. As I have already noted, these costs are largely conceived as related to the commission of drug-related crime which, according to some economists, is estimated to represent nearly 90% of all social and economic costs associated with drugs (Godfrey et al, 2002).
This shifting, or rather narrowing, of the definition illustrates two key points. First, it shows, as I observed earlier, the malleability of the concept of the problem drug user. It is capable of being aligned with diverse programmes and projects. Cave et al (2010:4-14) present a good summary of the diversity of ways in which it can be defined. It is perhaps this feature that has allowed the term to survive and even thrive in the face of shifting policy priorities since the early 1980s. Second, it confirms the analytical value of understanding the concept as governmental rather than descriptive. It follows that we can understand definitional shifts as connected in part with more general changes in governmental strategies.
The closeness of this connection is nicely illustrated by the recent definition in the national drug strategy quoted above, in which problem drug use is defined as the use of opiates and/or crack cocaine. Cave et al (2010:5) describe this as a ‘narrow’ formulation and indeed it is strikingly restrictive in many respects, excluding, for example, amphetamine injectors. But if we think of problem drug use as a governmental concept, this apparent narrowness becomes more understandable. Within the drug strategy, the primary means of identifying this group is through the drug-testing of arrestees in police custody suites, so that they can be targeted for interventions within the criminal justice system. The testing equipment detects the presence of opiates or cocaine only, as it is heroin and crack that are seen as most closely associated with acquisitive criminality. So the definition of problem drug users and the technology for targeting them fit together hand in glove and, of course, this is no coincidence: they do so because we made them that way.
Returning, then, to statement B, and extending our time frame, I think we can reformulate this into statement C:
C. In 1975, this was not a way to be a person, people did not experience themselves this way in their interactions with their drug workers, probation officers, solicitors and other ‘authorities’; but in 2005 this was a way to be a person, to experience oneself, to be governed in society.
So, in the sense implied by statement C, the problem drug user represents the invention of a new kind of person which did not exist before. At this point, we might raise two further questions:
a) Why was this new human kind invented at this particular historical moment?
b) How was it invented and then reproduced?
A proper answer to question a) is really beyond the scope of this short paper. As I noted earlier, one strand of an explanation would situate its invention in the context of wider social transformations, that is, the transition to neo-liberalism and the rise of risk-based forms of governance. But this gives us only a partial account. We cannot simply deduce or read off contemporary terminology in the drug field from an undifferentiated notion like neo-liberalism or the ‘risk society’. A full explanatory account would involve the development of a critical historical sociology of drug policy, along the lines suggested by Loader and Sparks (2004) in relation to crime policy. This is a substantial empirical and theoretical project in its own right.
A framework for answering question b) has been suggested by Hacking (2007). New knowledge of kinds within the human sciences is generated by a series of what he calls ‘engines of discovery’. The first step is the classification itself. A new kind of person obviously cannot be understood until we have produced the classification. After this, we variously, and in different contexts, count, quantify, create norms, correlate, medicalise, biologise and geneticise in relation to human kinds, and it is through these engines of discovery that ‘making up people’ takes place (Hacking, 2007:305-10). Not all are equally relevant in all cases. Here, I pick out three that particularly apply to the problem drug user, by way of illustration.
Counting. The enumeration of kinds of people is one of the oldest means of producing and reproducing classifications. In the case of problem drug users, actual counting of cases is very difficult. We can and do count those who come into contact with treatment services but to assess the total population we have to rely on estimates. Some quite complex statistical methods have been deployed to provide an estimated total count (e.g. Hay et al, 2006), notably the capture-recapture method originally developed within biology in the late nineteenth and early twentieth centuries for the study of fish and other wildlife populations.
Quantifying. The quantification of drug-related problems has taken on many forms. One of the most influential has been the work of economists in estimating costs associated with problem drug use (e.g. Godfrey et al, 2002). Quantification has also been built into the administration of people in treatment. For example, the Treatment Outcomes Profile (TOP), recently developed by the National Treatment Agency for England, is a mandatory tool that has to be completed for all adults in contact with structured treatment (Marsden et al, 2008). It records data on drug consumption (amounts and frequency), injecting behaviour (including frequency of sharing), health and social functioning and crime. In effect, the TOP generates a quantitative snapshot of the extent of an individual’s drug-related problems.
Correlating. This is the ‘fundamental engine of the social sciences’, dating back to around 1870 when Francis Galton created the correlation coefficient (Hacking, 2007:309). Galton, of course, also invented the term eugenics in 1883, indicating how this particular ‘engine of discovery’ has deep roots in the genealogy of the problem drug user. Lidbetter’s (1933) exhaustive study of poor families in the East End of London sought to identify the common characteristics of the social problem group. Similarly, contemporary researchers have correlated problem drug use with a range of factors, from employment status to offending behaviour to educational attainment (see Cave et al, 2010). Building up a picture of what the ‘typical PDU’ looks like in terms of these characteristics serves to reinforce the idea that they represent a distinctive class or category of person.
It should be evident then that further pursuing these two critical questions of why and how the problem drug user has been invented as a new kind of person can be done in a resolutely empirical way. The ‘engines of discovery’ can be charted, the processes of interaction involved in ‘looping effects’ can be described and the changing definitions and understandings of the concept can be mapped. One contribution of this paper, I hope, is to provide inspiration for a future research agenda which does not ‘take for granted’ the status of the term problem drug user.
A great part of the appeal of the term problem drug user to both policy-makers and researchers has been its apparent neutrality. It allows the heated debates about the ‘true’ nature of addiction to be side-stepped; it eschews the moralising of terms like ‘abuse’ and ‘misuse’; and it lends itself to a pragmatic approach which focuses on managing drug-related problems and leaving non-problematic use alone. The attraction of this is obvious in a field which is at times so highly contested, emotive and politicised. But in this paper, I have tried to show that things are not quite as simple as that. By way of conclusion, I will say a little more about each of these three aspects of seeming neutrality.
First, as I observed at the beginning of the paper, the idea of the problem drug user has not been a successor to the addiction concept, it is a new co-habitee in the field. So, in an important sense, the immense and long-running difficulties in pinning down the ‘real’ nature of the phenomenon we are all concerned with have been multiplied rather than evaded or side-stepped. The picture has become dizzyingly complex: there is now a suite of related and overlapping but still distinct concepts which are deployed in different ways in different contexts. It will require a much more gifted genealogist than me to tame this complexity and map out fully this terrain. One thing that I am certain this will involve is a significantly greater degree of dialogue than we have currently across the boundaries of academic disciplines, including between the natural and social sciences (see Kushner, 2006, 2010).
Second, it may well be the case that there has been a reduction in the use of moralistic language like ‘drug abuse’ since the rise of the problem drug user concept. Yet, it could scarcely be said that levels of stigma and prejudice against users of drugs like heroin and crack have diminished in recent years. Indeed, the UK Drug Policy Commission launched a project in early 2010 designed to tackle problems of discrimination associated with the stigmatisation of drug users, based on the view that prejudice towards this group has risen rather than receded6. This presents us with a puzzle. I suggest that it is here that we can see traces of the genealogy of the concept that I sketched earlier. The stigmatisation of problem drug users today is the twenty-first century counterpart of the fear and anxiety associated with the degenerate social problem group in the 1930s. As I observed earlier, the revival of interest in reproductive controls, as in ‘Project Prevention’ (see note 4), highlights this branch of the genealogy.
Third, the pragmatism of a problem-oriented perspective rests in part on the unstated assumption that we are clear what we mean when we describe something as a ‘drug-related’ problem. To some, this might simply seem obvious. But some 25 years ago Harry Levine (1984), writing about alcohol, urged us to be much more critical in how we understand that word ‘related’ – it can be as much construction as description, he argued. A good current example of this is the issue of drug-related crime. British policy documents in recent years have regularly asserted that up to 50% of acquisitive crime is drug-related, without providing a source for this proportion (e.g. Home Office, 2008:8). And this 50% figure has become part of the rationale for the increasing crime focus within drug policy. Yet there is good evidence that estimations of drug-related crime have been significantly exaggerated (Dorn et al, 1994; Stevens, 2008). Nor is it a settled matter whether the connection between drugs and crime is a causal one or not (see Seddon, 2006). So the pragmatic claims for the problem drug user concept may be less straightforward than we might think.
More practically-inclined readers may be wondering, what am I proposing? Should the term problem drug user be abandoned? And, if so, why or for what purpose? In fact, I do not think that whether we abandon or retain the concept is the most crucial issue at hand. To pose the debate in terms of its validity is to miss the point. Rather, what I hope to have achieved in this paper, or at least to have started, is to open up this apparently neutral and objective concept to critical scrutiny. Whilst this is, of course, a form of theoretical enquiry, it is also at the same profoundly practical in its implications. This, ultimately, is the lesson I draw from Hacking – ways of classifying human beings and ways of acting upon them are two sides of the same coin.
1. The concept of inebriety was an umbrella term for the predisposing condition believed to be connected to excessive consumption of alcohol, opium, morphine and other substances. It rose to prominence in the second half of the nineteenth century – see Berridge (1979) and Courtwright (2005).
2. Professor Neil McKeganey speaking in March 2004. See http://news.bbc.co.uk/1/hi/scotland/3508084.stm [last accessed 04/05/10]
3. Duncan McNeil MSP speaking in the Scottish Parliament in May 2006. See http://news.bbc.co.uk/1/hi/scotland/4763137.stm [last accessed 04/05/10]
4. http://www.projectprevention.org. For an example of some of the British media reaction, see http://www.independent.co.uk/life-style/health-and-families/health-news/charity-that-sterilises-addicts-to-come-to-uk-1940722.html [last accessed 04/05/10]
5. Thanks to Robin Room for generous help in pointing me towards some of these early references to the idea of the ‘problem drinker’.
6. UKDPC press release, ‘Commission wins grant to examine drug shame’, 7th January 2010. http://www.ukdpc.org.uk/resources/PHF_stigma_grant_announcement.pdf [last accessed 12/05/10]
I am extremely grateful to Ian Hacking and Susanne MacGregor for taking the time to read and comment on an earlier draft of this paper. Thanks also to anonymous reviewers who provided helpful feedback. The usual disclaimer applies.
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