Disciplining pleasure through harm reduction policy confronting drug

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Disciplining pleasure through harm reduction policy: confronting drug users’ personal experience of injection in

Disciplining pleasure through harm reduction policy: confronting drug users’ personal experience of injection in context with professionals'’ public health expectations Marie Jauffret-Roustide, Alexandre Truc, Aude Wyart Cermes 3 (Inserm U 988/CNRS UMR 8211/EHESS/Paris Descartes University)

Harm reduction and pleasure (1) • Harm reduction as a public health model has

Harm reduction and pleasure (1) • Harm reduction as a public health model has conveyed its own conception of the drug-using subject as a citizen able to make rational choices, such as taking care of her own health. This conception has challenged previous figures of the drug user seen as always addicted, irresponsible, but also simultaneously ill and guilty. • Harm reduction understands the drug user as an individual endowed with rationality (Fraser 2008) who needs quality information to make better consuming choices. Surprisingly, despite its normalization of the drug user as a consumer among others, harm reduction does not fully address the question of pleasure, even though it constitutes a major motivation for people who use drugs

Harm reduction and pleasure (2) • Harm reduction programs are still often centered on

Harm reduction and pleasure (2) • Harm reduction programs are still often centered on a biomedical approach to drug use, through the lens of addiction (drug use is therefore seen as a brain disease) or through the lens of risk (injecting drug use is therefore seen as an at-risk practice for acquiring infectious or bacterial diseases). This biomedical approach usually avoids taking into account the question of pleasure. • In the last decade, some French structures of harm reduction (led by Médecins du Monde) have developed a type of intervention called AERLI that cannot avoid the issue of pleasure. AERLI programs consist in educational sessions in which users inject under the gaze of harm reduction workers or volunteers. • We seek to analyze the way harm reduction professionals

Study methodology • Qualitative and inductive approach that seeks to analyze both the social

Study methodology • Qualitative and inductive approach that seeks to analyze both the social experience of users and professionals, and the meanings that these people give to their practices. • Community-based participatory research has been conducted with Médecins du Monde in Paris and suburbs. • Methodological tools: • ethnographic observations (we observed 80 sessions) • semi-directive interviews (we conducted 30 interviews with drug users and professionals). • Fieldwork ongoing since 2015.

Our research objectives • To study the role of various risk management controls (self

Our research objectives • To study the role of various risk management controls (self and hetero-controls) that PWID implement. • To analyze the processes of acquisition of risk reduction skills, and of user self-empowerment in the process of adopting safer injecting practices. • To describe the interactions between professionals and PWID (roles representations, opportunities for agreements to control drug consumption and to manage HIV and HCV). • Three main focuses: 1. the management of pleasure in harm reduction 2. the construction of knowledges on injecting practices and harm reduction between users and professionals 3. the tensions that harm reduction has to face in practice.

The AERLI program • AERLI, implemented in France since 2011, sets out to support

The AERLI program • AERLI, implemented in France since 2011, sets out to support and educate drug users about injection-related risks. Each session of this program includes one live injection during which the user will prepare her/his product and inject it in the presence of two harm reduction professionals. • Afterwards, professionals and drug users have an opportunity to discuss vein search, viral and bacterial infection prevention, consumption management, and psychoactive effect maximization. • AERLI’s objectives are to reduce the health consequences of intravenous drug use through individual and practical education linked to drug injection and to

Harm reduction confronted with pleasure (1) • Unlike other harm reduction programs, AERLI cannot

Harm reduction confronted with pleasure (1) • Unlike other harm reduction programs, AERLI cannot avoid the question of pleasure because the user injects him/herself and experiences the effects of the substance in the context of the program. • One professional who started AERLI defends the right to talk about pleasure: “one of the effects of AERLI is that it liberates speech, and to liberate speech is to work to take ownership of one’s consumption, to take ownership of what we’re looking for. You have the right to say you like this or that product, you have the right to say that you seek a strong high. These things become acceptable to hear, and in the end people aren’t really used to that. Some do it, but I’ve already seen people be destabilized when they were asked about their experience of the product or if they had felt pleasure. ” • In fact, the issue of pleasure is a way: 1. for AERLI staff to set themselves apart from other professionals, to value their progressive approach towards drug use, and to build legitimacy;

Harm reduction facing pleasure (2) • In a more pragmatic approach, taking into account

Harm reduction facing pleasure (2) • In a more pragmatic approach, taking into account the pleasure PWID seek is essential to this type of harm reduction programs. Otherwise, users won’t be interested to waste their psychoactive products and to perform an injection only for educational purposes. • On the ground however, the issue of pleasure has generated tensions at the core of harm reduction, one that is sometimes hard to accept for some users who become reluctant to participate in AERLI. • According to one staff member, “Either they don’t care when we ask them, or they’re afraid – it’s a weird thing, and there’s this kind of paradox between drug practices and clear health objectives that takes pleasure out”. • One user who has agreed to attend the AERLI program makes a distinction between the injections he conducts at home for pleasure and the ones he conducts within AERLI: “At home, it’s more risky because I have a different relationship with pleasure. At home, I shoot up to get super high and get a lot of pleasure, so I take stronger doses and new products, whereas I come here to learn and share. ”

Disciplining pleasure (1) • This first transcription of a staff-user interaction reveals the deep

Disciplining pleasure (1) • This first transcription of a staff-user interaction reveals the deep chasm between the discourse of users and that of AERLI staff concerning pleasure with opiates. • User: ” It’s really hard in the morning, with the withdrawal I’m awake by 5 am. ” • Staff: “Did you know that Skenan (morphine sulfates) has a sustained effect if you take it as a sublingual? It can delay the withdrawal effect. ” • User: “Yeah but then there’s no rush. Maintaining an opiate addiction is difficult and expensive, so if I’m not even getting pleasure from the rush, I don’t really see the point… unless I take Actiskenan, all 200 mg at once. . . ” • Staff: “The other good thing with sublingual is that you can rest your injection point. ” • User: “Yeah but if I wanted to rest my injection point, I’d just do methadone. Considering the loss of pleasure with sublingual, I wouldn’t take Skenan. If I’m gonna do an addictive opiate, I might as well get pleasure out of it as well. ” • The user constantly mentions pleasure and the staff member answers

Disciplining pleasure (2) • Second observation reveals differences in staff and users interpretations around

Disciplining pleasure (2) • Second observation reveals differences in staff and users interpretations around an itchy sensation when using opiates. • One user scratches himself, says “Oh that one felt good!” • Staff: “You know why you’re itchy? It’s an allergic reaction to the cutting agents” • User: “I wonder if there isn't more morphine in it. ” • In this second situation: • while the user seeks out an itchy feeling that he feels is an integral part of his sensation of pleasure as well as a token of the product’s purity, • the staff member will answer that the user is having an

Conclusion • Our research shows the way professionals strive to build expertise that takes

Conclusion • Our research shows the way professionals strive to build expertise that takes into account experiential knowledge in practice and in context while dispensing sanitary recommendations. Defining a professional stance that is neither of moral judgment nor of promotion or trivialization constitutes a major challenge. • In principle, the AERLI program demands that staff place users’ experiences of pleasure at the heart of the program. But in practice, the AERLI program faces tensions between attaining its sanitary and educational goals and allowing users to live fully their experience of pleasure. • Furthermore, the intimacy of the observation setting introduces complex factors of misunderstanding and discomfort on the part of both users and professionals. AERLI is therefore a typical example of the tensions that harm reduction is confronted with