choosing methadone colloquium

7/30/2019 Choosing Methadone Colloquium

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Department of Anthropology

University of Washington

Dissertation Colloquium

3 December 2012


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Acknowledgements

UniversityofWashington

LaadaBilaniuk

JanelleTaylor

NoelChrismanJaredBaeten

LornaRhodes

PATHAmieBishop

KatarynaGamazina

CentralEuropeanUniversity

DanielMonterescu

AlexandraKowalski


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Acknowledgements

DeborahJones

EditSzenassy

ElizabethPeacock

EmaHresanova

ErinKoch

EugeneRaikhel

HeidiBludau

JonathanSllo

MartaKordubaMarynaBazylevych

MichaelRassell

SarahPhillips


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Acknowledgements

FundingProvidedBy:

DepartmentofSociology,

CentralEuropeanUniversity

DepartmentofAnthropology,

UniversityofWashington

InternaonalResearch

&ExchangesBoard(IREX)TheWenner-GrenFoundaon


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PresentaonOutline

PrimaryResearchQueson

OpiateAddiconand

Treatment

TheUkrainianContext

TheorecalFrames

MethodologyPreliminaryFindings


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MyResearchQuesons Primary

Whydopeople(addictsordrugusersinparcular)in

Ukraineseektreatmentfortheiraddiconorfor

infecousdiseases?

Secondary Whatfactorsareshapingtreatmentseekingbehaviors? Whatsupporveorprotecvefactorsexist? Whatobstaclesorriskfactorsexist? Howdoaddictsunderstandtheirownbehaviors,which

anepidemiologistorclinicianwouldcalltreatment

seeking?Whatdotheythinktheyareupto?

(Geertz1973,9).


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1898:BayerBringsHerointoMarket


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AndThenHeroinWentBad


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TheMedicalizaonofAddicon

Twodifferentdisordersaredefined

SubstanceAbuse SubstanceDependence

Twodifferentstandardsofdiagnosis

DiagnoscandStascalManualofMentalDisorders,4thed.(DSM-IV)

InternaonalClassificaonofDiseases,

10th

ed.(ICD-10)


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TheMedicalizaonofAddicon


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MedicalProblem,MedicalSoluon

Subs6tu6ontherapy Short-termassisted

detoxOR Long-termmaintenance. Long-termuseis

consideredaharmreduc6ontac6c.


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SubstuonTherapyDrugs

MethadoneHCl

ScheduleIIdrug

Takendaily

Levo-alpha-acetyl-methadol

(LAAM)

ScheduleIIdrug

Takenthreemesperweek.

Buprenorphine

ScheduleIIIdrug

Takendaily


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ParallelSystemsofSpecializaon

Narcology:

specializaonin

narcocuseandotheraddicvebehaviors.


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Placebo/CodingTherapy

Usesthepowerofsuggesontocurepeople

ofaddicvebehaviors

BasedonPavlovstheoriesofhigherordercognion.

Thetreatmenthingesonthedoctorsperformance.

(Raikhel,2010)KaiRisdalsinterviewwithEugeneRaikhel

aboutcodingtherapyinRussia:

hp://www.marketplace.org/topics/

world/russia-rx/killer-cure-alcoholism-

russia


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UkrainesMedicalSystemToday

Severelackofresources

Burdenedbystateresponsibiliesto

Chernobylsufferers Feminizaonofthe

medicalindustry

De-professionalizaonofdoctors

Informalpaymentsandgisoennecessarytoreceiveservices


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UkrainesMedicalSystemToday

Poormedicalreporngandinfecousdisease

surveillance

Heavyemphasisonoutcomestascs

Strongincenvestomanipulatethese

stascs

Extremedistrust


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FundingandControlofHIV-prevenon

2002:$90milliontoUkrainesMinistryof

Health.

2004:TheGlobalFunddisenfranchisedthe

MinistryofHealth

2010:TheGlobalFundpledged$305million

toUkrainesCountryCoordinang

Mechanism(CCM)


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ThisisntAmericanheroin.

In-houseprocessingofrawopiumextract.

demerol-basedmixtures(shirka)arecommon.

Batchprocessingandfrontloading.

Pre-packingsyringesforsaleortrade.


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ExplanatoryModelsofIllness

Whatisit?

WhatCausesit?

HowdoIknowIhaveit?

HowdoItreatit?

HowdoIknowImgeng

beer?

(Kleinman,1988)


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Biopower(anditsdiscontents)

Diffusesocialpowerdisciplinespeople

intocertainbehaviors.(Foucault,1975)

Publichealthprogramsaskustobe

responsiblecizens.(Lupton,1995)

Butcanweescapethese

subjecvies?

Itsatrap!(Bourgois,2000)

Therearesomeemergenttheoriesthat

explainstructureandagency

differently.(cf.Carr,2011)


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EthnographiesofAddicon

TheClassic:

Cultural/interprevetheories

(Dai1937;Lindesmith1947).Druguseandsocialidenty

(Becker1963;Spradley1968).

Cognive/linguiscapproaches

(Spradley1968;Agar1973).


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TheFoucauldian:

Cricismofthediseasemodel

(Singeret.al.1992).

Druguseandriskasadiscourse(Beck1992;Glick-Schiller1994).

Neo-Marxistapproaches

(Bourgois1995,2000;Bourgoisand

Schonberg2009).


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TheNew:

HistoricalTraumaTheory

(BraveHeart,2003)

Narravesofmelancholia(Garcia,2010)

Ancipatoryinterpellaon

(Carr2011)Evenmorenewthings!

(RaikhelandGarrio,eds.,2013)


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GenderedIdenty

andUkrainianPersonhood


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BiologicalCi6zenship

AdrianaPetryna(2002)Life

Exposed:BiologicalCi6zens

a8erChernobyl.

AIDScizenship(Biehl,2004).

Therapeuccizenship(Nguyen,2010).

Themorecommonoutcome,whetheroneisahomelessAIDSpaentinBrazil,orapoorRomanianTBpaentisdeath,notcizenship-relatedredempon.

(Sllo,2012)


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Locaon

In2009surveyswereconductedforthefirstmeinsuchoblastcenters

asVinnytsia,Ivano-Frankivsk,Zaporizhia,Zhytomyr,Rivne,

Chernivtsi,Uzhhorod,andChernihiv.

(MinistryofHealth,

2010)


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Locaon

Thevastmajorityofepidemiological

studiesonHIVamongIDUsareconductedinOdesa,

Donetsk,Dnipropetrovsk,andMykolaiv.


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Recruitment

PHASE1(Sept-Nov2012)

ConvenienceSample:

Italktothepeoplewhoareeasiesttocontact,

regardlessofhow

representavemy

sampleis.

PHASE2(Jan-Dec2013)

TargetedSnowball

Sampling:

Movethroughthetargetpopulaonthrough

chainsof

recommendaon.

Especiallyworktotargetkeyand/orhardtoreachgroups.


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DataCollecon

Primarydatacollecon:Semi-structuredinterviews Begintheinterviewwithsomegeneralorbroadquesons. Adapttheinterviewscriptaccordingtowhatthesubject

findsmostinteresngorimportant.

Letthesubjectcontrolthedireconoftheinterview. Letthesubjectteachyouhowtheythinkaboutthattopic.


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PotenalPiallsandChallenges

Ineedtogainbasiclinguiscand

narravevocabulary.

Ineedtolearnhowtobringup

certainsubjects(likerulebreaking).

Someonecouldflipascript(Carr,

2011).

Thisisalong-standingproblem

amongethnographersworkingin

harmreduconsengs(Campbell

andShaw,2008).


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Analysis:GroundedTheory

Theresearcherremains

constantlyalertto

emergentperspecvesthat

willchangeanddevelophis

[sic]theory(Glaserand

Straus1967,40).


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Analysis:GroundedTheory

Producewholeorparaltranscriptsofinterviews

Readthroughthemandidenfymajorthemesandnarraves.Codethetextsforthese

themes Buildthesethemesintoyournextsetof

interviews.Testoutyourtheory

Refineyourtheoryandyourcodesbasedonthenewinformaonyouhavegathered.

Re-codeeverythingandrepeat. UsingMaxQDA(notAtlas.)


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SomethingsIvelearnedsofarthatI

canexplainandevenmorethatIcant.


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NewAddictIdenesAreEmerging

Thissocialconstruct

thatdefineswhoand

whataninjecondrug

userishasprimarilyincorporated

masculinetropesof

identy.

(Carroll,2011a)


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GenderedEologyofAddicon

Commonassump6ons:

Menself-medicatetheir

depression.Theirproblemis

psychologicalandmedical.Womenaretoostrong,too

focused,tooseriousto

foolaroundwithdrugs.

Theirproblemisnotpsychological,itspersonal.

(Carroll,2011b)

FilmsllfromBalka:ThreeStories

(Meskin,Meskin,andPinkham2010).


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DiscoursesofEvidenceinEvidence-

BasedPracce


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DiscoursesofEvidenceinEvidence-

BasedPracce

Thevalidityofevidenceissomethingthatis

discursivelymanaged(Carr2011,p.68)by

professionalsinUkrainesHIV-prevenonsphere

[makingthem]abletoclaimagencybystrategically

situangthemselvesassociallyandmorally

appropriatepersons(Zigon2008,p.90)withinthe

largerstructureofpublichealth,[whichis]guidedbytheideologyofEBM.

(Carroll,inpress)


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Tropicamide

Tropicamideareeyedrops

usedtodilatethepupil.

Itisallegedlyusedtoamplify

theeffectsofopiates.


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MethadoneMythology

Thesearenteasydrugslike

heroinorshirka.

IusedtobeonMethadikt,andthatwasfine.Thenthey

switchedmetoMethadol,

andnowImgeng

headachesatnight.Icanttellthedifferencebetween

thisstuffandwhatIusedto

inject.


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ThePolicsofLastResort

Thisisthelaststopontheirwaytodeath.


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Rumors

Rapidrehabilitaonprogramsdesignedtofail

AreHIVratesinthewesternregionsunderesmated?

Arewaitlistsdecreasing?

Generalpolicaluncertainty

Agar,M.1973.RippingandRunning:AFormalEthnographyofUrbanHeroinAddicts.NewYork:A d i P


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AcademicPress.

Becker,H.1963.Outsiders:StudiesintheSociologyofDeviance.NewYork:TheFreePress. Biehl,J.2004.TheAcvistState:GlobalPharmaceucals,AIDS,andCizenshipinBrazil.SocialText22

(3):105-132.

Bourgois,P.1995.InSearchofRespect:SellingCrackinElBarrio.NewYork:CambridgeUniversityPress. Bourgois,P.2000.DiscipliningAddiconsCulture,MedicineandPsychiatry24:165195. Bourgois,P.andJ.Schonberg.2009.RighteousDopefiend.Berkeley:UniversityofCaliforniaPress. BraveHeart,M.Y.H.2003.TheHistoricalTraumaResponseAmongNavesandItsRelaonshipwith

SubstanceAbuse:aLakotaIllustraon.JournalofPsychoac6veDrugs35(1):7-13.

Campbell,N.D.andS.J.Shaw.2008.IncitementstoDiscourse:IllicitDrugs,HarmReducon,andtheProduconofEthnographicSubjectsCulturalAnthropology23(4):688-717.

Carr,S.E.2010.Scrip6ngaddic6on:Thepoli6csoftherapeu6ctalkandAmericansobriety.Princeton,NJ:PrincetonUniversityPress.

Carroll,J.2011a.AWomanAmongAddicts:theProduconandManagementofIdenesinaUkrainianHarmReduconOrganizaon.AnthropologyofEastEuropeReview29(1):23-34.

Carroll,J.2011b.Addic6on,Gender,andtheLimitstoPublicHealthSolu6onstoIVDrugUseinUkraine.ResearchCompetencyPaper,presentedtotheUniversityofWashingtonDepartmentofAnthropology.

Carroll,J.InPress.EvidenceBasedMedicineandtheConstruconofMoralAgencyinUkraine,inCARGO:JournalforCulturalandSocialAnthropology.

Dai,B.1937.OpiumAddiconinChicago.Montclair,NJ:PaersonSmith. Field,M.1967.SovietSocializedMedicine:Anintroduc6on.NewYork:TheFreePress. Foucault,M.1975.Thebirthoftheclinic:Anarchaeologyofmedicalpercep6on.NewYork:Vintage

Books.

Garcia,A.2010.ThePastoralClinic:Addic6onandDispossessionalongtheRioGrande.Berkeley:University of California Press


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UniversityofCaliforniaPress.

Geertz,C.1973.TheInterpreta6onofCultures.NewYork:BasicBooks. Glaser,B.G.andA.L.Strauss.1967.Thediscoveryofgroundedtheory:Strategiesforqualita6ve

research.Chicago:AldinePublishingCompany

Glick-Schiller,N.1992.WhatsWrongwithThisPicture?TheHegemonicConstruconofCultureinAIDSResearchintheUnitedStates.MedicalAnthropology6(3):237-254.

Kleinman,A.1988.Theillnessnarra6ves:Suffering,healing,andthehumancondi6on.BasicBooks. Lindesmith,A.R.1968.Addic6onandOpiates.Chicago:Aldine. Lupton,D.1995.TheImpera6veofHealth:PublicHealthandtheRegulatedBody.London:Sage. MinistryofHealthofUkraine.(2010).Ukraine:Na6onalReportonMonitoringProgressTowardsthe

ANGASSDeclara6onofCommitmentonHIV/AIDS.Repor6ngPeriod:January200December2009.Kyiv

-2010.

Nguyen,V.-K.2010.TheRepublicofTherapy:TriageandSovereigntyinWestAfricasTimeofAIDS.Durham:DukeUniversityPress.

Petryna,A.2002.LifeExposed:BiologicalCi6zenshipA8erChernobyl.Princeton:PrincetonUniversityPress.

Raikhel,E.2010.Post-SovietPlacebos:EpistemologyandAuthorityinRussianTreatmentsforAlcoholism.CultureMedicineandPsychiatry,34(1):132-168.

Singer,M.,Valen}n,F.,Baer,H.,&Z.Jia.1992.WhydoesJuanGarciahaveadrinkingproblem:Theperspecveofcricalmedicalanthropology.MedicalAnthropology14(1):77108.

Spradley,J.1968.YouOweYourselfADrunk.ProspectHeights,IL:WavelandPress. Sllo,J.2012.WearetheLosersofSocialism:Tuberculosis,SocialCasesandtheLimitsofCarein

Romania.Presentedatthe2ndAnnualHealthinTransionConference.Bucharest,Romania.June2012.

Zigon,J.,2008.Morality:Ananthropologicalperspec6ve.NewYork:BergPublishers.


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THANKYOU!Theseslideswillbeavailableat:

www.jenniferjcarroll.net

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