Interviewing the Embodiment of Political Evil

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Australia the life-saving opioid reversal agent naloxone, or Narcan as it is more commonly known .... Jason and Carly are also life partners and have been for more than ten years now. Carly first ..... Random House, Inc., 1977). 15 Rance and ...
Intimacy and empowerment in a clinic of chronicity Ian Flaherty Abstract Drug addiction is often described as a chronic and relapsing condition. The Sydney Medically Supervised Injecting Centre (MSIC) seeks to ameliorate the negative outcomes of injection drug use, many of which are chronic and may include injection related injury and disease, overdose, HCV and HIV infection, and social isolation. Though not all attendees of MSIC are chronic injection drug users, many are. It is this group of people who are most susceptible to overdose morbidity and mortality, and social isolation. Opioid overdose is a common experience among this group of people, and as yet in Australia the life-saving opioid reversal agent naloxone, or Narcan as it is more commonly known, is not available for community distribution. MSIC is conducting a clinical trial of intranasal versus intramuscular naloxone in order to further advocate for its community distribution. This paper explores the experiences of both the clinicians who administer this trial as well as MSIC clients who participate. Building on earlier work at MSIC (Rance and Fraser, 2011), we argue that participation in this clinical trial may be a constituent part of an „accidental intimacy‟ that develops between clinician and client. In addition, by participating in the trial, the clients have furthered the cause of a life-saving technology that they themselves may be able to apply to their friends and family in the future. There is no good evidence to suggest that ready access to naloxone increases risk-taking behaviour among injection drug users, so certainly such access could only be a source of personal empowerment. Drug addiction may indeed be a chronic and relapsing condition, and this paper seeks to make sense of chronicity in the context of a clinical trial. It proposes that in this context, chronicity itself may lead to intimacy and empowerment.

Key Words: Injection drug use, clinical trials, emotional intersubjectivity, intimacy, empowerment. *****

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Introduction: This paper seeks to examine the way in which intimacy and empowerment may develop in the context of a clinical trial in a medically supervised injecting facility. Firstly, the landscape of the clinical trial is examined, and its significance among chronic opioid injection drug users. Secondly, the idea of „accidental intimacy‟ 1 is explored in the context of the relationships between the clients and the workers at Sydney MSIC. Case studies are presented illustrating the development of this form of intimacy as well as the foment of a sense of empowerment catalysed by participating in the clinical trial. Worker perspectives of this process are also examined. Finally, the development of intimacy and empowerment through participation in a clinical trial is placed within a theoretical framework in which emotional intersubjectivity in life‟s transitions provides a counterpoint to the often troubled interaction of chronic drug use and interpersonal relationships. It might be suggested that it is the chronicity of this drug use that underpins, in some ways, the development of intimacy and empowerment. By no means is it suggested that chronic injection drug use does not carry with it significant harms – it most certainly does2 – but it may be significant to critically examine the relationship between chronicity, in this case, of opioid use, and personhood. 2.

The landscape of the clinical trial: Drug overdose is a leading cause of death among people who inject drugs. The Sydney MSIC was established in 2001 with the primary aim of reducing the morbidity and mortality of drug overdoses in the local area. In eleven years, the MSIC has treated over 4000 acute opioid overdoses on site without a single fatality. Clients come to Sydney MSIC to inject drugs that have been sourced outside the centre. Overdose management protocols are in place for nursing staff to administer intramuscular (IM) naloxone, as well as provide external airway resuscitation and oxygen. Approximately 20% of all heroin/opioid overdoses (approximately 800 cases to date) have required the administration of naloxone. Due to the high frequency of opioid overdose routinely treated onsite, and the experienced staff who manage them, the MSIC provides a unique and ideal setting to investigate alternative naloxone administration routes. IM and intravenous naloxone are currently the standard modes of emergency treatment for an opioid overdose; however pharmacology data indicate that naloxone is 100% bioavailable through the nasal mucosa. 3 The purpose of the clinical trial is to compare two routes of administration: IM and intranasal. Naloxone can be sprayed into the nose via a mucosal atomisation device and evidence indicates that intranasal (IN) naloxone may not only be as effective a route of administration as IM administration, but also a practical and realistic alternative. 4,5 There have been a number of

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______________________________________________________________ previous studies examining IN naloxone. 6 These have generally been cohort studies7-11 with only two previous randomised trials 7 neither of which were double-blinded. The first randomised trial used a large volume of fluid for intranasal administration which may have limited efficacy. 8 The subsequent trial showed a slightly higher rate of „rescue „or second dose naloxone given to those patients whose initial dose was delivered intranasally. 9 The authors felt that this may have been due to the non-blinded nature of the study, with the additional dose being a subjective decision dependent on individual paramedic‟s comfort in waiting for a response. The aim of the study at Sydney MSIC is to determine whether naloxone, an opioid reversal agent, is as effective for the treatment of acute opioid overdose when administered via the intranasal route compared with the intramuscular route. The term 'opioid' refers to a class of drugs that includes heroin, and the prescription medications oxycontin and morphine. Injection of naloxone into a muscle is currently the standard method of emergency treatment for an opioid overdose on site at Sydney MSIC. However, naloxone can be administered as an intranasal spray using a 'mucosal atomisation device‟. Evidence suggests that IN naloxone may be an effective and practical alternative. The significant benefits of IN administration include removing the risk of needlestick injury (and thus any blood borne virus transmission risk) to treating personnel. This is particularly relevant to ambulance officers and paramedics, as well as other emergency health care workers, such as in the hospital emergency department setting. Additionally, given the ease of administration and reduced issues regarding disposal of used needles, the availability of IN naloxone may potentially be extended. This may include non-health care workers who regularly deal with opioid overdose in community settings, and drug users‟ peers, who are likely to be present in the event of an overdose. The Sydney MSIC provides the ideal setting for this study. 3.

Accidental intimacy at the Sydney MSIC: The Sydney MSIC was designed specifically as a clinic10 – a place where injection drug users can go to access clinical help to reduce the harm associated with their injection drug use. There are three stages in the clinic: stage one, where the client visit is entered into the database, stage two, where the client injects drugs sourced outside of the clinic, and stage three, where the client can seek referral, counselling and advice. All three stages are staffed by registered nurses and suitably qualified health education officers. The role of the director of the clinic was designated for, and is staffed by, a public health physician. Stage two of the clinic resembles a highly sterile environment. Each of the 18 two-person booths are sheathed in stainlesssteel and, regardless of booth, the clinic staff can observe at all times, clients

4 Intimacy and empowerment in a clinic of chronicity ______________________________________________________________ as they inject. What one might expect as a moment of the intensely personal and private comes under the gaze of the clinical, as Rance and Fraser reflect: The act of injecting, which, for many clients, operates as a symbolic moment of internalized shame and social marginalization, is performed within the MSIC in the immediate presence of staff. 11 Some have likened this gaze to a form of governmentality 12, such that clinics such as Sydney MSIC remove socially undesirable elements from the public gaze, as well as invigilate once in the realm of the clinic. This process stems, claim some authors, from the new order of the city, driven by consumption and that which is socially estimable: Consequently, the „dual city‟ is characterised by a mapping of socio-spatial order relying on the inclusion of those persons and activities beneficial to its agenda of consumption, yet increasingly facilitating the concealment and displacement of elements of the „Other‟ towards realms of the periphery and the margins. 13 This Foucauldian narrative 14 of medically supervised injecting centres may carry some weight, for it is indeed one of the key premises upon which such centres stake their claim – that they reduce public nuisance and increase public amenity in locales where street-based injecting is commonplace. Yet a wholesale acceptance of medically supervised injecting centres as a site of governmentality may belie a process that is of enormous benefit to both the clients and workers. Rance and Fraser 15 argue that it is precisely the space created by the operation of Sydney MSIC, that is, the connection of a highly-marginalised group with a place of trust and acceptance, which generates what they call “accidental intimacy”. 16 This point will be further elucidated in a discussion around emotional intersubjectivity, but for now, it is posited that the development of „accidental intimacy‟ provides an encouraging counterpoint to the expression of Sydney MSIC as a site of surveillance and governmentality. Two case studies from Sydney MSIC: Jonathon and Carly 17 Jonathon and Carly are two clients of Sydney MSIC and regularly attend the centre to inject heroin and other opiates such as oxycodone and morphine. Jason and Carly are also life partners and have been for more than ten years now. Carly first came to register at the centre over 9 years ago. At registration, Carly was 27 years old, and was living in a public housing unit in the local area. Carly left school at age 16 and at the time of registration 4.

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______________________________________________________________ was receiving government income support as her main source of income. Like many injection drug users, Carly had at some point contracted Hepatitis C. Carly is what might be described as a chronic and heavy drug user, reporting at registration to typically inject more than three times on any given day. She also reported having been hospitalised for mental health issues. Importantly, Carly reported at the time of registration that she had first overdosed when she was 17 years old and had had three subsequent overdoses. The last time Carly overdosed was in park, and had she not been injecting at Sydney MSIC on the day on which she registered, Carly reported that she would have injected in a public toilet. Her risk of overdose-related morbidities and mortality were therefore very high. In many ways, Jonathon and Carly share similar life-experiences. Jonathon also started injecting drugs at age 17 and had his first opiate-related overdose at age 22. Jonathon had had four subsequent overdoses. Like Carly, Jonathon too has Hepatitis C. He has been admitted to hospital for mental health issues and at time of registration, was taking mirtazapine for depression. Jonathon and Carly met through mutual friends. On a sunny day in March 2012, Jonathon and Carly attended Sydney MSIC, Jonathon to inject oxycodone and Carly to inject heroin. Carly overdosed while her partner Jonathon sat next to her in the booth. Both Jonathon and Carly had given their consent to participate in the clinical trial examining the effectiveness of IN naloxone for the reversal of acute opiate overdose. After 5 minutes of reduced respiration and consciousness, Carly was enrolled in the trial. In Jonathon‟s observation, 0.5 mLs containing 400mcg of naloxone was sprayed into each of Carly‟s nostrils. 18 Within ten minutes, Carly and Jonathon were able to leave the centre together. 5.

The narratives of the Carly, Jonathon and the nurses: A week or so after Carly‟s overdose, Carly and Jonathon were interviewed about their experiences of the clinical trial. While Carly was reserved about her involvement, Jonathon was effusive about the relative ease with which Carly‟s life had more than likely been saved. Jonathon was actually quite incredulous that it was as simple as “spraying something up the nose to save a life” and that clearly it had “caused no discomfort”. Jonathon reported that he would most certainly be able to do this himself were Carly, or anyone around him, to overdose. Similarly, the narratives of the nurses who attended the overdoses were sought. On the one hand, the narratives involved experiences of professional and sector development. One highly-experienced nurse, Tom,19 reported for example that, “I feel it is a great professional development opportunity for nurses to be involved directly with a clinical trial…” While this was as common response among both the nurses and health education officers, on the other hand, another narrative was also apparent – an equal

6 Intimacy and empowerment in a clinic of chronicity ______________________________________________________________ and opposite narrative of caring. This narrative of caring found expression in the nurses‟ apprehension that this novel formulation and administration of a drug that they knew had the capacity to save a life may have implications for their clinical practice. Another highly-experienced nurse, Christine,20 framed this conflict in the following way: I‟m used to using IM naloxone so I was a bit nervous at first, wondering if it will work and wondering if the client died, but know I could always back it up with another IM shot. Tom also expressed a similar apprehension, his focus being on his capacity to treat the client with the new method: “[I had an] initial nervousness about responding quickly clinically with the new procedure.” What then links the narratives of Jonathon, Tom and Christine? In all three instances, a focus is drawn upon the saving of a life. For Jonathon, the focus is upon the simplicity of the act; for the nurses, Tom and Christine, the act is a function their clinical roles. It is possible however, that the act of saving a life, at least in the context of Sydney MSIC, has another performative and constitutive role – the foment of intimacy and empowerment through emotional intersubjectivity. ‘Accidental intimacy’ and emotional intersubjectivity: It is at this point that Rance and Fraser‟s 21 expression of „accidental intimacy‟ becomes so salient. They describe how the physical space of stage 2 at Sydney MSIC itself conduces an emotional space of respect and trust in which the clients experience acceptance and safety: 6.

There is a sense in which this proximity grounds the clientpractitioner relationship, creating what we will call “accidental intimacy. 22 While Rance and Fraser describe this intimacy as a “somewhat intangible phenomenon”23, nonetheless it finds “concrete expression” 24 in the feedback provided by the clients in the comments book available in stage 3 of Sydney MSIC. Rance and Fraser25 draw in the work of Sara Ahmed 26 to, in part, explain how this intimacy develops. Ahmed 27 argues that emotions, in this analysis, the basis for intimacy, do not move out from the subject to society, nor from society inward towards the subject, but rather: …that emotion emerges between subjects, and between subjects and society: that it is in the space between these that emotions occur and have their effect.28

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______________________________________________________________ In this space it is equally possible to generate shame and acceptance. For Ahmed, 29 it is emotion that creates the subjects and objects which generate them. “From this point of view, it is possible to understand emotions as creating subjects rather than expressing them.”30 This then is the most important point about emotional intersubjectivity: it is the emotions of acceptance and care, formed in the interstice between client and worker at Sydney MSIC, that create subjects of both worker and client. How then can these subjects, and intimacy, be examined in the context of chronicity? If we take a life-course perspective, in which trajectories of drug use are influenced by social, physical and cultural forces, and transitions such as overdose, are embedded within these trajectories,31 then it is possible that chronic drug use, and injection drug use in the context of Sydney MSIC in particular, may yield unanticipated outcomes on personhood. In the context of the clinical trial at Sydney MSIC, these outcomes may include the sense of empowerment that occurs with the saving of a life. 7.

Conclusion: Clinics such as Sydney‟s Medically Supervised Injecting Centre have been established as a pragmatic and caring response to the reality of the morbidities and mortality associated with chronic injection drug use. Sydney‟s MSIC was established amidst an epidemic of overdose. At the time at which its establishment was first debated, more people died in Australia of drug overdose than in automobile accidents. Sydney MSIC is a place where drug users can come, bringing drugs sourced outside the centre and inject under medical supervision, and receive counselling, advice and referral. At present, a clinical trial examining the relative effectiveness of intranasal naloxone, an opiate antagonist and life-saving medication, is underway at Sydney MSIC. The idea of „accidental intimacy‟ is examined in the context of this clinical trial. Previously, Rance and Fraser 32 explored this intimacy by examining the book available to clients to provide feedback about the clinic. In this paper, this intimacy is contextualised within two case studies, and the experiences of these individuals in participating in the clinical trial. These case studies reveal a narrative of caring associated with the significance of the saving of a life. The space of Sydney MSIC, both its physical presence and in a metaphoric sense, provides a place in which trust and respect are fostered and clients feel acceptance and safety. It offers a site of emotional intersubjectivity in which subjects are created by the emotions that occur between subjects. Many of the clients of Sydney MSIC are chronic injection drug users. By participating in the clinical trial and experiencing „accidental intimacy‟ some clients have reported empowered by the possibility of saving a life.

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J Rance and S Fraser, „Accidental intimacy: Transformative emotion and the Sydney Medically Supervised Injecting Centre‟, Contemporary Drug Problems 38 (2011): 121-45. 2 T Rhodes, „The „risk environment‟: a framework for understanding and reducing drug-related harm‟, International Journal of Drug Policy 13:2 (2002): 85-94. 3 A Hussain, R Kimura, and C Huang, „Nasal absorption of Naloxone and buprenorphine in rats‟, Int J Pharm 21(1984): 233-36. 4 N Loimer, P Hofmann, and H Chaudry, „Nasal administration of Naloxone is as effective as the intravenous route in opioid addicts‟, Int J Addic 29:6 (1994): 819-27. 5 D Kerr, P Dietze, and AM Kelly, „Intranasal Naloxone for the treatment of suspected heroin overdose. Review article‟, Addiction 103: 3 (2008): 379-86. 6 Costantino H.R., Illum L., Brandt G., Johnson P.H., Quay S.C. Intranasal delivery: physicochemical and therapeutic aspects. Int J Pharm 2007; 337(12): 1-24. Loimer N., Hofmann P., Chaudhry H.R. Nasal administration of Naloxone for detection of opiate dependence. J Psychiatr Res 1992; 26(1): 39-43. Barton E.D., Colwell C.B., Wolfe T., Fosnocht D., Gravitz C., Bryan T., et al. Efficacy of intranasal Naloxone as a needleless alternative for treatment of opioid overdose in the prehospital setting. J Emerg Med 2005; 29(3): 26571. Barton E.D., Ramos J., Colwell C., Benson J., Baily J., Dunn W. Intranasal administration of Naloxone by paramedics. Prehosp Emerg Care 2002; 6(1): 54-8. Kelly A.M., Koutsogiannis Z. Intranasal Naloxone for life threatening opioid toxicity. Emerg Med J 2002; 19(4): 375. Robertson T., Hendey G., Stroh G., Shalit M. Prehospital intranasal versus intravenous administration of Naloxone for narcotic overdose. Society for Academic Emergency Medicine; 2005; New York; 2005. p. 166-7. Kelly A. M., Kerr D., Dietze P., Patrick I., Walker T., Koutsogiannis Z. Randomised trial of intranasal versus intramuscular Naloxone in prehospital treatment for suspected opioid overdose. Med J Aust 2005; 182: 24–7. Kerr, D, Kelly, AM, Dietze, Paul, Jolley, D., Barger, B. IHRA Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction. 2009: 104, 2067-20742008. Annual Conference Oral Presentation. Randomised controlled trial comparing the effectiveness and safety of intranasal and intramuscular Naloxone for the treatment of heroin overdose.

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Kelly A. M., Kerr D., Dietze P., Patrick I., Walker T., Koutsogiannis Z. Randomised trial of intranasal versus intramuscular Naloxone in prehospital treatment for suspected opioid overdose. Med J Aust 2005; 182: 24–7. Kerr, D, Kelly, AM, Dietze, Paul, Jolley, D., Barger, B. IHRA Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction. 2009: 104, 2067-20742008. Annual Conference Oral Presentation. Randomised controlled trial comparing the effectiveness and safety of intranasal and intramuscular Naloxone for the treatment of heroin overdose. 8 Kelly A. M., Kerr D., Dietze P., Patrick I., Walker T., Koutsogiannis Z. Randomised trial of intranasal versus intramuscular Naloxone in prehospital treatment for suspected opioid overdose. Med J Aust 2005; 182: 24–7. 9 Kerr, D, Kelly, AM, Dietze, Paul, Jolley, D., Barger, B. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction. 2009: 104, 2067-2074 10 I van Beek, In the Eye of the Needle: Diary of a Medically Supervised Injecting Centre (Melbourne: Allen and Unwin, 2004) 11 Rance and Fraser, „Accidental Intimacy‟, 130. 12 B Fischer, S Turnbull, B Poland and E Haydon, „Drug use, risk and urban order: examining supervised injection sites (SISs) as „governmentality‟‟, International Journal of Drug Policy 15:5-6 (2004): 357-65. 13 Ibid., 360. 14 M Foucault, Discipline and Punish: the Birth of the Prison (New York: Random House, Inc., 1977) 15 Rance and Fraser, „Accidental Intimacy‟. 16 Ibid., 131. 17 Names have been changed to protect the participants‟ confidentiality. While Jason and Carly are two individuals who participated in the clinical trial, some of their biographical details may represent an amalgam of lifeexperiences commonly reported by many of the clients of Sydney MSIC. 18 As the trial is double-blinded, the researchers are unaware if the intranasal preparation was naloxone or placebo. Jonathon‟s observation was that the intranasal preparation was naloxone. 19 Not his real name. 20 Not her real name. 21 Rance and Fraser, „Accidental Intimacy‟. 22 Ibid., 131. 23 Ibid. 24 Ibid. 25 Ibid.

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S Ahmed, „Collective feelings, or the impressions left by others‟, Theory, Culture and Society 21:2 (2002): 25-42. 27 Ibid. 28 Rance and Fraser, „Accidental Intimacy‟, 132. 29 Ahmed, „Collective feelings‟. 30 Rance and Fraser, „Accidental Intimacy‟, 133. 31 Y-I Hser, D Longshore and MD Anglin, „The Lifecourse Perspective on Drug Use: A Conceptual Framework for Understanding Drug Use Trajectories‟, Eval Rev 31 (2007): 515-547. 32 Rance and Fraser, „Accidental Intimacy‟.

Bibliography Ahmed, Sara. „Collective feelings, or the impressions left by others‟, Theory, Culture and Society 21:2 (2002): 25-42. Hser, Yih-Ing, Longshore, Douglas and Anglin, M. Douglas. „The Lifecourse Perspective on Drug Use: A Conceptual Framework for Understanding Drug Use Trajectories‟, Eval Rev 31 (2007): 515-547. Rance, Jake and Fraser, Suzanne. „Accidental intimacy: Transformative emotion and the Sydney Medically Supervised Injecting Centre‟, Contemporary Drug Problems 38 (2011): 121-45. Rhodes, Tim. „The „risk environment‟: a framework for understanding and reducing drug-related harm‟, International Journal of Drug Policy 13:2 (2002): 85-94. van Beek, Ingrid, In the Eye of the Needle: Diary of a Medically Supervised Injecting Centre. Melbourne: Allen and Unwin, 2004

Ian Flaherty is the Research Co-ordinator at the Sydney Medically Supervised Injecting Centre. His special interest is in the sociology of intimacy, love and friendship, and the impact drug use may bring to the fulfilment of personal and civic lives. Email: [email protected].