The becoming-methadone-body: on the onto-politics of health intervention translations

Abstract

In this paper, we reflect on health intervention translations as matters of their implementation practices. Our case is methadone treatment, an intervention promoted globally for treating opioid dependence and preventing HIV among people who inject drugs. Tracing methadone’s translations in high-security prisons in the Kyrgyz Republic, we notice the multiple methadones made possible, what these afford, and the onto-political effects they make. We work with the idea of the ‘becoming-methadone-body’ to trace the making-up of methadone treatment and its effects as an intra-action of human and nonhuman substances and bodies. Methadone’s embodied effects flow beyond the mere psycho-activity of substances incorporating individual bodies, to material highs and lows incorporating the governing practices of prisoner society. The methadone-in-practice of prisoner society is altogether different to that imagined as being in translation as an intervention of HIV prevention and opioid treatment, and has material agency as a practice of societal governance. Heroin also emerges as an actor in these relations. Our analysis troubles practices of ‘evidence-based’ intervention and ‘implementation science’ in the health field, by arguing for a move towards ‘evidence-making’ intervention approaches. Noticing the onto-politics of health intervention translations invites speculation on how intervening might be done differently.

Introduction

Methadone treatment is an opioid agonist therapy (hereafter, methadone treatment) used in treating opioid dependence. It is also promoted among global health networks as one of the best evidenced HIV prevention interventions for people who inject drugs. Systematic and meta-analytic reviews link methadone treatment to reductions in drug injecting and HIV risk practices as well as HIV transmissions (Degenhardt et al. 2010, McArthur et al. 2012). Such discourses of evidence-based intervention emphasise universal effect potential. Accordingly, there are coordinated efforts to translate methadone treatment as an intervention for treating opioid dependence and for preventing HIV internationally (World Health Organization, 2013). Global indicators of coverage map how this intervention travels (Larney et al. 2017). The translation of methadone treatment might therefore be imagined in evidence-based intervention approaches as an ‘immutable mobile’ (Latour 2005); an intervention or technology which adapts through its translation from one network to another but without changing its overall purpose or effect potential. Implementing evidenced interventions into new settings in the field of public health is a ‘complex problem’, involving adaptations of interventions-in-context (Campbell et al. 2007, Hawe et al. 2009, Mowles 2014). Implementation science has recently emerged as the set of multidisciplinary research practices designed to ‘bridge’ apparent ‘gaps’ between evidence and practice as a means to optimising intervention translations (Madon et al. 2007, Peters et al. 2013). There is a general shift in implementations research towards acknowledging implementation as a messy, contingent and complex problem that is made in practices (Greenhalgh and Wieringa 2011, May et al. 2016, Wood et al. 1998).

In this paper, we consider the translations of methadone treatment among people who inject drugs in prison settings in the Kyrgyz Republic (hereafter, Kyrgyzstan). We do this by drawing on a qualitative case study which explored the implementation of an internationally supported programme of methadone treatment, including as an intervention of HIV prevention, in three high security prisons.¹ Our analysis uses this empirical case to investigate the practice-based dynamics of health intervention and knowledge translations. In contrast to an ‘evidence-based intervention’ (EBI) approach (Sackett et al. 2000), which predominates how implementation science is framed in the health field (Peters et al. 2013), we orientate around what can be described as an ‘evidence-making intervention’ (EMI) approach. Whereas evidence-based approaches seek to optimise the implementation of prior evidenced interventions of assumed universal effect potential as they travel into new and complex settings, an orientation to how interventions are evidence-made as entirely relational matters of implementation practices unsettles assumptions of intervention immutability. Treating processes of intervening and evidencing as performative does not treat interventions and their effects as fixed and stable according to their prior evidencing, but instead proposes these as relational and emergent, and thus, multiple and mutable.

Background

Methadone treatment is considered by global health agencies as an “essential medicine” in combination intervention approaches to HIV prevention and opioid treatment for people who inject drugs (World Health Organization, 2015). Supported by systematic and meta-analytic reviews of evidenced harm reduction effects (McArthur et al. 2012), in combination with mathematical modelling of impact potential (Degenhardt et al. 2010, Vickerman et al. 2014), the introduction and scaling-up of methadone treatment as a technology of HIV prevention is promoted globally, including to lower and middle-income settings (Larney et al. 2017, World Health Organization, 2013). The region of Eastern Europe and Central Asia is presented by global health networks as in particular need of methadone treatment as HIV prevention (Mathers et al., 2010). The region is characterised as having explosive epidemics of HIV primarily attributable to drug injecting and linked to broader vulnerabilities precipitated by post-Soviet collapse (Altice et al. 2016, Atlani et al. 2000). Methadone treatment’s translation potential in the region is largely evidenced through estimates of health impact and cost effectiveness derived from locally adapted mathematical models (Alistar et al. 2011, Vickerman et al. 2014). Settings characterised by moderate to high levels of HIV prevalence are projected to require particularly high levels of HIV prevention and opioid treatment coverage to impact HIV epidemics (Vickerman et al. 2014). Here then, presents a complex problem of implementation when translating between evidenced technologies of modelled potentiality and situated accomplishments in actuality.

Kyrgyzstan is enacted by global health networks as affording particular promise as a site of methadone treatment for HIV prevention (Subata et al. 2016). Kyrgyzstan is one of only three countries in Eastern Europe and Central Asia offering methadone treatment in prison settings. Initiated in community settings as a pilot with international funding in 2002, the first prison-based methadone pilot intervention started in 2008. Methadone treatment now operates in six prisons and two pre-trial detention centres, engaging over 500 patients, relying exclusively on international funding as an initiative of HIV prevention (Subata et al. 2016). Kyrgyzstan thus potentiates a progressive translation towards the incorporation of globalised evidence-based intervention against the legacy of Soviet narcology emphasising criminalisation above public health.² The expansion of methadone treatment in Kyrgyzstan, and into prison-based settings specifically, is framed by international agencies as a “success story”, especially given “the context of post-Soviet economic, social and political realities” (Subata et al. 2016). Yet, methadone treatment uptake is low, and prison-based methadone treatment remains highly unpopular. A nationally representative bio-behavioural prison survey in 2014 estimated that 7% of the prison population was enrolled in methadone treatment compared to the 33%, likely an under-estimate, who reported ever injecting drugs (Azbel et al. 2016).

Methadone made in policy

There is a history of resistance, including politically and at the level of national governments, to the incorporation of methadone treatment in some Eastern European and Central Asian countries, especially Russia (Latypov 2011, Rhodes et al. 2010). Policies in Russia have constituted methadone a toxic drug of addiction, a cause of criminality, a failed treatment of the West, and as a resource for resisting international donor assistance (Rhodes et al. 2010). Here, methadone has become a site of translation in East–West relations as much as an evidence-based intervention in health. This accentuates methadone treatment as an object of the policies, discourses and practices which enact it. The methadone evidenced in Russian policy and other material-discursive practices emerges as a different methadone to that evidenced globally in HIV prevention policy and implementation science.

Russia arguably presents an extreme example in the enactment of a different methadone to that constituted in global health policies (Rhodes 2018, Rhodes et al. 2010). We can highlight less extreme examples of the apparently singular object of methadone treatment being made multiple through its material enactments. For instance, the methadone produced in medical practices as a treatment or pain-relief is a different methadone, with distinct effects, from that produced in material-discursive practices of illicit use and addiction (Keane 2013). Similarly, the methadone treatment of ‘post AIDS’ drug policies in parts of the West, such as the UK and US, is no longer framed by discourses of HIV emergency and harm reduction but by addiction recovery (Berridge 2012), and this produces a different methadone potential, with different effects and expectations (Dennis 2019). We can begin to appreciate methadone treatment as a fluid intervention of its shifting implementation relations (De Laet and Mol 2000).

Methadone made in practice

Our work investigating methadone treatment implementations in Kenya illustrates the ‘fluid intervention’ potential of translations (Rhodes 2018). Legitimised by HIV emergency, methadone treatment entered Kenya in December 2014 as an experimental policy solution to the problem of HIV linked to injection drug use (Rhodes et al. 2015). The performance of methadone treatment as an intervention of HIV prevention in Kenyan national policy chimes with its assembly in global health discourses of HIV concern (Degenhardt et al. 2010, Larney et al. 2017). Yet qualitative research investigating methadone’s implementations reveals that the methadones-in-practice are distinct from the methadone-in-policy. This work describes how local actor-networks – of methadone users, would-be users, clinicians, community workers, community and religious leaders – make-up methadone as an object of addiction recovery, and related to this, hope of normalcy (Rhodes 2018). These actor-networks produce methadone treatment as a technical solution to personal and community ills related to problems of addiction. This ‘addiction recovery’ methadone coexists with other versions, including policy-mediated ‘HIV prevention’ methadone, and the methadone of the ‘drug-dens’ which is enacted as a harmful experiment of Western intervention. This work notices that methadone is a virtual singular held together as a composite which prevents it from falling apart despite its multiplicity in practice (Law 2004, Mol 2002).

Implementation science tends to treat intervention translations as technical problems. Working with methadone treatment as an immutable mobile, it conceives of its complexity in translation as primarily a technical managerial problem (Law and Singleton 2005). For instance, methadone treatment’s implementation into East European and Central Asian settings tends to be constituted as a systemic problem of delivery systems and cultural understandings. Studies in Eastern Europe and Central Asia focus on how low rates of treatment engagement combine with high rates of attrition given certain context-based ‘barriers’ linked to programme quality and delivery, provider-patient relations, and ‘problematic’ patient or provider beliefs and expectations (Bojko et al. 2015, Boltaev et al. 2013, Mazhnaya et al. 2016, Polonsky et al. 2015, 2016, Subata et al. 2016). Here, implementation science can be treated itself as a set of material-discursive practices which seek to bring into line the multiple interpretations of methadone that co-exist with those of the evidence-based methadone performed by global health networks. In doing so, the possibilities for coming to know the different situated, relational and emergent versions of methadone that are made in practices are obscured.

Approach

In this paper, we reflect on how methadone treatment translates through its implementations in Kyrgyz prisons. At the outset, we do not treat methadone treatment as a stable object fixed by its prior evidencing in global health policy and HIV prevention science but as a performative matter of its practices of implementation (Rhodes 2018). We seek to reassemble methadone treatment from a prior evidence-based ‘matter-of-fact’ to a local evidence-making ‘matter-of-concern’ (Latour 1999, 2004). Latour’s naming of matters-of-fact as matters-of-concern draws attention to some of the limits of constructivist accounts in their re-framing of things according to alternative perspective without attending to their material performativity. Matters-of-concern accentuates things not as objective and pre-existing but as made-up in assemblages of social, material and political interest (Puig de la Bellacasa, 2017). Most importantly, it emphasises objects as lively, drawing attention to social and material effects as matters of becoming that are co-enacted through human and nonhuman entanglement. This offers a more distributed account of agency in which the human subject is not alone. Whereas matters-of-fact mistreats objects as separate to the social (as pre-existing and becoming objectively knowable through human centred science), matters-of-concern restages all things, nonhuman and human, as lively in their material becoming, thereby collapsing the binary bifurcations enacted by modern science which separate the natural from the social, the objective from the subjective, and facts from concerns (Latour 2004). This alters how science is done for it troubles an approach which seeks to ‘bridge the gap’ between two worlds – nature and society, evidence and practice, reality and representation, knowing and doing – to accentuate the materiality of all things made in practices. Far from science and knowledge-making technologies being outside the practices they evidence, as if observing ‘from a bridge’ (Puig de la Bellacasa, 2017: 33), they are entangled inside practices, at once enacting and being enacted by these. Indeed, the ‘letting go of the controlling power of causal and binary explanation comes with an immersion in the messy world of concerns’ (Puig de la Bellacasa, 2017: 33).

We therefore approach interventions (whether health or other technologies, including knowledge interventions) not as fixed and immutable but as fluid and mutable, that is, evidence-made in practices. Whereas evidence-based intervention (EBI) approaches tend to hold on to an intervention and its effect as pre-existing its actualisation into new settings, potentiating universality, an evidence-making intervention (EMI) approach emphasises effects as emergent gatherings of relational association, thus potentiating multiplicity (Latour 1999). In one, effect is located inside the specific intervention object; it constitutes the ‘substance’ of the intervention, it is something the intervention ‘has’. In the other, the effect is located inside the assemblage of implementation events; it is something to which an intervention becomes attached through its relations (Gomart and Henninon 1999). Intervention effects are therefore situated accomplishments which do not proceed their enactment (Stengers 2005). Approaching methadone as situated accomplishment is useful because it helps notice the ‘multiple methadones’ that become possible in practice, and the multiverse of effects that these might afford (Rhodes 2018). This multiplicity of intervention and effect might otherwise go unnoticed or be closed off from view in an evidence-based approach which fails to treat things as matters-of-concern. This is a shift in emphasis from investigating how ‘interventions that work’ translate (an evidence-based approach) towards investigating how interventions are made and ‘made-to-work’ through their translations in practice (an evidence-making approach). Our approach therefore focuses on what interventions can be made to do, and how they are put-to-use, including beyond their intended aims of translation.

In the field of drug use and intervention, there is growing attention to appreciating drug effects as emergent and material matters of assemblages linked to implementation events rather than simply treated as matters of intervening substances themselves (Dennis 2016, Dennis and Farrugia 2017, Duff 2013, 2014, Fraser et al. 2014, Malins 2004, Race 2011). The seminal work here as it relates to methadone is Gomart’s analysis of how methadone effects in clinical trials are made-up multiply and differently (2000). The properties of methadone, the substance itself, is produced through the implementation practices of the trials. Rather than a singular methadone object ‘having’ an inherent or stable essence, which is then subject to variable interpretations according to context, there are multiple and altogether different methadone objects made possible. Gomart notices that the methadones performed by American and French clinical trials produce different effects, including in comparison to heroin (for which methadone is posited as a treatment). However, the effects of methadone in the American trial were held to be different to heroin, they were held as the same in the French trial. The ‘sheer multiplicity’ of methadone makes it ‘impossible to hold that the substance is constant’ (Gomart 2002). Here then, we have ‘effects in search of a substance’, rather than a substance stabilised to produce a certain universality of effect. The implication for studying drug treatment translations is a shift from the substances in translation to the processes of implementation which make-up such substances (Barad 2007). This is in keeping with the view that phenomena do not precede their enactments in practices, but rather emerge, are transformed, and are performed relationally through their ‘intra-actions’ (Barad 2007). The notion of intra-action signi-fies ‘the mutual constitution of entangled agencies’ meaning that a ‘lively new ontology’ emerges (Barad 2007: 33). Importantly, this emphasis on the materiality of implementation practices also helps attune research to the onto-political effects that intervention translations can generate (Law 2004, Mol 2002). Methadone and drug intervention effects, for instance, affect a particular kind of body, making-up a particular kind of subject, normalising a particular kind of conduct, in relation to a particular kind of problem, according to a particular implementation context (Bourgois 2000, Dennis 2016, Fraser 2006, Harris 2015, Keane 2013, Malins 2004, Nettleton et al. 2013, Valentine 2007). Taken together, we can ask what methadone treatment translations perform in the context of Kyrgyz prisons: What bodies and subjects do they make? What effects do they afford? How do they govern?

Case study

In keeping with the use of the case study in science and technology studies (STS) as a means through which to reflect, shape and perform critical analyses on the materiality of technology translations (Law 2004), we draw on qualitative research led by Lyuba Azbel as part of a study supported by the U.S. National Institute of Drug Abuse (NIDA) investigating how prison environments in the post-Soviet space shape methadone treatment delivery.¹ We use this empirical case to trace how health interventions translate through their implementations. Our analysis is framed within an approach (see above) which seeks to trouble mainstream assumptions of evidence-based intervention translation to notice how local matters-of-concern make methadone fluid and multiple with particular onto-political implications (Mol 2002).

The impetus for the qualitative study upon which we draw here for our case was a large implementation science study designed to inform the delivery of methadone treatment into Kyrgyz prisons. Survey research has indicated moderate to high levels of HIV (10%) and hepatitis C (50%) among prisoners, and significant proportions (35%) of prisoners with a history of injecting drugs (of whom 85% inject drugs while in prison), yet only a minority (11%) of these engaged in methadone treatment (Azbel et al. 2018). In response, an implementation science project sought to trial a motivational intervention to encourage methadone treatment uptake, and a parallel qualitative study sought to investigate prisoner engagements with methadone treatment.¹ The problem, however, was that the motivational intervention did not appear to work as intended, with not a single person participating in the intervention linking themselves into the methadone treatment available. Rather than take an approach to implementations research which a priori locates the implementation problem as a matter for technical or managerial solution, linked to adapting the intervention or its delivery context, we use qualitative data to investigate more fundamentally how the object of intervention in question (methadone) is made to be in its particular situation (Law and Singleton 2005).

The empirical data comprises qualitative interview accounts with men in prison with a history of injecting drug use who were recruited from three high security prisons in Bishkek. These prisons were selected by the team driving the implementation science project because they represented higher proportions of prisoners who injected drugs and a higher likelihood of participation in methadone treatment.³ Interviews were undertaken, with written consent, before (n=22) and after (n=20) release from prison, between October 2016 and September 2018.⁴ Participants were recruited in close collaboration with local non-government organisations acting in partnership with the prisons. In addition to prisoners, 21 interviews were carried out with key actors in the field of prisoner health, including: representatives of the national prison administration (3); staff of linked non-government organisations (5); peer workers with people who inject drugs (2); informal prisoner leaders (4)⁵ and prison medical (4) and non-medical staff (4). Here, LA observed sites of methadone treatment distribution, the prison space, and interactions among key participating actors. Access to prisons for observational and interview work was enabled through a single day pass by application months in advance. While the qualitative interview data has been coded according to principles of constructivist grounded theory (Charmaz 2006), the analysis here works to incorporate ideas from STS regarding the multiplicity, fluidity and mutability of objects-in-practice (Mol 2002, Law 2004; Puig de la Bellacasa, 2017; Latour 2004) to ‘make a case’ (Law, 2017).

We do not have the space here for detailed reflection, but wish to make three observations regarding the ethics-in-practice of this research. The first concerns decisions regarding the spatial location of interviews. The prison sites were physically divided between the ‘red zone’ which housed the formal administration (from which methadone was distributed, see below) and the ‘black zone’, or zhilaia zona (living zone), which housed the prisoner community (from which heron was distributed, see below). These zones and their demarcations acted as material in the governing and making-up of people and substances in relation to agency and effect. The physical site of the interview location thus took on considerable significance in relation to its association with either the Reds or the Blacks, and thus a site equidistant between the red and black zones was selected. Second, the researchers placed considerable emphasis on assuring participants that the research was not linked to the prison authorities in any way, yet the qualitative research may have been associated by some with outside and prison authority supported efforts to implement methadone treatment within the prison. Third, assurances of confidentiality were not without complication. While all data generated and audio recorded were treated in strict confidence, according to ethics approvals,⁴ word about the study and its general topic (methadone) quickly travelled throughout the prisons. This produced a chain referral of interested participants, but not without others’ potentially knowing of their participation. In the very early days of the study, the only means of reaching prisoners, given that the prison colonies are very large open spaces,³ was by loudspeaker announcement (a routine means of calling prisoners to attention) with a request to report to the building designated for the research.

We shape our case study below in relation to two forms of translation relating to methadone: substance-making; and governing through substance.

Substance-making

First, we notice that This object is not a ‘bad’ (Extracts 1–3). This object is not health-producing but harm-producing. Methadone is toxic. In multiple ways, methadone messes with the health of the body. Users of this substance complain of sores, blisters, bad teeth, bad lungs, bad livers, an addiction worse than heroin, and unparalleled drug withdrawal. We are told, for instance, that methadone users “degenerate right before your eyes”. This degeneration is described as a loss of the body to methadone (Extract 2). Here, methadone is described as “taking over” the body. Users of methadone talk of it “seeping through the body”, to the point that the body is filled-up, made-up, of methadone. The healthy body becomes methadone-body. As was often remarked by longer-term users, unable to look back or quit their methadone entrapment: “My bones are now made of methadone”. The substance of the human alters through its incorporations with methadone (Extract 3). It is telling that those who felt themselves to be healthy avoided methadone. Methadone is enacted as the preserve of the ill, and the becoming-methadone-body an object of disease (Table 1).

Table 1.

Making-up methadone treatment

Extract 1: Methadone transforming addiction

Withdrawal from methadone, a person can’t get through it. If I was to just quit it, cold turkey, right now, as I quit heroin where I’m sick for a week and that’s it. With this [methadone], it won’t work. I’ll die. My body won’t be able to take it. / It is possible to give up heroin, but methadone addiction is much stronger, much worse. (Bashir, prisoner, male, 27)

Extract 2: Translating healthy to methadone bodies

I’m beginning to dry out from these chemicals. I’ve lost my health. I’m already dying. / Just imagine, I don’t eat, I don’t drink, I’m barely able to walk, I don’t have health. And then I go and drink methadone, and I start moving, my appetite returns. / It all builds up inside, right. And the heart suffers, and the liver, and urine, and everything. Basically, it’s the living dead. / They disappear, the veins vanish. They’re aware. They know that their veins are burning. They know about their liver. Their hearts grow weaker. They know and consciously do it. He gave up on himself. He just gets high. He needs nothing else. (Kalmurat, prisoner, male, 43)

Extract 3: Methadone bodies becoming less-than-human

A person begins to transform from a human into an animal. / They have ulcers, all of them. All of them are rotting, and such a smell./ It’s [the methadone treatment programme] like a monkey house. People are already not normal. (Kalmurat, prisoner, male, 43)

Extract 4: Dimedrol translating the methadone low into a high

I drink methadone, I’m going down a tunnel, I see nothing … I get Dimedrol, I shoot it up, and I see a white light, birds chirping, it turns out I’m alive. / They all do Dimedrol because methadone doesn’t provide euphoria, no high./ They take Dimedrol to prolong it, to have a high for longer (Alim, prisoner, male, 37)

Extract 5: Dimedrol translating methadone into a heroin-like high

Methadone without Dimedrol doesn’t get you high. It just takes away the withdrawal … But with Dimedrol, there’s some kind of reaction that takes place. It’s like heroin, as if you’ve injected heroin. / It seems the brain remembers that heroin trip, and Dimedrol gives this trip. And not for long. That’s why the Dimedrol dose keeps growing. (Oleg, prisoner, male, 38)

Extract 6: Methadone-Dimedrol becoming one, doing damage together

Dimedrol or methadone, it’s the same thing. This is the reason why I don’t want to go on this methadone, because I know what happens. / It gives hallucinations. It closes up a person. He becomes crazy, delusions, hallucinations, talks to himself, doing things, this noise. That’s it, he is lost. (Salamat, prisoner, male, 43)

Extract 7: Methadone-Dimedrol becoming Other

What a person in his right mind sees these zombies, excuse my language, all these people with abscesses, what person in his right mind would support this [methadone] programme? When doctors do autopsies on these methadone users and say they are all jelly inside. They’re like monsters. (Rano, NGO employee, female, 35)

Extract 8: Methadone death

It is killing people much faster than heroin … Just looking at them, how they are killing themselves. I don’t feel like it. I still feel like living. / We clearly realise it, that this is the killing of drug addicts, the methadone programme … During [its] nine years, half of the population died. In nine years, half of them died! It’s slow death by methadone. / Everyone died who started taking methadone. Everyone who I knew who joined the methadone programme. (Kamal’, prisoner, male, 40)

Extract 9: Different methadone worlds

They didn’t even want to go on these methadone programmes, because initially they were given this information that methadone is rock bottom. Everybody dies from methadone! For me, it was such a shock. And I say to them, doesn’t anyone die from heroin? I say, heroin for you is a treatment for all diseases, whereas everybody dies from methadone! (Alima, prison staff, female, 45)

Extract 10: Methadone translating heroin from a high to a low

They cannot appreciate heroin, even when they use it, they cannot appreciate it … There is no effect. Methadone neutralizes, counter-balances it. / Everybody knows full well that methadone knocks down the heroin concentration, you drink a sip and then you shoot up, useless, well useless. (Tair, prisoner, male, 52)

Extract 11: Heroin affording a high that methadone cannot affect

Any addict would choose heroin, of course [rather than methadone]. You would have to do something to our heads, probably some kind of surgery [for methadone to become preferred]. Maybe then we would be grateful to the [methadone] doctor. Honestly. All of our fates are crippled. Just because of our love for this drug [heroin]. Everyone would choose heroin [over methadone]. It gives a high. (Sasha, prisoner, male, 61)

* Emphasis (1talics) added

Second, we notice that methadone effects merge with those of diphenhydramine, locally branded and sold as Dimedrol®;⁶ antihistamine pills which are available illicitly, which are crushed and then injected in an attempt to turn methadone into a high (Extract 4–5). This affects, substantively, what methadone becomes. Whereas methadone-in-policy is pure, untainted and bounded, in light of its entanglements with Dimedrol, the methadone-in-practice is open and porous, and consequently, much messier. Methadone and Dimedrol are used together (Extract 6). They become inseparable become inseparable, a fluid intervention of a new kind. The effects afforded by methadone become indistinguishable from those of Dimedrol, a substance performed as particularly messy in the bodily damage it causes (Extract 6). The becoming-methadone body shifts, in time, to a less-than-human body (Extract 3). The methadone–Dimedrol subject is variously Othered as a zombie, a monster, an animal, as rotting, as garbage, as crazy, as beyond knowability or rationality (Extract 7). Accordingly, and significantly, methadone treatment is constituted a loss of human agency, a slow death, and for some, a sure death (Extract 8). It is little wonder that there is such low uptake within Kyrgyz prisoner society for this particular methadone.

Taking these observations together, the methadone-in-practice of Kyrgyz prisoner society is dramatically different to the methadone enacted through the practices of internationally supported HIV prevention and drug treatment programmes. The methadone-in-practice is not the same as the imagined immutable mobile in translation. Those working to translate methadone as a mobile technology of HIV prevention express shock at just how different the methadone-in-practice appears to be (Extract 9). This is not a simple ‘composite’ methadone or a ‘virtual singularity’ of methadone (Mol 2002). And neither are these object translations fluid or smooth adaptations. Rather, the singular object ‘methadone’ starts to rupture and fall apart. Methadone becomes combustible. Its translations are unpredictable, oppositional, and fiery (Law and Singleton 2005). Both the methadone object and its imagined subjects are ontologically ruptured through their implementations as different things. This is why the subjects of methadone made on the Inside (in prisons, in practices) are said by those on the Outside seeking to implement methadone treatment to defy rationality; for they are enacted as beyond knowing, as entirely Other things (Extracts 7 and 9). Methadone has become matter known otherwise.

Let us consider some of the actors in the assemblage of the becoming-methadone body. We have noted how the nonhuman actors of methadone and Dimedrol at once incorporate one another as well as the human bodies they associate with. Another actor in this assemblage is heroin.⁷ This is glimpsed by the shock expressed by one of the promoters of the prison methadone programme who notes how heroin is enacted as a relative ‘good’ in contrast to methadone enacted as a ‘bad’; the polar opposite of how these apparent same substances are materialised on the Outside in evidence-based health intervention (Extract 9).⁸ We notice that methadone’s knowing is relational, not only to Dimedrol, but also to heroin. Methadone is held as a relative harm to heroin: it is more dependence-inducing; it has worse withdrawals; and it is more health damaging (Extract 1). Crucially, methadone does not afford the euphoric-inducing effects enacted by heroin (Extract 10). Whereas heroin potentiates a high, methadone potentiates a low. Whereas methadone enacts docility and passivity, heroin enacts vitality and energy (Extract 11). Methadone constitutes loss, of the body, of the high. And this may go some way towards understanding the agency of Dimedrol in the assemblage; for Dimedrol is enacted as a device for affording methadone the high it does not produce (Extract 4–5). Dimedrol is used with methadone because it is said to generate a high reminiscent to that of heroin (Extract 5). Dimedrol constitutes methadone as a drug rather than as a medicine or treatment. It potentiates methadone with a ‘drug life’. We notice then, that the becoming-methadone-body of methadone treatment emerges immanently from matters of drug assemblage in which methadone, Dimedrol and heroin entangle. Furthermore, we notice that these associations make-up methadone as a drug but that this drug-in-practice is a poor drug, which is lacking in potential and failing in effect in so many ways, including how it falls short of heroin’s potentiality.

Governing through substance

It is important to note that the assemblages making-up the becoming-methadone-body do not merely comprise psychoactive substances interacting with human bodies but other actants as well. Noticing these helps attune our analysis to the situated practices of Kyrgyz prisons. We draw specific attention here to practices of everyday informal prison governance which are afforded through the device of ‘The Understandings’, an unwritten law or code of the criminal and prison community which enact methadone (and heroin) in particular ways.⁹ We are observing that methadone is afforded agency as material inside the day-to-day practices which make-up, and thus govern, prisoner social relations. The methadone-becoming-body is at once material and social. The becoming of methadone in prison is the making of prisoner society: how methadone is put-to-use, how it is made-to-matter, is an effect of the practices which generate the sense of social and societal relations.

With State capacity limited, law enforcement inefficient and corruption pervasive, the Krygyz prison is a stronghold of organised crime, a legacy of the Gulag, where prisoners themselves prescribe punishments, police hierarchical boundaries, disseminate rules, and function as guarantors of justice (Cheloukhine 2008, Kupatadze 2014). This informal governance, institutionalised through criminal organisation, enacts a disciplinary power in relation (and opposition) to those of the prison administration and State (Kupatadze 2014). Methadone treatment becomes an object of translation between the diametrically opposing rationalities of governance of the State, ‘the Reds’, and the informal Criminal Code, ‘the Blacks’. While there are exceptions, the day-to-day practices of the Criminal Code⁷ constitute signing-up to State-administered methadone treatment a problem of conduct. The methadone subject is enacted in prisoner society as lacking decency and agentic control, and as untrusted to work in the service of the Criminal Code, given associations of methadone with State supported intervention (Extract 12). Methadone’s power-of-acting extends beyond human centred psycho-activity into matters of translation between political disputes, normative values, and societies. These are some of the onto-political effects of methadone’s making (Bacchi and Goodwin 2016, Mol 2002) (Table 2).

Table 2.

Methadone treatment as an object in governance

Extract 12: The unvirtuous methadone subject

It [using methadone] shows that a person is not only addicted to drugs. He is already ill. He’ll stuff himself with all kinds of garbage. I don’t respect this category. They are not a step lower, they are a whole level lower. Although they live among the poriadochnye [the middle class, the “decent ones”]. To live is one thing. You have to behave accordingly. To live there doesn’t mean that much. You have to show too that you’re not just living with the poriadochnye, you have to act accordingly, like the poriadochnye [“decent ones”] … There are proper actions and improper actions. / Right away attitudes change towards him [the person using methadone]. He won’t be taken seriously. He loses trust right away. He’ll be an outcast. (Yurii, prisoner, male, 32)

Extract 13: The methadone subject is a risk, not to be trusted, and under surveillance

On methadone the withdrawal is very strong, stronger than heroin, and when you start going through withdrawal from methadone, a person loses his mind … The administration and the cops, they also know it. Because of that, they also try to somehow hook the person who drinks methadone … They take methadone away from someone to obtain some kind of information … On the other hand, the administration cops […] bring in Dimedrol themselves, they sell it to them, they make money from that, and they hook the person too … Because [he’s] leaking information his psychology is under the influence, first of methadone, second the cops, and on the part of the Obshchak. Because if he is discovered by the Obshchak he’ll really get it, and if he isn’t discovered, sooner or later everything comes to the surface. / Right away attitudes change … He [the methadone user] won’t be taken seriously. He loses trust right away … He’ll be an outcast. / He’ll be watched … They [prisoners accountable to the informal Thief-In-Law] will be listening in on him everywhere, and [also] through the cops.. The cops themselves will start leaking information about this person [to the prisoner society hierarchy]. (Timur, prisoner, male, 33)

Extract 14: The methadone subject is excluded from heroin capital

There is the common Razgon. On holidays, everyone is given the stuff [heroin] then. They do not give it to the ones taking methadone … If you’re drinking methadone, then drink methadone, and you’ll get nothing from the Razgon … You’ve gone for treatment, so get treated … If you sign up for methadone then that’s it for heroin, you’re done. (Bakyi, prisoner, male, 42)

Extract 15: The methadone subject is excluded from governing power

The guys on methadone, we are treated like the Obizhennye [a lower category in prisoner society hierarchy]. This is not openly declared, but we are treated as if we are Obizhennye. It’s certain actions – squatting or not greeting them – there is nothing in the open, but it is psychological, well emotional … You feel the contempt of someone towards you. They [methadone users] feel the contempt of the entire prison population … They compare this treatment, a silent one, cold, as the same as towards the Obizhennye. / The Obschak will say [to the methadone user] ‘It’s up to you. Either stop taking it and stay with us, and live as you have been living, or proceed with the treatment, but you will have to move with them, with the Obizhennye. (Zheenbek, prisoner, male, 49)

Extract 16: The methadone subject is powerless

Their word means nothing at all. Methadone users come last. Before it was the drug addicts, and now lower than drug addicts, it’s methadone users. (Mirlan, prisoner, male, 36)

* Emphasis (1talics) added

Reassembling methadone treatment as a matter-of-concern, as a thing made-to-matter locally, helps notice how apparent matters-of-fact have specific contexts and politics (Latour 1999, Stengers 2005). The methadone in translation from the Outside has disruptive potential in relation to vital matters-of-concern on the Inside. As elaborated more fully elsewhere, a core governing practice of the Criminal Code is the ‘Obshchak’. The Obshchak are those in the informal prisoner hierarchy or ‘caste’ system⁷ who govern the prison and manage a common fund of goods also known as the Obshchak. Prisoners (excluding the lower caste) determine how goods from the Obshchak are distributed amongst themselves according to need, work, and social status within the prisoner hierarchy, the latter determined by a lifetime of actions in relation to the Criminal Code. Specially assigned members of the Obshchak distribute the Razgon to the Poriadochnye – “the Decent Ones” – the second to highest class of prisoners in the hierarchy. The Poriadochnye are under the overall direction of the Polozhenets, the informal leader of the prison, who is under the direction of the highest criminal authority of the country, the Thief-In-Law. Those undertaking surveillance in all aspects and areas of prison life – from drug use to the canteen – are known as the Smotriashchie, and these report to the Polozhenets. While the Obshchak can distribute cigarettes or tea or other goods as part of its common fund, its primary exchange and capital is heroin. Heroin is distributed every 10 days to all prisoners, at no cost, and daily to those doing specific work for the Obshchak.

Methadone treatment is thus material inside a network in which heroin is also a key actor. This accentuates how heroin is valorised, relative to methadone, as a substance of multiple effect potential, with different capitals flowing through the bodies of the individual and society. Heroin affords a high of different kinds; from internalised embodied psycho-active effects to socially embodied positions of power and agency. The introduction of free methadone administered by the State threatens such vital matters-of-concern. Prisoners on the Inside who are incorporated into the Outside project of methadone treatment cross boundaries. We not only find that those on the Outside enact the methadone-in-prison as Other to that imagined or intended; as unknowable and even monstrous in its contaminations with Dimedrol (Extracts 7 and 9), but at the same time those on the Inside ‘other’ the subjects of methadone, not only as monstrous but more particularly as useless, unvirtuous and untrustworthy (Extract 12). The othering of methadone on the Inside is specific in how it performs a governable subject, enacting the methadone user as a thing that constitutes mess which does not work in its society (Law and Singleton 2005). The methadone user is at risk and of no use (Extracts 12–13). The methadone user cannot necessarily be trusted to work to uphold the Criminal Code. More than this, the methadone user fraternises with the State authorities, and must be held in suspicion, and even considered a traitor (Extract 13). We are noticing how methadone has governing agency on the Inside in how it is used as matter to confer citizenship and inclusion. For instance, those ‘signing-up’ to methadone treatment are excluded access to heroin via the Razgon (Extract 14). With heroin afforded high value – personally, materially, socially, politically – this is a technology of governance that really matters. Moreover, those taking-up methadone are more likely to be those who had been outcast into the lower classes of the prisoner hierarchy, known as the Obizhennye, with nothing left to lose (Extract 15). They become nothing; at once less-than-human in their embodiment (see above) and less-than-useless in their societal contribution (Extract 16).

Taken together, the methadone treatment imagined as evidence-based health intervention, and administered by the State, does not belong here. In their various associations, the actor-networks which make-up methadone treatment on the Outside and Inside enact this particular methadone as Other. The methadone-in-practice of prisoner society neither translates as the HIV prevention and opioid dependency treatment envisaged by its implementers nor is it in concert with the informal governing practices of prisoner society in relation to those of the State. This methadone does not work in its situation, and neither is it owned or desired. And this is why the subject of methadone is cast in these actor-networks as variably unknowable, useless and unfit. Indeed, methadone is a ‘slow death’, at once of the individual and social body. This methadone treatment is an entangled mess, in its multiple materialisations.

Methadone ontopolitics

What conclusions can we draw from this case? We have used qualitative data to make a case to reflect on the substance of health intervention translations as matters of their implementation practices. We have argued for an approach which treats evidencing as performative to accentuate how intervention objects are always matters of becoming inseparable from their knowledge-making productions. This has important implications for how we think regarding evidence-based interventions and their translations. First, and in contrast to mainstream public health implementation science, we question assumptions that interventions can be constituted as relatively stable entities which exist outside their evidencing events. Second, this leads us to question assumptions that interventions can be translated between settings and situations whilst holding their shape, fidelity and universal effect potential. We come to this conclusion through our reassembling of methadone treatment as a prior matter-of-fact to a local matter-of-concern (Latour 1999, 2004).

Specifically, we have noticed the multiple methadone treatment interventions made possible in practice in Kyrgyz prisons and what these affordances do in these contexts. This has enabled us to see the object of methadone treatment not as a stable substance which hosts certain essentialised effects, but as a fluid and fiery object which is put-to-use and made-to-matter to substantiate a multiverse of effects (Law and Singleton 2005). Our case study illustrates how substances are made relationally in their practices (Gomart, 2002, Mol 2002). Most importantly, treating methadone implementation as an evidence-making event (Michael and Rosengarten 2013), accentuates how object translations enact an ontological politics (Mol 1999, 2002; Puig de la Bellacasa, 2017). Stengers argues that reassembling matters-of-fact as matters-of-concerns “insists that we think, hesitate, imagine and take sides” (2018: 3). She writes: “The essential thing with ‘matters-of-concern’ is to get rid of the idea that there is a single ‘right answer’ and instead put what are often difficult choices on the table, necessitating a process of hesitation, concentration and attentive scrutiny” (2018: 3–4). In its different translations, in it is becoming altogether different things in relation to individual and social and political bodies, the methadone object is afforded agency to govern materially in different ways. Within the contextual limits of our case study, we have noticed how methadone enacts society; one that is relationally emergent and otherwise. The methadone of evidence-based global health translates, and changes shape, as an effect of the governing practices of prisoner society in relation to those of the State. Methadone and other drug interventions are at once onto-political interventions, with embodied effects that flow way beyond the mere psycho-activity of substances incorporating individual bodies to material highs and lows which incorporate the practices of social networks and societies.

Evidencing-making implementation science

This analysis also has some implications for how we think-with intervention effects and implementation science. We have shaped our case to do more than illustrate that evidence-based health interventions need not translate smoothly. As we move from methadone treatment as a presumed singularity and immutable mobile to an enacted multiple and mutable mobile in practice, we also alter how we imagine implementation science. We entertain implementation science as something other than a mere technical service intervention in an evidence-based intervention approach. Indeed, in an evidence-making intervention approach, we move towards what might be described as a more speculative implementation science attuned to noticing and exploring what might be otherwise (Stengers 2018).

The implementation science we are advocating questions interventions and their effects as fixed and stable, instead proposing them as relational and emergent, and thus also, multiple rather than singular (Mol 2002). It challenges presumptions of separation between the physical and social, nature and culture, and evidence and practice, which dominate mainstream evidence-based health intervention paradigms, instead proposing these as entangled in material practices (Latour 1999, 2004; Puig de la Bellacasa, 2017). And it expands notions of agency beyond those of human actors to include the effects of non-human actors (such as drugs, diagnostic tools, clinical guidelines, intervention devices, codes of practice, and laws) (Callon 1984, Latour 2005). This focus on materiality orientates towards a ‘flat ontology’ (Law 2004). It is a way of thinking about health intervention that does not privilege human objects, or their sciences, as either the primary agentic force or primary access to knowing. It places all objects, human and otherwise, on equal ontological footing.

Interventions are thus treated as ‘objects-in-practice’ (Mol 2002), with immanent effects which emerge from entanglements inside assemblages or actor-networks (Delanda 2016; Latour 2005). This is what we have noticed with the coming together of different actors in the becoming-methadone-body of Kyrgyz prisons. The becoming-methadone-body is an ‘intra-action’ of the different substances and bodies in an event and how these both encounter and incorporate one other (Barad 2007). The lesson here is that by investigating emerging patterns of intra-action, it also becomes possible to grasp something of the networks and apparatus that make these up (Barad 2007, Fraser 2006, Hollin et al. 2017). Through our analysis, we have accordingly moved between the noticing of patterned intra-actions of methadone effect and the apparatus which at once makes and is made-up from these, here called prisoner society, in which The Understandings⁹ emerge with the Obshchak and other nonhuman actors and substances including methadone, heroin and Dimedrol. An evidence-making approach leans towards a speculative implementation science because it is attuned towards noticing emergent effects in implementation events rather than delineating causative points and pathways between specific health interventions and outcomes (Savransky et al. 2017, Race 2014). We speculate beyond effects presumed to flow from, or be contained by, a specific drug or intervention to the emergent (and unpredictable, even fiery) effects that intervening makes. And this, as we have argued in the case of methadone’s making in Kyrgyz prisons, brings us closer to appreciating the onto-political effects of interventions as governing practices (Bacchi and Goodwin 2016, Duff 2015, Fraser et al. 2014). As Mol reminds us: “If each therapeutic intervention achieves something different, what counts as improvement may similarly tend to become less obvious. The question ‘is this intervention effective’ then dissolves into another question: ‘what effects does it have?’” (Mol 2002: 183). Noticing methadone treatment as an ontological politics is inviting various speculations, not only regarding the effects that methadone intervening makes, or might do, socially, politically and otherwise, but also regarding the apparatus and effects of implementation science in its evidence-making of health intervening.

With both methadone and implementation science in mind, this moves us to reflect ‘what is made-to-matter?’, and ultimately, what ‘effects do we want?’. Our case study of Kyrgyz prisons accentuates how methadone is made-to-matter in relation to heroin, among other actors, inside the local governing practices making-up prisoner society. In noticing the different methadones made possible in Kyrgyz prisons, we can speculate on how methadone is made otherwise, as well as on the kinds of methadones (as well as heroins and other drugs and interventions) that might be made possible. But it is important to note that an evidence-making approach to implementation science does not force or narrow a simple choice. This would be akin to ‘the promise of closure through fact-finding’ which is common in evidence-based intervention approaches (Mol 2002: 177). Rather, noticing how things might be otherwise attends to the politics of evidencing and intervening as matters-of-concern. This is a move from seeking closure on what works under what conditions (evidence-based implementation science as we know it) to inviting dialogue about what might be done in light of how intervening is made to matter (an evidence-making implementation science).

Our case proposes that the effects afforded locally in prisoner society in relation to methadone, as well as heroin and Dimedrol, are contingent in their mattering, and productive of a variety of fluidly situated goods, bads, harms and benefits. Noticing how the methadone that is enacted in practice in Kyrgyz prisons can be made damaging, to individual bodies as well as to embodied societies, prompts speculation as to how methadone intervening might be done differently. At the same time, we can speculate on the fluid effects of other substances acting in the assemblage which makes-up methadone’s effects, and how these might be worked-with to intervene differently. We notice, for instance, that the heroin enacted in practice afforded multiple forms of high and capital as well as treatment potential. Global evidence-based intervention efforts translating HIV prevention and opioid treatment into Kyrgyz prisons tend to work with methadone and heroin singulars. We are finding that an evidence-making implementation science notices methadone and heroin as multiples and potentials, and this prompts speculation on how intervening with methadone and heroin might be otherwise.