Moderation and coexistence with psychoactive substances use: Approaching a Drug Consumption Room in France

Moderação e coexistência com o uso de substâncias psicoativas: abordando uma Sala de Consumo de Drogas na França

Natália Heringer Mendonça heringer.natalia@gmail.com

Tribunal de Justiça do Distrito Federal e dos Territórios, Brasil

Esta obra está bajo una Licencia Creative Commons Atribución-NoComercial-SinDerivar 4.0 Internacional.

Drug consumption rooms (DCRs) are spaces in which people who use heroin and other injected substances can do it safely and under the supervision of professionals that have the task of assisting, yet never conducting injections. They provide people with social and medical support, screening tests, and aseptic material for substances consumption with the mission of reducing the psychoactive users’ mortality, morbidity, and exposure to risks, as well as bring them closer to social and care services (Jauffret-Roustide, 2016). In this article, which is a partial fruit of my master’s thesis (Mendonça, 2019), I expose some aspects of these structures and their attendees, observing a French case, starting from the premise that the DCRs’ polemical implementation tries to respond to the effects of a social process that turned the use of psychoactive substances into a crime/health issue and created the pathological, excluded, and punishable category of drug user/addict.

In the last 35 years, DCRs have been adopted by more than 10 countries as part of harm reduction policies. In France, strong drug-prohibition measures were taken during the 1970s, incarcerating or sending psychoactive users to compulsory hospitalization (Kokoreff et al., 2018). In the next decade, drug use became a public health issue with new actors and arguments joining the field of dispute (Boltanski and Thévenot, 1991) on this theme, such as researchers and institutions concerned about regular psychoactive consumers, which came to standardize the use of substances and lead to the implementation of French DCRs in 2016.

I highlight that drug consumption remains criminalized in France and that the permission to open DCRs was, primarily, experimental. Thus, this study has the critical point of view that this field of disputes which resulted in DCRs authorization reveals a cultural and moral shift. That is, it marks the transition from the prohibitionist model – centered on the Platonic notion of abstinence at any cost (Garrau, 2018) – to the harm reduction idea that rational psychoactive consumption is possible – which is linked to the Aristotelian concept of temperance (Aristotle, 1992) –, expressing a logic of moderation.

Considering all that, the objective of this research consisted of understanding how it is for psychoactive users to experience the use of substances in a Drug Consumption Room and how it impacts their lives and subjectivities. Carrying out a qualitative methodology, I designed a blending of methods by conducting interviews and a direct observation of the Strasbourg’s DCR (ARGOS) – using an ethnography-inspired field notebook –, whose outcomes I crossed and analyzed. I developed the text by bringing some information on the DCR I observed, moving then to explaining the methodology. Afterward, I presented the findings and its discussion with supporting literature by approaching, firstly, the concern of psychoactive users attending that DCR about hygiene, secondly, their relationship with responsibility and guilt and, thirdly, the reformulation of meanings they give to their substances’ consumption and to themselves, as well as the Strasbourg’s DCR’s sensibility to its audience’s precariousness.

The Strasbourg’s DCR, ARGOS, is one of the structures managed by the ITHAQUE association. Since its public lives mainly in a precarious manner, such as in cellars/squat, shelters, or is homeless, the service aims to provide them with a warm and judgment-free support and respect for anonymity. The room is located within the University Hospital of Strasbourg. It was inaugurated in 2016 and, since then, it works in partnership with the police to ensure that the latter respects the limits of ARGOS’ proximity zone because the opposite could imply a low frequency of attendees in the room due to their fear of having legal problems once drug consumption is still prohibited in France.

People over the age of 18 who wish to attend voluntarily are welcomed there every afternoon 7 days a week. In order to access the consumption area, it is necessary to show the substance they brought in the entrance and respect the limit of 2 grams or 7 capsules of the substance, as well as a time limit of 30 minutes between one consumption and the next. The consumption material delivered is more suited to their needs, such as pieces of paper one can roll when snorting some substance, needles of various sizes and varying colors to prevent accidental sharing, acidifiers, avoiding the use of vinegar or lemon juice to dissolve certain drugs, a case to properly keep used needles, and alcohol swabs to cleanse the skin.

Attendees can let their dogs be attached to the outer grill or next to the entrance to the interior of the facility. When arriving at the reception, people identify themselves with a nickname, obtain the quantity of aseptic material they need, and leave to use the material somewhere else or pass to other spaces of the DCR. In the consumer space, two professionals are present including at least one nurse. There is also a room with lounge chairs available to rest and another area for conviviality with a cafeteria, chairs, and tables, on which there are, frequently, snacks, paper, pencils for writing, coloring, drawing, and, sometimes, newspapers. People always find coffee and tea on the counter, and kitchen appliances can be used to prepare simple meals. Often, attendees go there simply to have small talk, appointments with doctors or social workers, dispose of used materials in proper trashcans, take a shower, or simply to be in a space that is not that of the streets.

The study applied a qualitative methodology designed through the use two technics, namely direct observation, with the use of a field notebook inspired by ethnography, and semi-structured interviews with seven attendees. I did the direct observation three times a week for two months, as well as interviews following a non-exhaustive script that was previously approved by the ARGOS coordination and respected ethical norms. I had freedom to move around in all areas of this facility, except the injection room to respect the privacy of its users.

I carried out audio-recorded interviews with seven psychoactive users who regularly attend the Strasbourg’s DCR and agreed to participate voluntarily in the study, having given their free and informed consent. Their names were changed in this research in order to ensure their anonymity. The respondents’ average age is 42 years old, higher than that of ARGOS (37 years old). Five of the interviewed are men (71.4%) and two are women (28.6%), which is close to the gender composition of this DCR audience.

Afterwards, I fully transcribed the interviews. The important ideas gathered in the same interview (longitudinal) or from one interview to another (transversal) became themes and their grouping by topics gave rise to an analytical grid (Ramos, 2015). This material was crossed with that of the field notebook analytical grid. As for the latter, I did several re-readings to find focal points, such as the quest for impregnation described by Laplantine (2015). To put it plainly, the thematic sections were ordered in the direct observation analysis grid and then linked to the interview analysis grid. By combining the two perspectives, I produced a third analytical framework from which the discussion was woven.

According to conversations I had with psychoactive consumers attending ARGOS, the facility makes it possible to feel welcome, to have access to a clean space, to a service that is more humanized and sensitive to their specific needs. Furthermore, the analysis of the data obtained in the field revealed that the interviewees’ narratives favored certain themes linked to three main categories, namely hygiene, responsibility, and guilt. Because they are categories of thought, that is, defined from reality, whose complexity is difficult to frame in its entirety (Kaufmann, 2011), the boundaries between them are blurred. For example, sometimes the mention of hygiene elicits responsible behavior; at other times, guilt arises from responsibility, as we will see in the following pages.

The data obtained show a clear attention to hygiene, either on the part of the staff or the attendees. This may seem obvious given it is an establishment of health care and prevention. However, in the same way health is a socially constructed concept (Fassin, 2000), hygiene is a set of standards stating ways of conducting human life, and the practices it implements reveal subjectivation aspects of individuals. Through the hygiene category, one can apprehend the subject who mobilizes this notion under the spectrum of the society that produced it, according to Mary Douglas (2003) in “Purity and danger”. With dirt being the expression of the disorder, hygiene is the gathering of actions aiming at reestablishing order. That notion can be found in the narrative of some attendees; for example, in Hermes’ response, when asked if he feels different when consuming safer in DCR:

“– Yeah, yeah, yeah, the surroundings are clean, you see, there are computers, telephones, well-dressed people.

– [me]: But what feeling does that give you?

– The cleanliness. It’s not a mess. Often the life of an addict is often [sic] a mess. In the head, in life, in tasks. Often. Not all the time, but often. And here, and here everything is clean, is well organized, all that. Yes, it is a bit of rigor. It feels good. I [sic] that makes me feel good” (Hermes and Mendonça, 2019)[1].

The passage shows a meaningful relationship between cleanliness, order, and rigor, while the direct opposition to cleanliness appears represented by the word “mess” in connection to drug addiction (source of impurity). The dirt, that here is represented by the disorder caused by drug use, would be dangerous since it has the potential to contaminate aspects of the subject’s life as well as other people with that lack of order. Accordingly, the relationship between impurity and danger appears once again when Hermes recounts his difficulty in projecting his future: “I’d like to have had kids, I’d like I had gone further in my work, I still have time. But if I put the drugs on, it’s still rotten, what [sic]. It doesn’t help moving on”[2] (Hermes, 2019). In this extract, Hermes explains that although he wants to rebuild his life, drug use limits him. He says drugs are that “rotten” element, that can refer to their ability to spread harm and contaminate a person’s entire life. The chaos is, thus, emphasized as a property of propagating disorder.

Aligned with the idea that hygiene is a value that symbolizes the subject’s ability to get in order, Foucault (1982) gives us clues to understand that holding a behavior as contagious sets moral values and practices ​​when he argues that ordinary daily rituals normalize life. Hygienic practices are one part of a multitude of procedures that inscribe human existence in the social order making up a set of meticulous techniques easily generalized when passed from one person to another and which imposes a discipline on the microphysical level of existence (Foucault, 1975).

Showering, disinfecting hands, and looking for clean material when injecting drugs are forms of action that convey senses. That means, being hygienic is an exercise in both self-determination and subjectivation, in which the subjects choose and demonstrate what treatment they give to the body according to what society expects. I highlight, however, that the DCR is one of the few places where some attendees can shower and that cleaning the skin prevents abscesses. Hence, it is difficult to draw the line that separates what is an act of reproducing norms or just reducing bodily inconvenience.

In the interviews, notions related to hygiene appeared frequently as a justification for consuming at ARGOS. We can find them through words such as “clean” and “healthy”, referring to “a level of hygiene to consume”[3] (Ulysse, 2019) the substances. For example, according to Hermes, one of the reasons he likes the DCR is because “it gives [aseptic] material, there is this way of being clean indeed”[4] (Hermes, 2019). There is, here, the idea of cleanliness as a mean to reduce exposure of individuals to evil and uncertainty, but also as a path of normalization. If daily hygiene procedures normalize individuals to the extent that acting in compliance with these mini rituals allows the subject to be recognized and recognize oneself as “normal”, then “clean” consumption can be a manner to bring the psychoactive user into this field of possible socially desired normality.

Analyzing the material collected in this research, I observed that the idea of being more responsible is one of the senses that a person can form consuming in a DCR. Even hygiene can be understood as an act of responsibility, with individuals more concerned with cleanliness and contamination, being seen as more in charge of themselves and others, something we can notice in what Achilles said when talking about why to attend the DCR:

I would say just, it’s better for everyone now [...]. Consuming the substance here also avoids us [sic] leaving kind of [sic] a lot of waste outside. There are a lot of people leaving material [after injecting] outside. For example, there are many, many different examples [sic] such as: leaving your material outside, for example, is not as good as leaving it here; the dogs, for example, or the children, the people who will pick it up it is not good at all and it is, for example, better because of that; here they give you a disposal case and it will be destroyed [...][5] (Achilles, 2019).

When talking about the means that the DCR makes available to dispose of used syringes that could remain in public space after substance use, Achilles shows he feels responsible for the consequences that his consumption brings to other beings. In this case, concentrating someone‘s substance use practices in a DCR allows one to identify oneself as a person who cares about other beings, as well as being concerned about oneself, as Helene states: “I’ve never had an abscess [sic] I come to ask for advice. For example, where not to do it [the injections], and what not to do, I really pay attention to this”[6] (Helene, 2019). In the first excerpt, we see the justification according to which one envisages preserving the community. In the second, Helene emphasizes that she searches for advice and that this is the reason she has no abscesses. It resorts to the justification of self-preservation. The collective and the individual wellbeing appear as part of this set of arguments related to the normalization of psychoactive use.

This is related to a contested point of harm reduction policy, to wit, concentrating the responsibility for the management of life on individuals (Ehrenberg, 1999). Plainly put, one is responsible for maintaining good health without causing threats against oneself and, in the meantime, this person incorporates the task of not putting fellow human beings at risk. It consists in locating individuals in a central place, so that they become more than actors of their own health (Dos Santos, 2016), but also of others. Thus, individuals become actors of public health once the task of caring for collective health is also internalized by them. Now users of psychoactive substances are responsible for the performance of acting with responsibility and autonomy, which is translated into controlling the forms of drug consumption in such a way it moderates the harm to others and themselves. Responsibility is, here, connected to the category of hygiene since the subject contributes to maintaining themselves and society in order when consuming substances responsibly.

Moreover, according to the data gathered in the field, responsibility functions as a double role: it attaches to the person the competence to answer for her or his acts, however, the fact of consuming a substance still weighs on the subject. Helene expresses it directly, saying “[…] sometimes I do it, and once I've done it, I feel good and then I feel guilty”[7] (Helene, 2019), and indirectly, stating “I haven't been back since November but, because I tried to calm myself down, but actually I, I keep doing my nonsense”[8] (Helene, 2019). In the first passage, Helene does not want to go to ARGOS because it means injecting heroin. She stays at home to avoid using it, but then she consumes it alone in her room and feels guilty. Her words indicate the tension in which the docile body (Foucault, 1975) argues against the wish to experience the sensation caused by the substance. In this perception aligned to Platonic rationalism, pleasure and reason are incompatible. In the second excerpt, the same internal struggle is repeated, and guilt is represented there when the interviewee concludes by saying that she continues to do “her nonsense”.

These are two sides of the same coin: acting in accordance with the desirable behavior provokes the sensation of doing good, while using the substance still means harming oneself. Consuming, even in a harm-reduced way, is still consuming; it is felt as controversial and causes guilt. Thus, the subject is a battleground in which guilt and responsibility collide. This issue is, in this case, the source of the feeling of inconsistency and suffering.

Thereby, the psychoactive user is crossed by the guilt-responsibility relationship. Each of them carries moral references regarding society, the rapport between the two being arranged by the subjects, as in the passages above. In practice, the lives of people in this situation can be a constant back and forth between responsibility and guilt once their consumption is not linear. Since drug use remains prohibited – with exceptions such as consumption in DCR – the austerity against drug consumption crystallizes in the mind of the subject, who imputes the severity to the self through specific punishments: guilt and the sensation of impurity. This punishment can be repeated each time the person consumes the substance, in a dynamic between consumption and guilt that reflects the Foucauldian panopticon paradigm (Foucault, 1975). By integrating ​​abstinence as a reference, the subject is in constant self-monitoring and, when using the drug, this person punishes oneself. The subject is, therefore, incarcerated in self-supervision and self-punishment.

This study found that, although the moral force of the prohibitionist model is still very present in the psychoactive users’ lives, there is a reappropriation of usages and senses done by the subjects regarding their substance consumption that can contribute to the exercise of autonomy. For instance, Hector reports that he is the one responsible for managing his opioid substitution treatment (OST). The substance is prescribed by the doctor, but he adapts the dosage to his needs. Sometimes he associates an opioid with it: “Well, I stopped with heroin and all that, and from time to time I use it, but it is very, very, very, very rare […]. I use it once or twice a year”[9] (Hector, 2019). Hector allows himself to use heroin sometimes at the DCR even while under substitution treatment. In his point of view, taking the two substances is not contradictory since his use of the opioid is rare. On the contrary, it gives him the satisfaction engendered by the feeling of control.

By adapting psychoactive use their own way, consumers can assert themselves as the subjects of their actions and, thus, as the subjects of themselves. In this respect, Dos Santos (2016) identifies the reappropriation of sense among the users who do the OST. They do the substitution treatments their own way, attributing their personal meanings and rites to them, combining prescribed substances with non-prescribed ones, illegal or not, and assigning them resignifications. Similar reappropriations are made by some people who frequent the DCR, as we saw in Hector’s talk.

Other users are quite comfortable with their use and do not consider quitting it. When asked if she plans to stop consuming, Penelope replies: “No, because it's just a [sic] a pleasure once or twice a week. That’s all”[10] (Penelope, 2019). Since she understands her consumption as not being problematic, not compromising her life, and feels that she has it under control, stopping the use of the substance is not of much significance to her. It is possible that, for psychoactive users like her, continuing this consumption can have more meaning than abstaining from it for several reasons, such as maintaining a life dynamic to which the person is already used.

Furthermore, the research with attendees of the Strasbourg DCR shows how the precariousness in which they live impacts them as subjects. It goes beyond the shortage of goods and services, extending to a precarity related to interpersonal relationships, such as connections and affection. Consuming the substance in a DCR is also a possibility to handle social interactivity and affectivity. These last two aspects are sometimes reduced, sometimes restricted to peers, as Helene explains: “From the moment we start, we already [sic] we isolate ourselves and then we hang out with people who who [sic] also consume it because we are ashamed of, of [sic], we don’t want to do it in front of other people [...]”[11] (Helene, 2019). She expresses that psychoactive use reduces one’s relationships due to the fear of losing the respect of others. In Helene’s case, the loss of her daughter is a great source of suffering: “I lost a four-year-old girl and at the time I just used [sic] I smoked cocaine. I used heroin, but I never injected myself. Injecting is [sic] it has been a year”[12] (Helene, 2019). According to her, the use of substances by injection started after the death of her daughter, giving signs to think of the possibility that the pain caused by this loss is somehow embodied through the taking of the drug.

In this regard, from Le Breton’s (2012) perspective, this kind of non-materialized pain becomes embodied by the person through certain behaviors, such as consuming drugs. Thus, suffering takes shape in one’s flesh and the person would become strongly linked to the feeling of a partial relief caused by substituting involuntary for voluntary pain. This mechanism would translate unbearable and fortuitous suffering, such as that of the loss of a child, into a pain that is palpable and of which the perpetrator is known (oneself). Hence, we are also in the realm of meaning, which here consists of resignifications of suffering.

It is important to notice that suffering and other feelings play a role in the attributions of meaning which psychoactive users make of themselves and their lives. Since elements of this sphere are present in the data of this study, how to ignore that all kinds of feelings are an integral part of people’s discernment? Evaluations that justify every human action also emerge from the dimension of feeling, not only from that of reason (Joas, 2001). This hierarchy between the rational and the sensible reinforces the labeling of psychoactive users as “drug addicts”, meaning beings commanded by pleasure and by the mania of taking the toxic product. Its effects are catastrophic since this label keeps them distant from health services and their loved ones, nourishing their vulnerability and weakening this population.

Concerning their vulnerability, a significant portion of ARGOS’ public is homeless, whose precariousness is aggravated by the lack of stable housing. In this regard, Helene recounts how this deprivation affects the possibility of undergoing treatment:

[...] So I said “doctor, I need help, I’d like to go on rehab” and at that time I was homeless. He told me, “The treatment won’t work. The priority is the apartment, stability, to have your place because if I send you to rehabilitation and you leave, you’ll be on the street and you’ll be tempted again”[13] (Helene, 2019).

As Helene lives in a shelter, the physician tells her it would not characterize the stability necessary to follow the treatment. She complains about this requirement and the idea that rehabilitation without fixed housing is useless. Paradoxically, on the one hand, the person could not go on treatment since he or she does not have a fixed address. On the other hand, being homeless makes it harder to cut down on drug use once the person remains exposed to all kinds of vulnerabilities that subjectify them as drug addicts.

Housing precariousness is, thus, an urgent issue for many psychoactive users. Being homeless in drug use is challenging when finding a shelter to continually stay. For this reason, the Strasbourg’s DCR intended to adapt to the needs of its target audience. Accommodations within the second floor of the facility were planned to open by the end of 2019 to lodge ten regular attendees of ARGOS in more vulnerable situation, with their dogs, to provide them with a continual service. In case of success, the accommodation would be expanded.

Therefore, DCRs in France express a specific kind of wisdom, namely, practical wisdom (Ricoeur, 1990), which consists of changing morals through action. When the strict application of the norm becomes dramatic – because to disagree with it or to follow it in both cases imputes suffering and increase in mortality, morbidity, and exposure to harm –, the conviction puts into practice actions that prove that this norm has less meaning in reality than in the law text. The fact that the law establishes that drug consumption is still a delict shows that morality has never overcome the prohibitionism installed since the 1970s and the abstinent model remains in our moral references. In this context, the action of ARGOS goes beyond the implementation of harm reduction measures. Ultimately, it is about changing the law based on practical experience.

The immersion in the research field showed that attendees of the Strasbourg’s DCR are quite satisfied with it in general. In their perceptions, the importance of this facility in terms of harm reduction sometimes appears as an extension of the idea of hygiene and, therefore, of tidying up the subject. Some re-signify themselves as more responsible consumers. However, this can happen in the form of more or less regular times of consumption and frequentation of ARGOS and sometimes comes with a feeling of guilt due to the psychoactive use.

There is a tendency that people re-signify their relationships with drug use and/or to themselves through frequentation of the DCR. Being treated as people worthy of the exercise of their autonomy and responsibility, also worthy of attention, makes that change of perspective viable. For some, the consumption under harm control is less paradoxical than for others, who feel that consuming in a harm reduced space protects their and others’ lives, however, does not release the guilt when consuming the substance.

Although DCRs are part of a policy that can overwhelm the psychoactive consumer with the responsibility of being the actor of individual and collective health, they can facilitate the exercise of autonomy and modeling of drug use through harm reduction. They are able to embrace the fragmented experiences of its attendees, made up of the alternation between more or less intense consumption, between responsibility and guilt, between harm-taking and its reduction, as well as the mixture of substances and a multiplicity of apprehensions of meaning. Hence, the fact that it welcomes psychoactive consumers in the integrity of these fragments approaches people from health/social services. Besides, the DCR shows a practical wisdom intending to face the urgency of its attendees’ precarious situation.

In conclusion, the study points out that a major ambiguity lies in the fact that the harm reduction model, whose basic idea is moderation, coexists with that of abstinence. The latter resists inside the morals of society, as well as the prohibitionist spirit of a law that still interdicts drug use by imposing penalties on it. How to conceive that reasonable consumption of these substances is acceptable if using them remains punishable? Given this controversy, many users might continue far from social and care services. Therefore, further studies must be undertaken in order to go beyond the question of discussing the relevance of DCRs, debating, instead, the inconsistencies of the larger context.