ORIGINAL ARTICLE

Drug abuse: from subjectivity to legitimacy through psychiatric discourse

Pablo Ornelas Rosa

Núcleo de Estudos Sociais, Universidade Tecnológica Federal do Paraná, Ponta Grossa, Paraná, Brasil

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Original Title: Uso abusivo de drogas: da subjetividade à legitimação através do poder psiquiátrico. Translated by: American Journal Experts

ABSTRACT

Drug abuse has been considered a medical issue by practitioners of medicine since the 20^th century. Several explanatory theories and practices directed at both the treatment of addicted individuals and the minimization of the damage caused by the use of such substances have been developed. However, medical discourse is still dominated by the theory that the mere use of psychoactive substances a problem, even though there have been several attempts to understand the phenomena related to the use of drugs through theoretical models associated with cultural issues. The views imposed by modern medicine continue to expand because of value judgments based on the discourse on drug abuse. In this paper, we analyze the impositions of the medical discourses on other fields of knowledge, including the social sciences and humanities, regarding the relationship between psychoactive substance use (cultural practices) and addiction (disease). We advance a thesis that the examination of drug use can and must be focused from other points of view that do not reduce the issue to the assessment of the disease but that rather analyze the relevant social and cultural issues.

Keywords: Substance-Related Disorders; Street Drugs.

BETWEEN POISONS AND MEDICATIONS

There are two types of substances that when introduced into the body via any route (i.e., oral, intradermal, intravenous, rectal, intramuscular, or subcutaneous) can be assimilated and converted into material for the development of new cells, although this assimilation may not occur immediately. Such substances are referred to as "food" and include anything that enters the body, is immediately assimilated, and contributes to the body's renewal and maintenance. However, there are two basic types of substances that are not immediately assimilated by the body. There are those that, like copper or the majority of the plastics, are expelled intact and have no effect on body mass or state of mind, and there are those that provoke an intense psychological reaction⁶.

Those substances of the second type are called drugs and are known to act in a significant way even when absorbed in minimal quantities when compared to the food quantity ingested daily. However, within this group of substances, there are also compounds that act somatically (such as cortisone, sulfonamides, or penicillin) and ones that not only act somatically but that also impact on our emotions, altering our level of consciousness. According to Escohotado⁶, the systematic use of psychoactive substances that act on our nervous system, on consciousness, or on the human psyche, has been present since the beginning of human civilization. In his manuscript, he cites an extensive and diversified bibliography that lists several different ways these substances were collected, produced, used, and represented by different societies throughout history. This second type, which was considered by several ancient and modern cultures as being miraculous, is, for the most part, closely related to substances that exchange messages with the nervous system (the so-called neurotransmitters) and are vulgarly referred to as drugs⁷.

Termed as drugs or medications, whichever is more convenient, these compounds can damage and kill in relatively small quantities. They can also be referred to as poisons, because every drug is characterized by its toxicity or poisonous nature. Aspirin, for example, can be lethal to adults starting at dosages of 3 g.

Surely, the toxicity or poisonous nature of a substance will never have an abstract qualification, as it is determined by the proportions used by and in each individual. For that reason, even at the risk of losing our lives, we frequently use aspirin, quinine, and potassium cyanide. The ratio between the quantity needed to reach the desired effect (average active dosage) and the quantity sufficient to cause death (average mortal dosage) is called the security margin of a substance.

Fundamentally, within the security margin, the use of toxic agents raises two questions: 1) that of the benefits and risk of using a substance and 2) that of the organism's ability to adapt to intoxication. The cost depends on collateral or undesired effects at the organic and mental level, as the capacity of the organism to face the intruder depends on the tolerance factor, which is linked to each compound.

The tolerance and the psycho-physical cost are subjective as compared to the objective nature of the security margin calculation. Although individual differences are very important, it is not possible to affirm that the heroin margin is lower than 1 by 20, the LSD margin to 1 by 650, and the aspirin margin to 1 by 15. When mentioning costs, it is common to highlight certain aspects in detriment to others, presenting one side of the subject as if it were the totality. Therefore, for instance, for decades the "official" medical science denied any therapeutic use for cocaine due to its ability to cause hyperexcitablity, insomnia, and even brain damage, while it generously prescribed amphetamines as invigorants, anti-depressives, and anorexigenics (in the treatment for obesity). With regard to stimulants, the amphetamines are considerably more expensive than cocaine in the short, medium, and long term.

Until the middle of the 20th century, pharmacologists understood that familiarity with these substances would come from the decrease of the intoxication, making a more reasonable use of toxics a gradual habit. However, with the creation of more repressive laws, the opposite occurred, resulting in the loss of the tolerance factor; this repression has decreased the body's ability to have regular contact with drugs without experiencing harmful effects, and as a consequence, drugs are now taken in an abusive manner. In other words, the frequent use of the drug, which could have provided opportunity for the adaptation of the organism, was not possible, as increased frequency was thought to cause the individual to become more dependent, resulting in increased use to obtain the same effect.

A drug with which an individual can become familiarized (i.e., that which has a high tolerance factor, such as coffee or alcohol) presents a smaller risk of acute intoxication than a drug with a low tolerance factor (e.g., barbiturates and other sleeping pills), whose continuous use does not significantly increase its security margin. At the same time, it is also true that it is possible to increase drug dosages to get a level of inebriation where the risk of acute intoxication approaches the risk of chronic intoxication.

However, the chronic use of certain drugs is much more harmful for the nervous system, liver, kidneys, and other organs than the chronic use of others. Finally, the fact is that each drug has a particular system of advantages and inconveniences.

DISCOURSES ABOUT DRUGS

During modern Western history, many approaches have been constructed regarding drugs, which allowed not only the creation of laws that prohibited the use of some of these substances but also the creation of a stereotype of the subjects involved in their consumption. Zorrilla¹⁵ presented three types of norms that produced these stereotypes and that work as a coercion and consensus factor about good and evil when referring to drug control. They include the following: the approach of the means of communication, the political-judicial approach, and the medical approach.

The means of communication approach presents the drug user as an "addict" and creates the cultural stereotype of this individual as someone who is young, dependent, and lazy. It also depicts drug usage as a prohibited pleasure, a poison, or a scourge of the soul and spreads the moral stereotype that is seen not only in the means of communication approach but also in the legal approach (product of the dissemination of the ethical-legal model).

The three stereotypes presented by Zorrilla15 refer fundamentally to the individual that makes use of these substances, reinforcing the legal approach that appoints all drugs into one of two groups, either narcotics or psychotropics, and describes drug users and dealers as dangerous, minimizing important differences. At the same time, it legitimates the differences between good and evil when declaring illegal only the drug-related conducts this approach defines to be illegal14.

Still, Zorrilla¹⁵ added a fourth type, called the criminal stereotype, present since the beginning of drug legislations, but that has currently been converted to the political-criminal stereotype, as it used the political approach to legitimate the legal approach (product of the dissemination of the geopolitical model). For the geopolitical model, the drug is seen as an enemy, and the dealer, the main focus of interest for this approach, is seen as an invader, conqueror, or more specifically, as a narco-terrorist or a narco-guerrilla, although the drug dealer may not be an individual, but rather a country or a nation.

For Karam¹², it was from the war against drugs that the radical facet of the English word narcotics was added to the expression "traffic". As that word is also present in other idioms, it simultaneously allowed the standardization of language and a stronger emotional burden with reference to the production and distribution of the so-called illicit drugs. The expression "narcotraffic" was uncritically repeated and internalized, without realization - or intention of realizing it - of the lack of commitment to reality and science embraced in the distortion and functional use of the language. To create a useful and exacerbated emotional environment, the principal target of the prohibitory policies was, and still is, cocaine, which is not a narcotic (a psychoactive and depressive substance), but to the contrary, a known stimulant.

The political-legal approach, better known as geopolitical, spread quickly in the American continent during the 1980s, is consistent with the incorporation of the National Security postulates, which identify who the enemies are and decisively combats them.

The medical approach (product of the dissemination of the medical-sanitary model), when considering the subject that uses psychoactive substances as an "addict" or someone who is sick, and the drug as a "virus", an "epidemic", or a "plague", creates the medical stereotype. More specifically, it creates the stereotype of dependence or disease, centralizing the problem as a public health issue. This work will be developed based on the medical approach and more specifically on the medical and psychiatric power, which densely permeates that discourse.

For Foucault⁹, the psychiatric power is a power in which, and through which, the truth is not on the table. Therefore, psychiatric knowledge does not have as its fundamental role to base a therapeutic practice on the truth; rather, to the contrary, its aim is to add a supplementary mark to the psychiatrist's power. In other words, the psychiatrist's knowledge is one of the elements through which social mechanisms organize reality's superpower around madness.

In traditional societies, representations of disease are more related to conceptions of the universe, gods, people, relations within the same lineage, etc., where the diagnoses and treatments always included magical-religious elements, for example, divination sessions to identify the causes of a problem, sacrifices to gods or genies, and exorcisms to evict demons or other entities that were causing the disease. Very frequently, the therapist was also a priest or a skin-walker, and, in some cases, these three individuals were considered equally able to treat or cure the troublesome diseases.

With the development of modern scientific medicine, there has been a paradigmatic change characterized by an increasing empirical orientation, by the specialization of the medical role, and by the search for a very sophisticated rational knowledge. All medicines of ancient or traditional societies included empirical elements; consequently, it is also possible to notice the remaining religious aspects seen within Western medicine. In Latin, the term "professio" is the origin of the word profession, and it designates the practice of medicine, contains this idea: someone that executes a professio is the one that declares his or her faith and takes vows as initiates into ecclesiastical or monastic career1.

The disease can, and should, also be defined in social terms, as each society recognizes specific diseases. Societies have always tried to develop different answers to the misfortune that constituted disease and the several ways to treat patients. However, it has only been in modern societies that the disease gave way to the emergence of roles, professions, and institutions that were extremely diversified and complex, such as those seen in scientific medicine.

Therefore, the study of the interaction between sick and healthy people embraces a diversity of aspects that allow us to estimate the importance of the activities based on scientific knowledge and techniques in industrial societies, making us aware of the emergence of a different form of the work organization: the profession, followed by the specific authority of a specialist. Under this view, medicine has a general value with a scope that transcends the simple care dedicated to organic phenomena1.

While assuming full authority on the subject of the diseases and a monopoly on their treatments, modern scientific medicine, due to medical activism, assumed more power. To that evolution, a privileged position was achieved, which is still currently in force and to which sociology assigned as approaching the position of a profession. Doctors determine the curriculum for the so-called medical studies, and they were the ones who wrote the medical ethics codes, which were recognized by State; in other words, they depend on their own associations (Medical Councils). Therefore, their regulation is essentially a self-regulation, which makes them prevail in the health field, as the other health care professionals, for example, nurses and physiotherapists, are directly dependent on medical activities and are considered an inferior category.

The doctors' mobilization, their collective fight, is, therefore, also determinant. In each circumstance, they knew how to value the progress of their knowledge, the importance of their activities to the elites and popular classes, and they could also present themselves as better than their competitors. Hence, they could move their competitors away or place them in a subordinated position. Finally, there is the crucial role of the State: at the end of the century, the interest in the population's health gave credence to the doctors' claims. However, that interest has increased by the perception that the medical and scientific development could get to solutions for the health problems we face.

In contemporary industrial societies, disease results in direct contact with medicine because the general and immediate attitude of a person who feels sick or feels that something may be different in their body is to see a doctor and follow the prescriptions made by that doctor. Before the Second World War, a doctor was only called in serious cases. However the evolution to the current situation of a "medicalized" society took centuries to come about, which presupposes a rejection of seeing disease as an unavoidable evil.

In the 20th century, the idea of a medicalized society reflects the fact that the medical model, strongly influenced by psychological knowledge, has been imposed regarding the definition and treatment of other numerous contemporary social and public problems. Conrad and Schneider5 showed how the designation of practices such as alcoholism, homosexuality, mental diseases, child abuse, and drug consumption, among others, were transferred, over time, from religious or criminal penalties to medical records. Therefore, that which was considered a condemnable act (evil) became known as a disease (sickness).

In this manner, medical knowledge achieved a normative value in the face of other sectors of individual and collective life, which have increased in number over time, defining and evaluating issues related not only to physical health but also to social problems. This situation, permeated by the perspective of the relationship between doctors and individual patients, consequently produced the notion that the doctor would be the one to define which patient's needs could be possibly and legitimately handled. However, it was exactly this difference between knowledge and specialized competences that concomitantly transformed into the detachment and domination of the body.

It is certainly not the first time that the body has been the object of such imperious and urgent investments. In any society, the body is tightly bound by powers that impose limitation, prohibitions, and obligations. Many things, however, are new in these techniques. First, the scope is not to roughly treat the whole body as if it were an inseparable unit, but to work on it in detail, i.e., to perform a non-stop coercion and to keep it at the mechanical level -movements, gestures, attitude, and quickness: an infinitesimal power on the active body⁵.

THE NOTION OF DRUG ABUSE IN MEDICINE

The discussion about the abuse of psychoactive substances has been assumed by medicine as a medical problem since the last century, reinforcing the idea of control over the body, according to Foucault's analyses¹⁰. Despite the development of explicative theories and practices directed both at the treatment of addicted individuals and at the approach of minimizing the damage caused by the use of such substances, we notice the hegemony of the medical and psychiatric discourse, which suggests the denial of individual autonomy in detriment to the idea of a cure; even though there are attempts to understand the phenomena related to drug use through theoretical models linked to cultural questions, for example, we perceive that many times the medical and psychiatric approach mistakenly consider the mere use of psychoactive substances as a problem. This relation of power imposed by modern scientific medicine gets closer, as there is an imposition of the professional judgment of a doctor or a psychiatrist on the so-called abuse.

Upon diagnosing a disease, the doctor simply decodes an organic condition. By declaring that a person is sick, he or she makes a judgment that transcends the organic condition and impacts on the individual's identity, thus determining the person's place in society. Through studying medical institutions and professions, as well as their functioning, we can note how science, daily put in practice by professionals, interferes in the life of the society¹.

Thus, the use of the term "drug abuse" becomes very problematic as we notice that a value judgment is strongly present in the practices and diagnoses suggested by doctors who attribute a disease, generally called chemical addiction, to those that, for many times, make only an eventual use of psychoactive substances. After doing so, they then interfere in the lives of these individuals, who end up being considered deviants or problematic for not adhering to a certain normality subjected by the doctors or psychiatrists themselves and legitimated by the power that these professionals hold.

When a person is diagnosed as having a problem derived from drug abuse, it is noteworthy that the judgment made in this imputation is, to a large extent, subjective. The doctor attributes the problem to the individual from what he or she (subjectively) considers a simple or abusive and problematic use. Thus, we can identify enormous errors due to the creation of a possible problem where in fact a problem does not exist. The limits of the measures that distinguish simple eventual use from abuse are centralized in the medical and psychiatric power, which presupposes the subjectivity of the medical professional in diagnosing the disease called chemical dependence.

By no means are we saying that there is no problematic use of psychoactive substances. We fully agree that there are several cases of lack of control in the use of such substances. What we state is that the term "drug abuse" possesses a tremendous gap, to the extent that the subjectivity or the value judgment of a medical professional, a doctor or psychiatrist, is used in the measurement of what would represent an eventual use and what would be drug abuse, and, therefore, a pathology. Furthermore, this term is insufficient because, in fact, it does not necessarily represent the symptoms felt by the individual, but the representations that the doctors or psychiatrists make in their subjective analyses.

In every culture, at a specific moment, a certain number of representations are favored, which could be called dominant, in detriment of other representations, which are not absent, but are marginalized in relation to the dominant form. Indeed, some of these representations are even discarded (definitively or momentarily); in other words, they are eliminated from the current social field. Every society in every epoch is obsessed by what it considers relevant causes for the disease¹³.

In all societies, diseases are interpreted in a specific manner and are strongly present in the collective imagination, such as the association between the use of drugs and chemical dependence in modern societies. The notion of the disease itself also serves as support for the expression of wider beliefs and values. Therefore, the collective interpretation of the disease is always set up in terms that involve the society, its rules, and the idea we have about the society. This is how the conception we have of health and sickness manifests our relationship with the social order. To this end, we notice more and more an enormous difficulty in deconstructing the paradigms that are so consolidated in modern scientific medicine, which make claims to and have a position of retaining the largest and most valid scientific truth as to issues related to the use and/or abuse of psychoactive substances.

Bourdieu³ believes that scientific innovation does not occur without social ruptures with the assumptions in force (always prerogative and privilege). The "pure" scientific capital, even if in compliance with the ideal image that the field wants to have and to give itself, is, at least in the initial phase of accumulation, more exposed to controversy and to critiques - "controversial", as the Anglo-Saxons say -than the institutionalized scientific capital, and it can occur, in some disciplines, in such a way that the great innovators (Braudel, Lévi-Strauss, Dumézil, for example in the case of social sciences) are marked by the stigma of heresy strongly fought by the Establishment.

Thus, as it is noticeable that in societies where modern scientific medicine prevails, medical knowledge communicates concepts and explanations about the nature and causes of most of societal problems, it is also perceptible that the representations created around chemical dependence and allocated to the eventual drug user can produce stigma, which will possibly be more harmful than the use of such substances. Hence, the medical or psychiatric power can reinforce stigmas that may produce effects that are more harmful to social health than to the individual's physical health.

To Goffman¹¹, it is likely that the stigmatized individual feels that he or she is "being exhibited" and leads his or her self-conscience and control over the image he or she is presenting to extremes and to behavior areas that cannot be reached by others. In addition, the stigmatized individual can also feel that the normal framework used to interpret daily happenings is weakened. He or she feels that the smallest acts can be evaluated as signs of notable and extraordinary feats in these circumstances¹¹.

The human and social sciences try to question the power of modern scientific medicine regarding its conception of chemical dependence as a disease only without considering relevant aspects such as cultural practices in the use of psychoactive substances. However, leaving the quality of longevity extended by psychoactive substances aside, indeed we note that there is much difficulty in overcoming the conflict between medical and psychiatric power and cultural interpretations.

Foucault⁸ does not suggest a conflict between one medicine and the other, or against medicine in general in favor of the absence of medicine. He tries to extract from the discourse the conditions of its own history. The relevance in what people say is not what they have thought of or beyond themselves, but instead what systematizes them from the beginning, making them, over time, infinitely accessible to new discourses and open to the task of transforming them.

It is important to understand that these intellectual conflicts are also conflicts of power. Every scholarly strategy simultaneously carries a (specific) political dimension and a scientific dimension, and all explanations should consider these two aspects together. However, the relative weights of these dimensions can vary a great deal according to the field and the position in the field. The more heterogeneous the fields are, the greater the discrepancy is with regard to the distribution of non-specific (political) powers, and to the structure of a specific power distribution, i.e., recognition and scientific prestige³.

CONCLUSION

In our contemporary Western society, we notice that health policies have been grounded by modern scientific medicine in such a way as to spread information in order to change individual behavior with regard to the consumption of food and, especially, alcohol, cigarettes, and other legal or illegal psychoactive substances. However, we note that such changes turn into very difficult objectives, as they violate people's individuality by imposing a "normal" or adequate behavior and a "deviant" or inadequate behavior.

Social rules are created by specific social groups. Modern societies are not simple organizations where there is common agreement as to what the rules are and how they should be applied in specific situations. To the contrary, they are highly differentiated along social classes, ethnic, occupational, and cultural lines. These groups do not need to share the same rules, and in fact, they frequently do not. The problems they face when dealing with their environment, history, and traditions result in the evolution of different sets of rules. As the rules of several groups conflict and contradict one another, there is often disagreement as to the type of behavior that is appropriate in any given situation2

The imposition of these principles permeated by the idea of normality that is imposed by the rules of modern scientific medicine ends up blaming individuals themselves for behaviors harmful to their health, violating people's freedom of choice. However, we have seen that the biggest interest of this science, which has been legitimated by the medical and psychiatric power, is the longevity of people's lives and not the quality of this longevity. This shows that we are facing an absolute absence of autonomy, which is a noteworthy situation, as our lives are contemporarily controlled by the medical and psychiatric power through the imposition of life styles based on the subjectivity of professionals that, in addition to prescribing the medication that they believe to be the most adequate for the treatment of physical diseases, regularly prescribe treatment for conditions subjectively considered "social diseases".

Therefore, when politics becomes biopolitics and takes health and, as an extension, life as the objective of total preventive intervention, it deprives life of openness, restricting it to biologic longevity. The mechanisms of protection and preservation of health then consist of the denial of life and in the sustaining of expected survival. It is likely that the extensive and normalized surveillance ends up impeding the possibility of transcendence in order to live for a long time. To live under the aegis of biopolitics is to perpetuate life through the existential sacrifice of the living being, reducing it to the biological range. In persecutory health, one lives under the paradox of the sentence and the guilty condemnation without felony as a strategy for keeping away the risks to surviving, which, to be protected under this form, gets crushed within the somatic limits at the price of denying people the most human part of life⁴.

REFERENCES

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11 Goffman E. Estigma: notas sobre a manipulação da identidade deteriorada. Rio de Janeiro: J. Zahar; 1988.         [ Links ]

12 Karam ML. Pela abolição do sistema penal. In: Passetti E, coordenador. Curso livre de abolicionismo penal. Rio de Janeiro: Revan; 2004.

13 Laplantine F. Antropologia da doença. São Paulo: M. Fontes; 2004.

14 Olmo R. A face oculta da droga. Rio de Janeiro: Revan; 1990.

15 Zorrilla CG. Drogas y cuestión criminal. In: Bergalli R, organizador. El pensamiento criminológico II. Bogotá: Temis; 1983.

Correspondência/Correspondence/Correspondencia:
Pablo Ornelas Rosa
Universidade Tecnológica Federal do Paraná
Av. Monteiro Lobato, km 4, s/n
Ponta Grossa-Paraná-Brasil
E-mail:pablorosa13@gmail.com

Recebido em/Received/Recibido en: 27/5/2009
Aceito em/Accepted/Aceito en: 14/10/2009