Review Essay: On Knowing Addiction

On Knowing Addiction

In June 2018, artists placed a 700-pound sculpture of a massive spoon used for cooking heroin outside the headquarters of Purdue Pharmacy, the controversial manufacturer of OxyContin accused of knowingly contributing to a massive increase in opioid abuse in recent decades. The number of Americans killed by opioid overdoses each year in the United States now exceeds the annual toll of gunshots deaths and car accidents. Earlier this year in a speech introducing his anti-opioid plan, President Donald Trump promised to “get tough” on those responsible for the epidemic by executing dealers of illicit opioids. Meanwhile, a public service advertisement above the entrance to the subway outside of Columbia University’s main gate promotes the public distribution of naloxone, an antagonist that reverses opioid overdoses. In a further commitment to harm reduction efforts, Mayor Bill de Blasio endorsed a plan to pilot safe injection sites that would reduce the negative consequences of drug use by helping users to inject opioids more safely. These diverging responses to the growing human costs of opioids in the U.S. re-invigorate long-standing debates about the causes of and appropriate responses to drug addiction, including what forms of care and deterrents should be authorized by the state.

Three recent publications, Rashi Shukla’s Metampathamine: A Love Story (2016), Helena Hansen’s Addicted to Christ: Remaking Men in Puerto Rican Pentecostal Drug Ministries (2018) and Eugene Raikhel’s Governing Habits: Treating Alcoholism in the Post-Soviet clinic (2016), while not directly concerned with opioid use in the U.S., speak powerfully to these concerns.

Rashi Shukla, a criminologist, opens her gripping Metampathamine: A Love Story with an unusual “author’s note”: “This book contains material that is not appropriate for young children, the faint of heart, and those not interested in knowing” (2016: xv). I found myself puzzling over the relationship she posits between representations of addiction and the politics of knowing, a theme I will return to later in this essay. As forewarned, Shukla quickly plunges the reader into the messiness of the “meth lifestyle” in Oklahoma, where she conducted multiple interviews with 33 former meth users. The first chapter includes a description of the sloping left temple of an interviewee who, Shukla informs us, had his skull re-constructed after an attempted suicide by gunshot years before their encounter. The organization of the text follows the arc of drug users’ “spiral into darkness” (ibid.: 154), jumping from “pathways” to “loving” to “dealing” to “manufacturing” meth, then to describing “intoxicating,” “risky” and “dark” lives of users, before finishing with a consideration of “life after meth” and policy implications. The “love story” Shukla continually centers here is the relationship between user and illicit substance: “Once they love (meth), there is nothing else” (ibid.: 39).

Shukla presents herself as an outsider who reports rather than judges. In her formulation, “they” tell “us” the “truth” about the dangers of meth and “we,” benefiting from “their” “tragic and soul-crushing experiences,” then “see things as they really are” (ibid.: 3). The country’s policymakers, like her readers, must accept this reality and recognize the failure of contemporary prohibitionist approaches (ibid.: 212-3). Extended transcribed excerpts from her interviews make up nearly half of the text and give the account a raw, heteroglossic power. The unsettling force of the book is undeniable: I find weeks after reading that I still remember her interviewees’ vivid testimony, included waiting for the arrival of “the train” (the roaring an interviewee felt in his ears after use) (ibid.: 107), cooking meth as “creating a child” (ibid.: 177), performing painful home surgeries to extract “slivers” of sores caused by injecting (ibid.: 136), and experiencing negative effects of the drug as “tweakin’ and freakin’ and peekin’ and thinkin’ the meth man’s after [you]” (ibid.: 113). Shukla has succeeded in rendering palpable the initial attraction and subsequent misery so often associated with addiction.

Precisely because of the power of her interviewees’ words, I found the author’s “love story” framing of this material as potentially dangerous. Shukla herself, in the opening pages, briefly discusses the damaging effects of the early 2000s “Faces of Meth” campaign (ibid.: 4)—the circulation of post-arrest mugshots of users that created a spectacle out of meth-ravaged bodies, included cringe-inducing depictions of “meth mouth.” This objectification of meth users occurred in a long history of troubling representations of drug use among marginalized groups, including Chinese opium addicts, Mexican marijuana deviants, and African American crack users. These narratives have in turn contributed to punitive and racist policies, including the anti-Chinese exclusion act at the end of the 19th century and the Norton laws imposing mandatory minimums for crack cocaine possession a century later. Drawing attention to this racialized representational economy, Naomi Murakawa has argued that the recent “meth epidemic” in this country has been constructed as both symptom and cause of white status decline as media images feed a “fear of” and “fear for” dynamic (2011: 220).

While reading her text, I wondered if Shukla’s commitment to depicting the meth lifestyle as “the darkest of things” (ibid.: 226) inadvertently contributes to the stigmatization of meth users, especially active ones. The organization of her account produces dichotomies between healthy (clean) and diseased (using) bodies, abject love of the substance and affirming love of other humans, and the “altered reality” of the addict against the centered, self-knowing interview subject that may not reflect the realities of her interlocutors’ lives. A focus on naturalized understandings of the drug’s destructive effects—she approvingly cites a study that calls meth “the most dangerous drug” (ibid.: 13)—potentially deflects attention from the ways contexts of use, social networks, access to healthcare, law enforcement tactics, economic stratification, and a host of other social, cultural, and political factors inflect the experiences and behaviors of those who use. The “path” of the “meth lifestyle” is made of up ideas and practices relating to power, labor, money, sex, and risk that are not particular to the drug but rather the historical moment and place of her research. Though we learn her sample is majority-white and in certain cases grew up in extreme poverty and neglect, interviewees appear throughout the text only identified by first names. Race and class as they come to be lived—inflecting the outlook and identifications of meth users—are largely absent in this study.

Despite these shortcomings, the text often complicates its own “love story” narrative in interesting ways. In her discussion of police enforcement, Shukla helps to illuminate the broader forces structuring the suffering that she captures so vividly throughout the book. Recently in the news for teacher strikes against deep cuts to state education funding, Oklahoma has the highest incarceration rates of women in the country, and all but two of Shukla’s informants served prison sentences, with certain interviewees arrested more than 30 times. Interviewees noted how the rhythms of their laboring lives—“working three full time job” while taking care of children (ibid.: 108), brutal long-term truck driving assignments, or a recently accelerated pace of life that leaves “no time for farmers to sit down” (ibid.: 103)—contributed to early interest in the drug as a stimulant that keep exhausted bodies in motion. This user-identified “poor-people drug” (ibid.: 172) appeared to offer the hope of satisfying the overwhelming requests of sexual partners, relatives, and employers (ibid.: 113). Meth use, one recovering user remarked, becomes attractive to those who “don’t have a lotta hope for things to get any better, or for things to change” (ibid.: 207). In this story within the story, the drug does not create a nightmarish love story on its own, but rather extends into the complicated – at time desperate – lives of individuals who have frequently experienced the world from the very start as a hostile, unfriendly place.

In her powerful and beautifully written Addicted to Christ: Remaking Men in Puerto Rican Pentecostal Drug Ministries, Helena Hansen explores how evangelical churches have come to play a central role in Puerto Rico’s drug treatment landscape. Struggling with legacies of colonialism and an unhealthy dependence on the U.S., government officials and Puerto Rican drug users alike often came to see addiction as a “spiritual-social” problem better addressed by faith-based interventions than biomedicine (2018: 82). The Puerto Rican drug ministries that have proliferated around the island in recent decades are staffed by ex-addicts working in a radical evangelical tradition extending back to William Seymour, a black minster whose store-front mission in Los Angeles in the first years of the 20th century inspired a transnational movement committed to transcending barriers of race, nationality, and class (ibid.: 67). Serving a traditionally Catholic community, these Pentecostal institutions offered a “citizenship of last resort” (ibid.: 162) to Puerto Rican users with few other options. Drawing on extended fieldwork in two ministries and visits to dozens of others, Hansen, an anthropologist and psychiatrist, shows how the moral economy of evangelical churches offered powerful remedies to familial strife, narco-violence, and a moribund postindustrial economy that fueled a dynamic of hopelessness and addiction.

In early chapters, Hansen explores the specific therapeutic technologies and resources that evangelical residential centers offered to help recovering “brothers” and “sisters” build new worlds. Arriving with substance abuse history that could include heroin, cocaine, crack cocaine, and alcohol, detoxing users in one center were confined to cots without access to medications in a room where speakers, bolted to the wall, played spiritual rock music. Routines at the centers included performing chores, attending Bible study sessions and participating in culto, the daily worship service, which could include jumping for Jesus, speaking in tongues, and, in particularly intense sessions, struggles with unconscious spirits who held participants to the floor (ibid.: 42). Hansen argues that testimony, prayer, and other technologies of transformation helped this group “achieve a symbolic inversion of domination and submission, weakness and strength, in what they would call ‘spiritual victory’” (ibid.: 63). Enduring pain in this world came to be embraced as a spiritual practice crucial to identifying with other converts and the Holy Spirit (ibid.: 49). Testimony, at once a relational and internal practice of memory creation, served as a narrative tool that brought the enchanted world of spiritual knowing into the everyday. Learning to interpret events in their lives as a series of “tests” helped recovering addicts to break from frustrations of the past and find new energy to rise above toxic influences to achieve a fusion with the Holy Spirit (ibid.: 37-9).

A particularly fascinating and ethnographically rich three chapter sequence offers a detailed gender analysis of treatment at the ministries that helps to elucidate both the successes and limitations of their interventions. For male attendees, the ministries at times promoted an individualist approach, encouraging converts to sacrifice, deny bodily needs, and attend to spiritual rather than biological children (ibid.: 110). However even as they claimed to value the “ultimate authority of personal, mystical experience” over and against extended family networks (ibid.: 14), Hansen argues that a crucial part of Pentecostal healing involved promoting a “new masculinity” encouraging their male charges to invert dominant ideas about properly masculine behavior and embrace emotional sensitivity and conjugal responsibilities (ibid.: 100-101). Drawing on a strong community presence created through “evangelical entrepreneurship” and pastoral care, the drug ministries were often able to provide male attendees leaving residential programs with the “spiritual capital” necessary to repair damaged familial relationships, regain patriarchal authority, and achieve a sense of purpose, even in instances where they were unable to find full-time employment.

In sharp contrast, the opportunities for “spiritual mothers” to grow were limited both inside and outside the treatment centers. Ideas of legitimate womanhood in evangelical communities often required “maternal discernment, self-sacrifice, vulnerability and obedience” (ibid.: 129). Whereas men received help in returning to the families they had neglected, women found that when they decided to seek treatment they could risk losing custody of their children, who were generally not allowed in the centers. By tracing the trajectories of women through time, Hansen convincingly shows how the “the spiritual capital of Pentecostal ministered mirrored economic capital: reproducing itself by widening social inequalities” (ibid.: 133)—in particular gender inequalities. Precious Gift, an alternative treatment space specifically focused on caring for women, eschewed middle-class respectability politics and pushed back against the “disintegrating family metanarratives” circulating in both local media and religious institutions. Embracing on-site family housing and daycare, its leaders instead advocated for a more fluid understanding of “extended family” that emphasized often overlooked matriarchal traditions in Puerto Rican families (ibid.: 130-33).

In contrast to Shukla’s “us” and “them” research dynamic, Hansen’s account explores how her personal life and professional career merged in complicated ways. Raised in Oakland by her African American mother and grandparents, Hansen writes that her “family’s frustrated aspiration, tenuous class background, and ethnic marginality” (ibid.: xiii) guided her own research interests. In the field, she frequently brings her one-year-old daughter, and later her young son, to ministries and house visits, participating in the extended family structures that she describes. Hansen also explicitly explores her own positionality as a non-believer studying evangelicals. She writes about how her fieldwork at the drug ministries shook her own understanding of the world as she began to interpret everyday events, such as her car stalling, as part of the mythical realm of demonic possession that converts lived in. The boundary between believer and non-believer came to be permeable as “sermon after sermon was about doubt” (ibid.: 35) and conversion itself was often tenuous. While continually drawing attention to social determinants of addiction, Hansen avoids making definitive pronouncements about her interlocutors’ lives, refusing a form of narrative control she worries might contribute to new forms of domination (ibid.: 5). Testimonies, including her own, matter greatly, but are never completely authoritative.

One intriguing place where Hansen remains silent is on her own role as a clinician. She describes herself as holding a tension “between a clinical and ethnographic gaze” (ibid.: 20) due to her dual training in medicine and anthropology. Stories from her time as a medical student and resident sprinkled throughout the book highlight her own discomfort with the dehumanizing tendencies that at times appear in biomedical care. The final chapter follows a patient of Puerto Rican descent at the hospital where Hansen works in New York who blossoms through his participation in a combination of supportive services, including group therapy, methadone maintenance medication, a Sobriety Garden and, in particular, an art program. She argues that biomedical care, like Pentecostal ministries, must help create new social communities and projects of selfhood that give patients a purpose. Hansen is clearly committed to advocating for changes to psychiatric practice: elsewhere she has written about power in the training of medical residents, structural competence in domestic healthcare, and the importance of integrating biosocial models in the DSM diagnostic criteria. But while her critiques of the limits of biomedical interventions and hope for forms of treatment that might “re-enchant” the lives of recovering addicts are convincing, we are left to wonder, what does Hansen believe should remain of the psychiatric clinical encounter? How does the role of psychiatrist as medical doctor (as opposed to, say, as social worker or concerned member of an extended family network) best contribute to the “elaborate practices of social alchemy” (ibid.: 63) that she tracks so carefully in other spaces?

It is precisely questions related to hierarchy and efficacy in the clinical encounter that animate Eugene Raikhel’s highly nuanced and innovative Governing Habits: Treating Alcoholics in the Post-Soviet Clinic. Narcology, as Russian state-sponsored addiction medicine is known, has an extremely poor reputation in the international addiction community. Practitioners’ promotion of aversion treatments, long-standing affinity for authoritative and coercive measures, and frequent opposition to harm reduction interventions are often interpreted by critics as signs of the country’s backwardness and illiberal tendencies. Raikhel, however, argues that analytic categories pitting “humanistic” international best practice against “authoritarian” Russian forms of treatment obscure more than they reveal. Moving between municipal narcological institutions, private clinics and a residential twelve-step residential program in Saint Petersburg, the author draws attention to the “epistemic assumptions, clinical practices and embodied experiences that make up the everyday encounters between narcologists and patients” (2016: 5). In the process, he shows how practitioners of addiction medicine in Russian reinvigorate Soviet therapeutic technologies while dynamically responding to changing political and economic conditions in a time of rapid social transformation.

Raikhel sets the tone of the book through a critical exploration of the country’s widely reported “demographic crisis.” Emerging in the 1990s and early 2000s, media reports and studies linked decreasing population and increasing mortality rights with rampant alcoholism among Russian men. This chapter responds to this narrative by weaving together hospital conversations that brought up other, competing “crises”—of national security, “modernization,” spirituality, masculinity, and the hospital system itself. Middle-aged alcoholics spoke of their fate as “thrown away people” and referenced culturalist discourses about vodka—and drunkenness—as a part of national identity (ibid 49). Narcologists commented on how Vladimir Putin’s sober, resolute, masculine strength was helping to overcome the mess created by Boris Yeltsin’s drunkenness and lack of discipline in the 1990s (ibid.: 53). Meanwhile, public health demographers pointed to a loss of social cohesiveness during mass privatization programs as contributing to rising mortality rights (ibid.: 41-43). Discussions of krizis in post-Soviet Russia thus “index different understandings of the social and its attendant norms, logics and forms of exclusion” (ibid.: 29) and, by extension, suggest competing ideas about the etiology and appropriate treatment of alcoholism.

The rise and subsequent erosion of the profession of narcology provides the crucial backdrop for understanding the slippery problem of efficacy in contemporary Russian clinical encounters. After decades of vacillating between profiting from and prohibiting the sale of alcohol, the Soviet state in the mid-1970s created narcology as a profession by “assembling” a group of pre-existing institutions into a coordinated network overseen by a new type of doctor specifically charged with treating addiction. This system offered services for different categories of problem drinkers: “Heavy drinkers” could be seen on an outpatient basis in narcological clinics, “alcoholics” needing more intensive treatment could be committed to municipal addiction hospitals or narcological residential clinics, and “addicts” could be sent for up to a year to “therapeutic-labor prophylactories” (TLPs) modeled on earlier Soviet labor camps (ibid.: 68). State authorities integrated a variety of approaches to defining and treating addiction. Particularly intriguing was a Soviet commitment to Pavlovian-inflected neurophysiological understanding of the mechanisms of addiction that embraced hypnosis and suggestion as viable treatments. Neither overtly criticizing nor romanticizing the efficacy of this earlier institutional configuration, Raikhel observes that narcologists once wielded considerable power within a system that reached far into the lives of its citizens. His doctor-interlocutors frequently spoke of late Soviet times with fondness, in part due to the attraction of the “idealized abstraction of plans and blueprints” (ibid.: 55) of this earlier system.

In the first decade of the 21st century, state institutions—and by extension the authority of the doctors who ran them—were under assault as the government cut funding for public treatment of addiction and abolished compulsory treatment. At the same time, private and non-profit treatment institutions, including the Orthodox Church, spiritual healers, and anti-psychiatric Scientologist therapeutic and rehabilitation centers, increasingly bickered over what constituted appropriate treatment. Narcologists seeking to survive in this new institutional landscape began to offer private detoxification services to coveted wealthy patients. Raikhel inadvertently landed in the middle of an escalating professional war when, on his first day visiting the private Bekhterev Center, bribed government inspectors raided the building. A subsequent cat-and-mouse game took an absurdist turn when hospital officials debated hiding expensive lab equipment in the gynecological ward to save it from being confiscated by “movers.” In a less humorous turn of events, the deputy director of the Municipal Addiction Hospital was murdered by a remote-controlled bomb. A competing group of narcologists and their associates known as the “gang of orderlies” were later arrested for the crime (ibid.: 90). Competition for permits, prestige, and money in an unevenly deregulated “rapacious market” complicated simple ideas about what a “transition” to a privatized economy might mean.

It is on the topic of efficacy and clinical practice that Raikhel makes his most original contribution. The author offers a nuanced and ultimately sympathetic take on the state of contemporary Soviet narcology, arguing that practitioners deployed a clinical style of reasoning informed by both Soviet traditions and a “moral and social calculus” (ibid.: 133) linked to a subtle understanding of patient demands in the contemporary moment. One particularly interesting case is that of placebo therapy. Disulfiram, a drug that creates unpleasant reactions to alcohol, is administered orally in pill form, intravenously in regular shots at the clinic, or subdermal implantation. Clinicians, believing that the power of suggestion rather than neuro-chemical effects of the drug is the key to their intervention, often provided vitamins or saline when patient asked to be treated with disulfiram. Similar to “coding” and “stress free psychotherapy” sessions where patients came to be convinced that their bodies had been altered by hypnosis (ibid.: 105-7), placebo therapy relied on the therapeutic ability of the clinician to inspire fear in the patient as a motivator.

Anticipating his liberal reader’s likely protests against treatments he refers to as “prostheses of the will,” Raikhel emphasizes that many post-Soviet patients actively sought out narcologists to help them “program [their] sobriety” (ibid.: 140). Narcologists, meanwhile, argued that hypnosis, coding, and other treatments could provide patients with more autonomy than interventions such as religious conversion or 12-step programs that required extensive work of self-transformation. Rather than anarchistic hold-overs from obsolete Soviet times, the narcologists in this account appear as canny and ethically committed market actors, able to find new ways of consolidating their therapeutic legitimacy in rapidly shifting conditions. This is vividly demonstrated in the performance of an Orthodox psychotherapist who, when lecturing about the biomedical aspects of addiction wore a white coat, and when speaking of craving as “temptation of Satan” donned an all-black suit connoting his status as a priest (ibid.: 138). Even as state narcological institutions lost their influence, professionals found new ways to draw patients to their practices as “social and political meaning and processes” came to be “translated into clinical and commercial value” (ibid.: 133, 181).

Where, then, does this text stand on the question of what constitutes appropriate treatment for addiction? In certain moments, Raikhel’s and Hansen’s approaches seem to converge. His description of “illness sodality,” a term for mutual help based on a common identification that spanned across the globe amongst twelve-step followers, echoes the ways that evangelical believers distributed “spiritual capital” through transnational networks. Like Hansen, Raikhel is committed to interpreting therapeutic interventions within cultural logics of neoliberalism, and he also argues for the crucial importance of attending to the social trajectories of patients’ lives – including their precarity as laborers – in understanding prospects for treatment. Yet while Addiction to Christ might, as Philippe Bourgois writes in his blurb, be classified as a work of “critical engaged medical anthropology,” Raikhel’s text resists such categorization.

Instead, Raikhel’s approach to clinical authority marks a third way of conceptualizing the relationship between representations of and knowledge about addiction. If Shukla offers a relatively unproblematized relationship between word and world and Hansen mixes a powerful condemnation of structural inequalities with a considered study of the ambiguities of the lived trajectories of recovery, Raikhel commits to an exploration of treatment that radically questions the universality of any travelling clinical intervention. Partially inspired by Michel Foucault and Ian Hacking’s destabilizing, nominalist approaches, Governing Habits continually traces interlocutors’ statements to particular discourses, logics, and fields of knowledge. Debates about the significance of therapies “became an important aspect of a broader therapeutic economy” (ibid.: 129) as therapeutic legitimacy—and thus the potential efficacy of a particular intervention—is constantly shown to be produced and managed through an intricate array of social processes.

Readers committed to activist platforms or convinced of the merits of certain treatments may feel frustrated by Raikhel’s consistent insistence on the importance of context over therapeutic protocol or material substance. Some might argue that Raikhel’s decision to privilege extensive conversations with narcologists—rather than direct observation of clinical sessions or more in-depth longitudinal tracking of the recoveries of particular addicts—has resulted in his overestimating the importance of this representational economy. Ultimately, however, this reader found that Governing Habits offers a highly convincing defense of the principled refusal of its author to take familiar, sweeping positions and instead focus on the fascinating particularities of the post-Soviet narcological practices and epistemological commitments. While not easily converted into implementable policy prescriptions, Governing Habits makes an important contribution to the anthropology of medicine through its vivid exploration of a history of medicalization that radically diverge from the “two minds” of American psychiatry (Luhrmann 2001) and, by extension, the practice of addiction medicine in North America.

Let us return to how these distinct ways of knowing addiction might inform our thinking about the contemporary opioid epidemic in the U.S. In her attention to the importance of users’ participation in drug economies, Shukla would no doubt urge us to consider how the complex interactions between licit and illicit production and circulation of OxyContin, heroin, fentanyl, and other opioids impact users’ lives. Her commitment to foregrounding the reflections of meth users in her account made this reader, as a frequent consumer of media reports about opioids, aware of the striking absence of opioid users’ voices in popular representations of the epidemic.

Raikhel’s attention to overlapping Russian “crises” offers a potential model for analyzing how recent media attention to the opioid abuse epidemic in the U.S. intersects with crises of the healthcare system, economy, and national identity. In addition, his interest in how authority and efficacy operate in the clinical encounter is particularly timely given the recent rapid expansion of Vivitrol (naltrexone) as a first-line treatment for recovering opioid addicts. After heavy promotion by its manufacturer as a “non-addictive” treatment, more than a dozen states have in recent years written the drug into laws, with some offering “Vivitrol courts” for arrested users. The Russian connection to naltrexone is an intriguing one: the U.S. Food and Drug Administration approved the drug after a single clinical trial conducted by Saint Petersburg-based narcologists. Like disulfiram, Vivitrol, which blocks opioid molecules from attaching to opioid receptors, is administered as a monthly injectable. U.S.-based harm reduction advocates have noted with concern that rapid expansion of this brand-name medication is a “siren song of enforced abstinence” (Wolfe 2017) and potentially limits access to methadone and buprenorphine, opioids that treat not by “locking up” the brain but instead by “maintaining” the user on a fixed dose. There is an urgent need to better understand the particular patient-provider interactions that are making possible the explosive growth of this treatment.

Though not a focus of her book, Hansen has published extensively on opioid abuse in the U.S. Rather than examine the lifestyles of users, she draws attention to the “neuroracial politics” and economic inequalities that fuel both expanded opioid abuse and the emergence of a “two-tiered” system of treatment for patients. She notes how a surge in opioid abuse corresponded with the marketing of OxyContin as a “minimally addictive” pain killer to predominately white middle class Americans, and explores how a recently constructed delivery system provides convenient, office-based treatment to suburban and rural insurance-holding white populations while confining majority-black and Hispanic urban populations to a less flexible, clinic-based treatment system (Hansen and Skinner 2012). Hansen suggests that dealing with our country’s deep and ongoing racial and economic divides – in part by moving to a single payer healthcare system – is a crucial part of tackling the increased toll of addiction in this country.

Knowing addiction, as these three authors demonstrate, can encompass a variety of different objects and questions. Following Shukla, future studies might attend to the politics and poetics of the language of opioid users to evoke lifeworlds organized, in part, through participation in complex economics of production and distribution of drugs. With the growth of for-profit addiction companies, expansion of independent private practitioners and uneven implementation of the Affordable Care Act, Raikhel’s work invites closer attention to clinical encounters as a way to understanding potential shifts in epistemologies, authority, and technologies in this rapidly shifting institutional landscape. Accounts inspired by Hansen’s work might track the trajectories of recovering addicts, paying particular attention to how experiences of gender, race, and faith in familial, community, or alternative treatment spaces supplement biomedical care. Any of these projects would necessarily grapple with how state funding, policy priorities, and media representations in the divisive Trump era come to inflect the recovery prospects of drug users in the U.S and elsewhere.

Nick Bartlett, Barnard College, Columbia University

Reviewed in this Essay

Hansen, Helena. Addicted to Christ: Remaking Men in Puerto Rican Pentecostal Drug Ministries. Berkeley: University of California Press, 2018.

Raikhel, Eugene. Governing habits: Treating alcoholism in the post-Soviet clinic. Ithaca: Cornell University Press, 2016.

Shukla, Rashi. Methamphetamine: A love story. Berkeley: University of California Press, 2016.

References Cited

Hansen, Helena, and Mary Skinner. “From white bullets to black markets and greened medicine: The neuroeconomics and neuroracial politics of opioid pharmaceuticals.” Annals of Anthropological Practice 36.1 (2012): 167-182.

Luhrmann, Tanya. Of two minds: An anthropologist looks at American psychiatry. New York: Vintage, 2001.

Murakawa, Naomi. “Toothless: the methamphetamine “epidemic,” “meth mouth,” and the racial construction of drug scares.” Du Bois Review: Social Science Research on Race. 8.1 (2011): 219-228.

Wolfe, Daniel. “Vivitrol offers the fantasy of being drug-free. But that’s not the most important thing in tackling addiction.” State News, June 29, 2017.

About Matthew Wolf-Meyer

Matthew Wolf-Meyer is an anthropologist and historian of science and medicine in the United States. He is author of The Slumbering Masses: Sleep, Medicine & Modern American Life (UMN Press, 2012), Theory for the World to Come: Speculative Fiction and Apocalyptic Anthropology (UMN Press, 2019), and Unraveling: Remaking Personhood in a Neurodiverse Age (UMN Press, 2020). He blogs at and

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