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105
blank, I start to see white” illustrates the notion of the body without organs as a
process of desubjectivation, where the eyes and memory are lost, but these organs
resume their function before death comes, and the body makes its way back from
the extreme experience.
Understanding substance use as more than purely a public health situation
implies closing our eyes to infrapolitical realities (Scott, 2004); that is, substance
use also includes a dimension of resistance to hegemonic social apparatuses that do
not achieve their promised results among the poorest of the population. When one
of our informants says “I don’t like being scolded… I like to be free,” referring to
his substance use, he is standing on the border of social exclusion and the institu-
tional inclusion of connement, which ranges from the rehabilitation center to the
hospital and psychiatric hospital, to the prison. But he also expresses the possibility
of creating street apparatuses, where the collective allows for survival and the man-
agement of use. There is undoubtedly a relationship between problematic use and
life on the street, but it would be very risky to assume that one denes the other,
especially without observing that street life generates collectives of help, care, and
survival: “Well, we may be all dirty and such, but, well, we don’t see each other for
our appearance, it’s like a bond that exists among tecatos.”
The user’s relationship with the substance is also dened by their ability to get it.
“I don’t have enough to be buying that shit,” declares one. “I do smoke it,” says
another, “but not every day. With a crackhead it’s almost every day; they live to
smoke it.” “I have always controlled myself a little more, like I have been a little
more thoughtful,” says a third, exemplifying how the relationship with the sub-
stance involves a class situation and denes the management of use. Among those
who are not quite as poor, the pleasure of substance use is managed according to
how it is felt in the body and issues of access are used as a management tool: “I can
go buy it and smoke it, but I only smoke one and that’s it… I don’t have enough
money to get addicted.”
8.3 Drugs andAbandonment asaSubjectivation Apparatus
at theExtreme: “Fucking Society Has Already
Puked Me Up”
Reguillo (2010) warns that his category of “overowing modernity” is not a process
of homogenization, as societies have different ways of appropriating the materials
of modernity. However, contemporary biopolitics, according to Esposito, is a nega-
tive, a biopolitics of life, has the mandate to “make live” one particular way and “let
die” other forms of life (Moreno, 2020a, 2020b).
It is social apparatuses like the legal and health systems that decide which lives
are “worthy of being lived.” In this precarized narrative of life itself, guilt and
responsibility are laid on the individual subject, displacing the responsibility of the
8 Extreme Experiences: Social Exclusion of Young Users of Inhalants, Crack…
106
institutions in such a way that individuals feel responsible for their “inability” to t
into the system.
Already at the time of addiction and all, well, what you prefer is to be alone and keep on, so
to speak, getting high, you no longer worry… the responsibility, your job and all, again at
that moment I threw everything away, I lost everything, the job, my obligation, I lost the
respect of society, I lost my parents, I lost everything because I isolated myself, I isolated
myself from all people…" (36-year-old male, crack user)
As we have been arguing here, we have arrived at an analysis of the biopolitics and
biopower of substance use (Foucault, 2002), mediating between the structures and
logic of capital and cultural interpretation. We understand that biopolitics as a tech-
nology of power does not mean the suppression of other technologies (such as dis-
cipline, the panopticon, and sovereignty) but is constructed to take life as the center
of domination; that is, public policy proposals, laws, orders, and a variety of other
strategies are carried out based on the quality of being alive and link political power
with other social agencies to exercise a governmentality that has life as its object,
according to the principles of “making live” and rejection unto the death
(Foucault, 2007).
We also understand that contemporary biopolitics is a biopolitics of life (Esposito,
2006b), which means that it designs policies seeking to promote a single form of
life, and is exacerbated by the current neoliberal impulse in capitalism that presents
itself as capable of turning anything, even life, into a commodity. Neoliberal bio-
politics, if the trope is allowed, insofar as it appeals to rationality, knowledge, and
science as an instrument of domination, is based on economics as the fundamental
science.
The power-knowledge that emerges from this relationship is at the service of
regularization and control that is exercised over individuals, or to be more precise,
over the bodies that must be disciplined (Foucault, 2002). In this sense, if the scien-
tic knowledge of medicine is responsible for treating or curing sick subjects, in a
system that includes and excludes them at the same time, in both the scientic and
the political sense (Esposito, 2006a), the power-knowledge of economic science
amplies the functions of exclusion and, at the same time, of inclusion in isolating
institutions that turn untamed lives into pure life (Agamben, 2003), generating eco-
nomic benets: life as a bare commodity. Here, discipline is not simply an art of
distributing bodies but the use of techniques and tactics to combine forces and
obtain an effective apparatus of control and extraction of prot (Foucault, 2002).
Rights, both human and political, and in equal measure the process of subjectiva-
tion, are the analytical subject of contemporary biopolitics, because this biopolitics
presents the dilemma between the inclusion of the citizen and the exclusion of those
without rights, of the non-citizens, who are assumed to be subjects without “a life
worthy of being lived,” a “bare life” (Agamben, 2003; Esposito, 2006a). That this
life, in Foucauldian terms, is simply biological and serves purposes of exclusion and
extermination: colonization, war, crime, madness, and mental illness, among other
phenomena (Foucault, 2002). It is inscribed even more in the negative form of bio-
power, which uses elimination through euthanasia, eugenics, and genocide as a
M. J. Domínguez and H. C. Moreno
107
form of domination and of generation of prot (Esposito, 2006a). Biopolitics is
incorporated in the subject, and it penetrates and objecties bodies in order to tell
them politically who they are.
All the tecatos [junkies], all of us tecatos are a fucking disease… a plague, a thing that isn’t
normal, we’re like those guys in the movie… the living dead, I mean the fucking zombies…
I even say so about myself, I discriminate against myself… fucking addict. (38-year-old
male, heroin user)
The disciplines in charge of enforcing the law, based on the principles of elds such
as criminal, civil, and labor law, sanction the practices of these subjects, which are
linked to delinquency, crime, idleness, and violence. Scientic power-knowledge
treats them as useless lives, “lives not worthy of being lived,” in the eyes both of the
law and of medicine. These lives, as Foucault explains in his work on madness and
the prison, are subject to the dominion of biopower, controlled through connement
in clinics and prisons (Foucault, 2002).
With the term “biopolitics,” we refer to institutional care for the biological lives
of individuals through the implementation of disciplinary apparatuses that render
the subject an object of (political) care. “Life must be separated and enclosed in
spaces of progressive desocialization that immunize it from any drift toward com-
munity” (Esposito, 2005, p. 199), because “to insure a common life, the law is
forced to introduce into it something that holds it back behind itself, to render it less
common, immune” (Esposito, 2005, p.43).
The immunization in the link between young people and drugs has placed the
young subject in a condition overloaded with valuations and labels that often result
in de facto criminalization, and that, with substance use, reafrms the intervention
of the state and its institutions. Because of their practices and behaviors, they are
said, without analysis and regardless of whether they actually have a problem with
substance use, to need control and care. However, even given the notion of disease,
not everyone ends up having an addiction.
It may be that problematic use of psychoactive substances (Sepúlveda etal.,
2008) causes the labels to be applied in a generalized way to all users, so that they
themselves are convinced that they are what they are said to be. However, not all
users see themselves in that way; on the contrary, some question the political dis-
course that tries to dene them.
We are “addicts,” we are “street kids,” the monosos of the street. I like vice, I like vice.
(22-year-old male, inhalant user)
They see us as sick and say no way, why would I invest in someone who’s killing him-
self? (26-year-old male, crack user)
You’ll never get cured… but it would be interesting… okay, they’re sick, but the root of
the disease, what is it? (25-year-old woman, crack user)
It is necessary to recognize that in the construction of the subjectivity of young
substance users in contemporary societies, most subjects are controlled by their own
use: they monitor themselves and are docile (Esposito, 2005). However, the appara-
tuses and technologies used to control, measure, and channel individuals and turn
them into docile and useful subjects are found in hospitals, schools, the military,
8 Extreme Experiences: Social Exclusion of Young Users of Inhalants, Crack…
108
families, and churches—in the spaces where bodies are subjected, manipulated, and
disciplined (Foucault, 2002).
There is no pharmaco-biological apparatus meant to turn citizens into useless
subjects; it is, rather, the articulation of the pharmaco-biological relations of the
subjects with other apparatuses that promote the designation of “lives not worthy of
being lived.” Because although substance use is just one of many forms of consump-
tion created by modernity, in that sense consumer subjects are also consumers of
drugs. We use the word “drug” here to associate a set of senses and meanings.
Contemporary neoliberal societies have built a complex pharmaceutical industry to
support public and private health systems.
Drugs are just another element inserted into social apparatuses to control ram-
bunctious children, to improve the abilities of neurodivergents, to alleviate ills, and
to reduce the pain of workers. But those same drugs promote problematic use. This
is not the place to detail how the opioid crisis in the United States was constructed,
but it is a product of the public health-medicine-pharmaceutical industrial complex,
a crisis that is characteristic of capitalism in its neoliberal stage (Suárez, 2020).
According to Derrida, “Pharmacia (Pharmakeia) is also a common noun signi-
fying the administration of the pharmakon, the drug: the medicine and/or poison”
(1981, p.70). In the drug or pharmakon, there is a dual power: relief or poisoning;
the same substance heals or kills. In this sense, substance use is not a desire to nar-
cotize the population; nor is there a conscious interest in producing mentally ill
people or criminals. The interest is to separate these “disposable subjects” from the
rest of the population because the interest of biopower is that healthy subjects not be
contaminated (Foucault, 2002). But if the pharmakon is used to improve health, to
“make live,” one is facing the possibility of divergences in use. Derrida notes that
the pharmakon contains both pleasure and pain: “This type of painful pleasure,
linked as much to the malady as to its treatment, is a pharmakon in itself. It partakes
of both good and ill, of the agreeable and the disagreeable. Or rather, it is within its
mass that these oppositions are able to sketch themselves out” (1981, p. 99).
Relieving pain means offering relief that, in turn, provides pleasure. The analysis of
substance use should include the right to relief and pleasure, even the right to pain-
ful pleasure.
Although not everyone perceives themselves with exclusionary labels or dis-
criminates against themselves, they know that others do label them as contaminat-
ing subjects, and they resist, in the attempt to accomplish what Foucault calls
making one’s own life a work of art, by appealing to a political stance based on
culture, elaborating oppositional forms of power both within and outside the politi-
cal, on the border, in the interstices that remain between culture and civilization, in
the impolitic (Esposito, 2006b). There, the subject produces oppositional values, in
what Foucault calls an afrmative biopolitics, which makes no distinction between
animal life and the human life that constitutes the subject: the “animalization of
man” ows into the aesthetics of existence (Esposito, 2006b, quoted in Moreno,
2014, p.80).
M. J. Domínguez and H. C. Moreno
109
They don’t stop calling me a thief, a drug addict… they look at you funny… everyone stares
at me, as if I were a fucking Martian. What they think of me is the worst, dude, that I’m a
fucking drug addict and that guy is never going to get ahead, fucking failure… society
doesn’t accept you, it’s never going to accept you, that’s why among ourselves we under-
stand each other… No way, fucking society has already puked me up, the truth is it has
already puked me up… and people are always going to be pointing at you, people have
already labeled you, for them you’ll always be a drug addict. (32-year-old male, crack user)
When Michel Foucault says in his interview with Paul Rabinow, “I believe that from
the idea that the self is not given to us, we can only extract a practical consequence:
we must constitute ourselves, manufacture ourselves, order ourselves as a work of
art” (Rabinow, 1984), he puts into play the idea of apparatuses producing subjectiv-
ity (the self is not given to us), to the extent that the subject is always in the process
of subjectivation and is therefore always in a position to give itself a lifestyle, a
unique form of life, as a work of art (we must constitute ourselves, manufacture
ourselves, order ourselves as a work of art). In art, the form is not necessarily beauti-
ful, but in the uncanny (Freud, 1990), there is an aesthetics that opposes the idea of
a unique form of life. The use of the pharmakon carries the possibility of living that
extreme experience between pain and pleasure, and perhaps it is time to think about
substance use from the perspective of the right to pleasure and allowing oneself a
unique form of life.
8.4 Final Considerations
We reiterate that our intention is not to analyze substance use as a desirable situa-
tion, but we distance ourselves from the idea of thinking about it from the perspec-
tive of disease, criminalization, and decitizenship. We seek to understand substance
use as a constant of human development that fosters diverse forms of life, linking
social, cultural, and economic productions at a distance from the violence and death
that today embodies the global economy of drugs, both licit and illicit. The testimo-
nies presented here are from people who have been stigmatized, excluded to the
extent that they do not feel they “t into society,” who say: “I do not feel accepted,
I feel rejected.” Their relationships with substances are diverse, and there are care
and management processes that allow them the “painful pleasure” involved in the
use of the pharmakon.
We hear the voices of people in extreme situations, nomads on the edge implied
by the extreme experience of problematic substance use and the social exclusion
into which they are thrown: “I lost the respect of the society, I lost my parents, I lost
everything because I isolated myself, I isolated myself from everyone.” But it is
impossible to ignore the awareness regarding their situation and the acceptance of
the relationships they establish with their peers and the rest of society (“all of us
tecatos are a fucking disease… a plague, a thing that isn’t normal”), but from that
position there is also the creation of other forms of life (“that’s why we understand
8 Extreme Experiences: Social Exclusion of Young Users of Inhalants, Crack…
110
each other”), forms of life that must be treated from a position of inclusion (medical
and psychiatric), and that treats them with dignity and respect for their rights.
When we talk about a way of life, we are thinking about the idea of a biopolitics
for life like that of Roberto Esposito, a biopolitics that, rather than dening how life
should be, contributes to the proliferation of ways of life, that promotes human
diversity and confers dignity on divergences, even on those ways of life that are sup-
posedly deviant. In this way, we assume that substance use must be understood from
the dichotomy of its pharmakon etymology. That is, it entails the double meanings
of relief and damage, cure and death, pain and pleasure. Thinking about substance
use with the idea that there is a right to pleasure would allow effective treatments
that avoid death and violence.
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113© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
T. Mota Ronzani (ed.), Social Stigma and Drug Use,
https://doi.org/10.1007/978-3-031-94813-8_9
Chapter 9
Stigma, Discrimination, andSubstance
Use: AnIntersectionality-Based Approach
JazmínMora-Rios, MarcelaTiburcio, andAdánAranda
9.1 Introduction
The aim of this study is to draw on the theoretical approach based on intersectional-
ity to achieve a greater understanding of the complexity of addiction in low- and
middle-income regions. Mexico, like Latin American countries such as Brazil,
Colombia, Argentina, and Peru, is characterized by deep social inequalities. To this
end, we provide a review of the research that has adopted intersectionality in the
approach to addiction and refer to our own research ndings as part of a previously
published mixed methods study (Mora-Rios etal., 2017) on stigma and discrimina-
tion in different groups (users, relatives, health personnel, and the general popula-
tion). For the purposes of this study, we refer only to persons with lived experience
in addiction, as well as health personnel working in this eld.
Addictions are a growing problem globally and have increased the global burden
of mental and addictive disorders associated with high levels of mortality and
chronic disease. It is estimated that around 284 million people aged 15–64 used
drugs worldwide in 2020, a 26% increase over the previous decade (UNODC, 2022).
J. Mora-Rios (*)
Direction of Epidemiological and Psychosocial Research. Ramón de la Fuente Muñiz
National Institute of Psychiatry, Mexico City, Mexico
e-mail: morarj@inprf.gob.mx
M. Tiburcio
Department of Social Sciences in Health, Ramón de la Fuente Muñiz National Institute of
Psychiatry, Mexico City, Mexico
e-mail: tibsam@inprf.gob.mx
A. Aranda
Faculty of Psychology, National Autonomous University of Mexico, UNAM,
Mexico City, Mexico
114
The stigma associated with substance use interferes with the timely search for
care. Kohn etal. (2018) revealed that the gap for the treatment of substance use
disorders is greater in Latin America (83.7%) than in North America (69.1%).
Moreover, it is possible that in low-and middle-income countries, the magnitude of
this problem is underestimated due to the limited research on stigma (Rehm &
Shields, 2019).
Stigma is a concept proposed by sociologist Erving Goffman (1963) to designate
the social rejection a person experiences because of a condition that discredits them
socially. The process of stigmatization, according to sociologists Link and Phelan
(2001), has to do with an asymmetric power process from which an anomalous
identity is constructed from the interaction between stigmatizers and stigmatized.
This process includes labeling, attributing beliefs and assigning stereotypes, and a
separation between subjects into “them” versus “us,” which implies a loss of status
of the stigmatized subject and can contribute to discrimination. For the purposes of
this analysis, we consider the denition of stigma proposed by Medina-Perucha
etal. (2019): the “social process that involves the segregation of groups and social
individuals based on socially valued attributes, and that result in inequities based on
social, political, or economic power” (p.316).
Research on stigma and addiction has gained great interest in recent years
(Commission on Narcotic Drugs, 2022; UNODC, 2022). In a comprehensive review,
Yang et al. (2017) identied 2,386 articles on stigma and addiction published
through August 2016, originating from the United States and various European
countries, including the United Kingdom. However, despite advances in the eld,
myths and stereotypes persist related to irresponsibility, lack of control, and crimi-
nality attributed to people who use substances. These are deeply rooted in the gen-
eral population and are expressed in fear, rejection, avoidance, denial of rights,
discrimination, loss of opportunities and timely access to adequate care, which has
additional negative effects on the stigmatized person, limiting their activities and
restricting their participation in social life.
This persistence was shown in one study that was carried out in different
European countries in the 1990s and 2020s, which found that stigmatizing attitudes
toward people who use substances continued to predominate (Kilian etal., 2021). In
Latin America, addiction tends to generate greater social rejection from the general
population than other mental health-related problems, as has been documented in
countries such as Brazil, Chile, and Mexico (Mora-Rios et al., 2017; Sapag
etal., 2022).
In Mexico, data generated in national surveys on substance use identied an
increase in the negative attitudes of the general population toward those who used
drugs in 2016 than in those who used them in 2011 (Bustos-Gamiño etal., 2022).
There was an estimated 26% increase in substance use in 2010–20, mainly of can-
nabis and amphetamines, with only one in 11 users requiring treatment. Of those
who seek treatment, it is estimated that 85% are men. The average age of onset of
use of any psychoactive substance is 13.6years, and there is an approximate delay
of 11.5years from the beginning of experimentation to seeking help related to use
(CONADIC, 2021).
J. Mora-Rios et al.
115
Within this complex reality, the social stigma faced by people with substance use
disorders intersects with other manifestations of discrimination and inequality. This
stigma, seen from the perspective of intersectionality, could reveal patterns of exclu-
sion and discrimination that are essential to understand and address the problem.
9.2 Concept ofIntersectionality
Intersectionality has a long history, but it has been popularized by the work of
Crenshaw (1989). Its origins come from Black feminist thought and the activism of
women of color. Hankivsky (2012) took up the concept to account for its scope in
understanding different social phenomena, as it allows for the analysis of the simul-
taneous interaction of various social factors at different levels.
Intersectionality is an analytical tool that refers to the interconnection of socio-
political categories that contribute to discrimination in different areas, including
ethnicity, gender, migration status, social class, and age. These categories overlap
and generate a synergistic effect. For Grzanka (2020), intersectionality “is the study
and critique of how multiple social systems intersect in producing and sustaining
complex inequities” (p.453), with an emphasis on the role of justice. In this sense,
the approach is useful for addressing addiction, as it is a public health problem
closely linked to processes of globalization, with production and marketing net-
works at a global level, that involve other social determinants based on social
inequality, power structures, and gender, as well as ideological, political, and cul-
tural aspects of drugs.
From the perspective of intersectionality, it is essential to include structural and
institutional discrimination in the analysis, which refers to the set of norms, poli-
cies, and procedures of public and private entities that deliberately restrict the rights
and opportunities of people with mental disorders, legitimize power differences,
and reproduce inequities and social exclusion (Link & Phelan, 2001). It is also vital
to include the dimension of power. Mental health care has been marginalized from
public policy and is reproduced in institutions, including health care institutions. An
example of this marginalization is the lack of resources and care strategies allocated
to the care for people with mental health problems and addictions. According to
national and international estimates, resources for mental health, in addition to
being insufcient, are distributed inequitably and are used inefciently; despite the
availability of treatments, only a minority of people with substance use problems
receive attention.
In an interesting review of these topics, Meyers etal. (2021) argue that intersec-
tional stigma is multidimensional, as it involves various forms of oppression, includ-
ing racism, xenophobia, and stigmatization of substance use. It is also multilevel, as
it operates on individual, interpersonal, and community levels, and it is multidirec-
tional, because it involves reciprocal inuence among these levels. This approach
allows for the highlighting of qualitative differences within the stigmatized group at
the interpersonal level that generate unique experiences. The relational
9 Stigma, Discrimination, andSubstance Use: AnIntersectionality-Based Approach