The Lethal Burden of Survival: Making New Subjects at Risk and the Paradoxes of Opioid Substitution Treatment in Norway

Patients in opioid substitution treatment (OST) in Norway are assigned a treatment modality based on their risk profiles, with an emphasis on overdose risk. One of several medications may be administered, including methadone, buprenorphine, buprenorphine–naloxone, and occasionally morphine. OST patients who are not satisfied with the assigned treatment are required to negotiate with OST staff to switch treatment modalities. During these negotiations, some inherent paradoxes arise: (1) OST contains both a harm reduction approach and an ideology that emphasizes abstinence and a drug-free life and (2) legal requirements for patient involvement in the choice of treatment clash with the clinicians’ intrinsic suspicion toward patients’ knowledge, experience, and pharmacological preferences. Drawing upon a year of ethnographic fieldwork, I discuss in this article how OST simultaneously reduces and reproduces risks. OST medications are primarily designed to manage withdrawal, with the patient’s survival as the priority rather than quality of life. But this corporeal focus combined with a mantra of harm reduction reduces patients to their physiology. Consequently, many OST patients live in a chronic survival modus—“I am surviving, not living”—which complicates their ability to acquire new social roles. As they struggle with medication side effects, poor health, isolation, and a need for recognition, many abandon their rehabilitation plans and disengage further from society. Thus, OST can produce a new kind of vulnerability, creates new subjects at risk, and by extension maintains risk of diversion, polydrug use, and overdose