Reviewed Book
The Clinic and Elsewhere: Addiction, Adolescents, and the Afterlife of Therapy. Todd Meyers, Seattle: University of Washington Press, 2013, 170 pp.
The Clinic and Elsewhere is full of shadows. A key strength of the book is Meyers’s ability to present, gesture toward, and theoretically engage the shadow spaces of the individual addicted lives of the adolescents who appear and disappear throughout the text and the knowledge about addiction produced through clinical research pharmaceutical trails, medical charts, and ethnography. These lives and this knowledge are forever partial and incomplete.
Addiction as a lived experience and an object of knowledge is spatially located and constructed in the clinic. But, of course it also moves, morphs, and proliferates “elsewhere”—in the home, on the street, and in the car of the anthropologist seeking to understand the progression and regression of its symptoms in the lives of adolescents. The crux of the anthropological quandary of adolescence, addiction, and therapeutics that The Clinic and Elsewhere is asking us to grapple with is: What can the shadows spaces of addiction medicine tell us about the possibilities of healing?
Meyers has situated his engagement with addiction medicine around buprenorphine, the more colloquial term for two distinct pharmaceutical replacement therapies, Subutex and Suboxone, which are now becoming widely prescribed in the United States for the management of opioid dependence. Meyers initially traces buprenorphine’s entrance into the U.S. market through a history of the clinical trials milieu and an analysis of the deployment of the national anxieties about the “adolescent addict.”
The addicted adolescent is seen as a particularly dangerous and tragic figure, whose incomplete brain development provides fertile ground to establish, perhaps irrevocably, the negative long-term consequences of opioid dependence. Baltimore is both an appropriate and an exceptional geographic site for this study. John Hopkins University was the academic medical site in which the first clinical trials for buprenorphine were conducted, and Baltimore’s city government has established public policy to support buprenorphine availability in a variety of in- and out-patient clinical settings, unlike most other cities in the United States in which buprenorphine access is more privatized.
By examining the ways in which “the sharp divide between licit and illicit use of pharmaceuticals is becoming increasing blurred” (p. 5), the books demonstrates how specific rationalities of addiction affix themselves in localized settings and become molded onto what is recognized as “care,” “healing,” “success,” or “failure.” Jeff, one of the adolescents featured in the book, is a treatment success who leaves treatment only to die later as result of gun violence within Baltimore’s drug economy. Cedric and Megan are failures because they are misusing their prescribed buprenorphine at home, even as ethnographic evidence demonstrates how they establish and self-police their own logics of care.
Other adolescents disappear outside of the anthropologist’s reach—their outcomes slipping into the domain of speculation. This is speculation that Meyers refuses to indulge in, analytically or ethically. The Clinic and Elsewhere takes limits seriously and organizes itself conceptually as much around the failure of our forms of knowledge production as around attempts to track what is failure or success in opioid addiction management for adolescents.
Changing forms and registers of opioid addiction management become the ground on which Meyers can extend his extensive and multi-faceted relationship with Canguilhem—a philosophical interlocutor who is present throughout the book. In theorizing an “afterlife of therapy,” Meyers effectively leverages Canguilhem’s argument about the proximity of hope and failure, in his reluctance to use his own ethnographic work to demarcate the boundaries of success or failure in addiction treatment. This astute reluctance, paired with the critical examination of the types of knowledge that are desired and constructed in clinical trials, in settings of clinical care, and in the settings of “elsewhere” where medically managed, opioid-dependence adolescents end up, make The Clinic and Elsewhere an appropriate book to teach a wide range of anthropology classes.
Science studies students will appreciate the conceptual depth in analyses of knowledge production and localized modes of rationality. Urban anthropologists and anthropologists of space/place benefit from Meyer’s insightful explorations of physical space, sensory experience, and regulation. Psychological anthropologists and anthropologists of addiction are provided with a complex and nuanced rendering of comorbidity, pharmaceutical management, inherently progressive clinical logics, and modes of care. The book is also appropriate for undergraduate and graduate teaching as an excellent example of writing about the intersection of methodology and theory.
Meyers goes to deliberate lengths to upend static stereotypes of city dwellers addicted to opioids by emphasizing the diversity of the ethnicity, class positions, and family histories of the 12 adolescents who he followed ethnographically for three years. However, in the admirable effort not to black-box the adolescent patients, an opportunity is also missed to understand how this age group, so constructed, might understand itself relative to adult opioid-addicted people. The patients in The Clinic and Elsewhere are not children and they are not adults. They are managing their opioid dependence within the dynamic, fascinating, and confusing interstitial spaces in between childhood and adulthood. The massive cognitive, emotional, and social transitions that mark this period of life are not directly examined here—except early on as a cautionary tale of why adolescent substance abuse/addiction is such a worrying clinical and public health problem. At times it is unclear whether the patient/ethnographic subject being discussed is 14, 16, or 18 years old. Anyone who has lived with, or worked with, adolescents will note that 14, 16, or 18 bring very different perspectives, limits, and opportunities in those persons’ relationship to themselves, parents/family, institutions, and their imagined futures. One wonders: How is adolescence reshaped when patients on buprenorphine venture beyond the clinic walls yet remain pharmaceutically tethered to its clinical rationalities?
Methodologically and theoretically, The Clinic and Elsewhere is a meditation on restraint. Even the four simple photographs that accompany the book’s conclusion are haunting and lifeless, evoking people and action that might be continuing somewhere off screen, or perhaps not at all. Questions are left hanging in the air. Shadows might obscure our access to forms of knowledge. Methods—whether the epidemiological surveys collected for clinical trials research, a clinician’s chart notes that document the progression of healing, or the sporadic ethnographic encounters from elsewhere that exist outside the clinical domain—are partial, limited more by their own internal logics than by the otherwise sincere ethical efforts of their practitioners. Disappearances represent the loss of actual people and the loss of potential—our potential to fully understand or to feel closure, even at an intellectual level. Through its seriousness of purpose and intellectual rigor, The Clinic and Elsewhere leaves us, thankfully, curious and unsettled, asking: What will happen next in addiction medicine? And, equally importantly, how will we think about it?