Regimes of Drug Desires: Depot Buprenorphine as a Technology of Becoming

Abstract

Long-acting injectable depot buprenorphine is the latest opioid agonist therapy to be offered in Australia. There has been increasing scholarly interest in the lived experience of this treatment; however, the current qualitative research on this issue is limited to reports on the benefits and challenges individuals experience during treatment. This study expands and complicates this body of work by delving into the social, affective, and material aspects of the depot buprenorphine experience. By applying a Deleuzo-Guattarian framework to the analysis of 40 semistructured, open-ended interviews conducted with individuals who were either currently receiving depot buprenorphine, were in the process of discontinuing, or had discontinued treatment, we argue that depot buprenorphine is a technology of becoming situated within regimes of desire. That is, depot buprenorphine is a catalyst of social, affective, and material changes that is realized and dwells within a set of cocreated assemblages comprised of human and other-than-human actors. According to the regimes of desire at work within these assemblages, individuals in treatment pass through a series of thresholds that mark their becoming into different kinds of persons. Four critical thresholds emerged in participants’ reports of depot buprenorphine: thresholds of geography, freedom, the body, and abstinence. These thresholds opened up radical new ways of being for participants, with some being more positive than others. We close by discussing the implications our findings have for the ongoing delivery of opioid agonist therapies in Australia and elsewhere.

Introduction

This is an article on the joys and troubles individuals encounter while undertaking an opioid agonist therapy (OAT) called depot buprenorphine. However, it is much more than a report on what the experience of this treatment entails. In the surfeit of qualitative research into OAT, there is a surprising lack of analysis of the emotional, embodied, material, and affective complexities of the OAT experience. Little attention has been paid to how these aspects emerge within a wider cast of social contexts and processes. This narrow focus omits much of the felt immediacy of OAT, limiting the kinds of insights needed to inform a truly holistic model of care. This article seeks to develop these insights by exploring the myriad forces that encompass the depot buprenorphine experience. To do this, we turn to the works of Gilles Deleuze and Félix Guattari to draw a map of the depot buprenorphine experience and trace the sprawling elements that come together to create this experience. By understanding more of the social, affective, and material forces at work within this treatment modality, we identify how these forces participate in the expression of an “assemblage of health” (Duff, 2014, 2023) and what new models of care are required to sustain this assemblage. We can trace the affects, events, and encounters expressive of “becoming-well” in a given OAT treatment experience by mapping the “abstract machine” that organizes this assemblage (see Buchanan, 2021).

Deleuze and Guattari are well-suited for this job because becoming and the immanence of social reality are the cornerstones of their transcendental empiricist philosophy (Bryant, 2008; Deleuze, [1968] 2001; Rölli, [2003] 2016). They push us to look at life as a constantly expanding and contracting arrangement of “rhizomatic” connections. For Deleuze and Guattari, our experience of reality is a confluence of emotions, interpersonal interactions, social structures, cultural beliefs, sensations, and material/physical encounters (Deleuze & Guattari, [1972] 2013, [1980] 2013). This commitment to an immanent social ontology (Coleman & Ringrose, 2013) provides a useful mode of thinking in the context of OAT because it sheds light on the broader sociocultural dimensions of substance use treatment and the issues people experience in treatment. It also allows us to see how seemingly remote or unrelated dynamics/experiences directly impact a person's ability to achieve their treatment goals. We apply Deleuze and Guattari's concepts of becoming, thresholds, and desire to our participants’ experiences to show that depot buprenorphine is a technology of becoming that is put to work within distinctive regimes of desire (see also Malins, 2017). Expressed differently, depot buprenorphine is a catalyst of change that is used in active and passive ways, and this process of change sits within a complicated system of social forces and dynamics.

This article adds to the growing body of research on depot buprenorphine by expanding our understanding of the ways people who use drugs experience intersectional marginalization, such as the intersection of financial hardship, stigma, mental illness, and institutional violence. It uses a unique lens to understand the complexities of OAT and sheds more light on the OAT “journey.” It also gives insight into processes of well-being as they unfold during OAT and how individuals enact or express this well-being according to particular events, affects, desires, and encounters within a broader treatment assemblage (see also Duff, 2014). Additionally, the findings help to elucidate what an effective/positive OAT treatment outcome looks like for individuals, how they go about achieving this outcome, and why particular outcomes may be regarded as desirable in the context of “effective” treatment. By thinking about OAT as a particular force or “machine” within an individual's process of organizing, expressing, and/or embodying a unique assemblage of health, we can begin to map the novel connections between the elements within this assemblage. This mapping is necessary for tracing more holistic models of care for people seeking to access health and social support in Australia. In advancing this work of mapping, our article contributes to recent critical accounts of treatment programs and initiatives that, like us, seek to identify a broader cast of human and nonhuman forces and entities at work within the treatment assemblage (see Barnett et al., 2024; Farrugia et al., 2019; Fomiatti et al., 2017; Sultan & Duff, 2022; Theodoropoulou et al., 2022).

What Is Depot Buprenorphine?

Depot buprenorphine is the most recent addition to the current suite of opioid dependence treatments available in Australia. It is an injectable form of buprenorphine available in weekly and monthly formulations. This treatment has a range of unique benefits. Dropping dosing intervals to once a week/month reduces the administrative burden on healthcare providers and frees consumers from the hindrances of daily dosing. It makes for a more practical treatment option for consumers who live outside metropolitan centers (Lofwall & Fanucchi, 2021). It is naturally resistant to diversion because of its injectable formulation, which makes it an attractive treatment option for clinicians. Studies have found that individuals receiving depot buprenorphine are more likely to maintain abstinence, gain employment, have reduced contact with the criminal justice system, and experience an overall improvement in quality of life. These studies also show that depot buprenorphine facilitates greater treatment retention/engagement and reduces instances of drug-related hospitalizations (Martin et al., 2022; Parsons et al., 2020).

There is a substantial amount of qualitative research on the consumer experience of depot buprenorphine treatment (Allen et al., 2023; Cheng et al., 2022; Clay et al., 2023; Matheson et al., 2022; Neale et al., 2023a; Parkin et al., 2023; Scurti et al., 2023; Wyse et al., 2024). The majority of these studies describe a similar set of benefits and drawbacks. Individuals often report a marked improvement in quality of life because they can socialize more, hold down a steady job, and have more spare time for leisure activities. They also gain a greater sense of stability and agency and can rekindle connections with family and friends (Barnett et al., 2021; Scurti et al., 2023). Relevant to our interests in the present paper, Lancaster and her colleagues (2023) found that depot buprenorphine has a profound impact on the way individuals experience time. The change from daily to weekly/monthly dosing dilates time, producing a radical sense of potential and liberation. The reduced contact with pharmacies and clinics means that individuals can evade the stigma of drug use and regain a sense of normalcy (Johnson et al., 2022, Neale, McDonald et al., 2018; Neale, Tompkins et al., 2019). Depot buprenorphine is cheaper than other forms of OAT because individuals are only paying dispensing fees once a week/month instead of daily (Barnett et al., 2021).

There are other financial benefits too. The reduced travel saves both time and money, gaining stable employment brings in regular income, and money that would otherwise be spent on drugs is diverted to food, rent, etc. Some studies show that depot buprenorphine is particularly effective at reducing relapse because it works on both a social and pharmacological level. As an agonist, it helps to prevent cravings and withdrawal symptoms, but because individuals are not visiting dosing centers every day, they are less likely to come into contact with old dealers and friends/acquaintances they used to take drugs with (Johnson et al., 2022; Neale, Parkin et al., 2024; Neale, Tompkins et al., 2019). Depot buprenorphine is not without its drawbacks. Many individuals find the initial (and sometimes ongoing) adverse side effects difficult to manage, leading some to discontinue treatment early (Clay et al., 2023; Neale et al., 2023a; Wyse et al., 2024). Despite the social freedoms depot buprenorphine affords, some find that it curtails choice and agency. The depot cannot be extracted once administered, so the recipient must wait until it has dissolved if they wish to pursue another type of OAT. This inability to deftly switch from depot buprenorphine to another form of OAT can lead some to feel like they are being “held hostage” by the “substance under [their] skin” and are not in control of their health or body (Neale et al., 2018, p. 4). Furthermore, the long-acting formulation combined with buprenorphine's blockade effect means that individuals do not have the option to sporadically/spontaneously use opioids (Neale, McDonald et al., 2018; Neale, Tompkins et al., 2019). This is a problem raised by both prospective recipients of depot buprenorphine and those who have received this treatment. It is more than a moral concern/objection too (i.e., individuals should have the right to use substances while on treatment if they wish). The crux of the issue is that many individuals with a long history of substance use find “straight” life (sobriety) “boring,” and consuming opioids allows them to feel “human” and “alive” (Neale et al., 2018). Other studies describe how some participants rely on the emotional “numbing” effect of methadone or heroin to get through the day due to the ongoing presence of trauma and hardship in their lives (Matheson et al., 2022). So, depriving individuals of the option to use opioids during treatment can have considerable consequences for quality of life. Diversion represents a valuable source of income for those experiencing financial hardship, thus moving to depot buprenorphine can negatively impact a person's livelihood. However, the combined social and personal benefits that come with this treatment, such as relief from cravings, gaining a new sense of stability, and not spending money on opioids, can sometimes outweigh the financial hit (Johnson et al., 2024). It is not uncommon to hear stories of individuals feeling coerced by clinicians into starting depot buprenorphine because clinicians perceive it to be a superior form of OAT (Clay et al., 2023; Johnson et al., 2022). The reduced contact with clinics and pharmacies can increase social isolation, and the closure of daily interactions with healthcare workers can eliminate an important source of emotional and social support (Allen et al., 2023; Barnett et al., 2021; Neale, McDonald et al., 2018; Neale, Tompkins et al., 2019).

Deleuze and Guattari on the (Treatment) Assemblage

The above research shows some of the complexities and contradictions that attend depot buprenorphine treatment. The reduced contact with clinics can make someone feel both liberated and socially isolated; not being able to feel the full effects of opioids can liberate one from the temptation to use these substances whilst also curtailing their agency around deciding if and when they want to use; and the reduced expenses from receiving weekly/monthly dosing can enhance financial well-being yet erase a vital source of income. These studies also highlight how the treatment experience encompasses much more than interactions with healthcare workers, visits to clinics and pharmacies, and pharmacology. OAT involves the congregation of feeling bodies in clinics and other medical spaces that carry a freight of meanings. As Lancaster et al. (2023) have shown, OAT dilates and contracts time in ways that shift a person's understanding of themselves in relation to others.

While we draw from much of this existing literature in our analysis below, we also seek to develop a conceptual approach more sensitive to the cast of human and other-than-human forces, entities, processes, and actors at work in the OAT experience. Below is an overview of the key concepts we use in this paper to achieve this goal, namely: becoming, health/recovery assemblages, and desire. These ideas are entangled with each other and cannot be fully understood in isolation; they must be taken together. Examining them in concert helps to clarify the conceptual contours of a treatment assemblage that generates lines of health and recovery (see Duff, 2014; Theodoropoulou, 2023; Sultan, 2022).

In briefly characterizing this conceptual and analytical figure, we will emphasise Deleuze and Guattari's concept of becoming as a way of fleshing out our discussion of drugs, desire, and pleasure. The convergence of forces is the thread that connects these concepts within an assemblage. Briefly put, assemblages express the sociocultural and material dynamics that allow for events and experiences to occur. Deleuze and Guattari describe this emergent process as “becoming,” or an eternal unfolding of the new. Desire is both the product of becoming and the force that drives it. Deleuzo-Guattarian desire is a productive force that governs the structure of assemblages and is generated through becoming. That is, desire precedes assemblages and becoming and is also created by them. In the next three sections, we elaborate on aspects of our conceptual framework before showing how these concepts informed our research design, methods, and data analysis.

Health Assemblages and Posthuman Drug Use

There is a growing literature on the social life of drugs that combines Deleuze and Guattari's work with posthumanism (Dennis, 2016, 2017; Duff, 2013; Malins, 2004a, 2004b, 2017; O’Byrne & Holmes, 2011; Rhodes et al., 2019). This body of work has created a radical new way of understanding the social significance of drug use, recovery, and treatment. Dennis (2017) proposes that drug consumption is an “event” that emerges when various human and other-than-human actors interact, transforming bodies and allowing for queer subjectivities to materialize. These ephemeral and fragile events appear in insistingly unique ways and are shaped by the dynamic forces expressed within them. Conceptualizing drug use as an event brings attention to the way bodies, substances, feelings, environments, culture, subjectivity, and meaning coalesce to produce the drug use and recovery or treatment experience (Alexandrescu, 2017; Poulsen, 2015; valentine, 2007).

Drug events are central to work on health assemblages (see Duff, 2014). This approach offers a useful way of thinking about health and illness within the key conceptual logics common to much of this recent critical and posthumanist work. Duff (2014) conceptualizes health as an ongoing process of becoming comprised of sociocultural and material assemblages that advances an individual's power to act. Illness, on the other hand, occurs when the body becomes fragmented as relations between its constituent parts are disrupted in ways that undermine particular activities or capacities. These disruptions “overcode” and reterritorialize the body and turn it into something other: the mad body, the sick body, the broken body. A health assemblage is the arrangement of converging forces and actors that produce certain health-related subjectivities.

Approaching substance use as a “drug-body-world entanglement” (Dennis, 2016) or health assemblage holds promise for improving health outcomes and support services for people experiencing problematic substance use. Traditional recovery narratives position addiction as a moral failing where the individual has lost control of their behavior and is no longer a functional member of society. The addict can only begin their recovery “journey” once they admit they have lost control of their life and are prepared to work towards regaining it (Brookfield et al., 2023). The individual must become a willing, passive, and disciplined subject in such recovery tropes. This understanding of recovery is individualistic and views recovery as a linear progression the individual is responsible for achieving. Moreover, it pathologizes “harmful” substance use as a neuropsychiatric disease (Frank & Nagel, 2017).

If the normative recovery narrative is flawed because of an overly moralizing and individualistic logic (see Theodoropoulou et al., 2022), how should we think about treatment? Posthumanism offers an alternative conceptual framing for understanding the experience of bodies within treatment settings. A posthuman model of care involves decentering the individual and focusing more on the social, affective, and material aspects of health and illness (Fox & Alldred, 2022). It promotes a dynamic treatment model that does not rely on the moral imperative to “attain” abstinence but instead highlights the need to take into account how social networks, living conditions, geography, personal desires, and social structures influence health outcomes (Brookfield et al., 2023). That is, recovery is an ongoing and fluctuating process, not a straight journey from A to B. Recovery and treatment processes ought to be understood as a dynamic assemblage of human and other-than-human actors and forces (Theodoropoulou, 2023).

In her book on recovery assemblages, Sultan (2022) proposes a similar theory of health to those advanced by Dennis (2016), Duff (2014), Theodoropoulou (2023), and others. She suggests that we need to think critically about recovery in ways that go beyond the immediate and the material. It is often assumed that everyone understands “recovery” in the same way (i.e., one becomes a “new” person by “achieving” and maintaining abstinence). However, Sultan writes that recovery is “created through continuous motions of relations, transformations, and mediations” (2022, p. 201). It involves the insistent reproduction of overlapping subjectivities that gradually replace one another through practices related to the body and health.

Discussions on recovery focus heavily on abstinence, with the underlying assumption that this term has a stable and consistent meaning, yet this is not true. Among people who use drugs, abstinence can mean: not using their drug of dependence but continuing to use other illicit substances; taking a hiatus from their drug of dependence until they regain stability in their life; abstaining from illicit substances only (i.e., continuing to consume alcohol, tobacco, and caffeine); or no longer consuming any and all substances, including OAT and other pharmaceuticals drugs that can cause dependence (Neale et al., 2011). With no agreed-upon definition of abstinence or recovery, and a growing acknowledgement that these terms refer to complicated and constantly changing processes, it can be difficult to navigate discussions on these topics, particularly for healthcare workers and service providers in the drug support field.

The works of the authors cited above strongly suggest that health and treatment outcomes can be improved by viewing treatment modalities like OAT as a collection of constantly unfolding elements, forces, and bodies that may be “tinkered” with (Lancaster et al. (2024) as an assemblage of health (Duff, 2023). This Deleuzo–Guattarian posthuman paradigm of treatment assemblages helps to elucidate what is often latent in the existing depot buprenorphine literature. It shows how OAT is a composite of many social systems that come together in intricate ways. We build on these research leads and employ a Deleuzo–Guattarian framework to draw attention to the different social, affective, and material dimensions of OAT treatment and identify how the depot buprenorphine experience might become more effective for individuals in treatment according to their unique needs, aspirations, and desires.

Thresholds of Becoming

One of the key implications our work has for the literature reviewed thus far is that depot buprenorphine should be regarded as a technology of becoming, but what does this mean? How might the idea of becoming advance our goal of creating more effective treatment? What even is “becoming” and how does one get there? Deleuze and Guattari write about becoming in a plethora of ways, though it can be broadly described as the making and unmaking of subjectivity. Becoming takes us into unfamiliar territory and is therefore beyond recognition. It is an entirely new way of experiencing and understanding the world. Certain aspects of our subjectivity are sloughed away and new components emerge. Becoming defines and disturbs the borders of experience and meaning, and can be a swift yet imperceptibly slow process. Deleuze and Guattari ([1980] 2013) describe how perceptions of movement bookend becoming: “movement in itself continues to occur elsewhere … the movement always takes place above the maximum threshold and below the minimum threshold, in expanding or contracting intervals” (italics in original, p. 327). Lawlor (2008) uses aging as an example of becoming. Aging is experienced as a series of invisible changes or “micrological cracks” that are suddenly noticed, and then everything feels different. You look in the mirror one day and see a set of eyes haloed with crow's feet; you hit 50 and realize the career you pursued with such vigor leaves a hollow feeling in your chest; the existential anxieties that riddled your early adulthood now seem trivial. The subject is destroyed and made anew. Lines of becoming lead the subject to wander about and stumble over thresholds. The notion of thresholds appears across much of Deleuze's work and refers to the process of deterritorialization and desubjectification (Deleuze & Guattari, [1972] 2013, [1980] 2013). To cross a threshold is “to find a world of pure intensities where all forms come undone” and enter a state of becoming (Deleuze & Guattari, [1975] 1986, p. 13). They are the junctures at which becoming occurs.

Many scholars have engaged the concept of becoming to facilitate a better understanding of the OAT and drug use experience. Rhodes and his colleagues (2019) describe the “becoming-methadone-body,” or the fluid way methadone treatment subjectifies individuals and transforms them into different types of people with different levels of agency. Methadone consumers become powerless subjects through stigma and state governance; they become other and less-than-human. Undertaking methadone treatment also brings about a shift in the experiences and meanings behind being an “addict.” Others have written about OAT along similar lines. The OAT experience produces various types of becoming that alter the subject and create a new way of experiencing the world (Dennis, 2019; Rhodes, 2018; Theodoropoulou, 2023).

There is an intrinsic connection between assemblages and becoming. Assemblages are a confluence of productive forces and dynamics that create something new. This generative process opens the way for becoming to occur. It is the immediate and distant sociocultural, affective, and material conditions of an assemblage that shape how becoming can/will emerge. Becoming cannot be fully understood unless the preceding assemblage which produced it is examined.

Drugs, Desire, and Pleasure

Pleasure and desire are important concepts when discussing drug use. Ironically perhaps given how productive their thinking has been for so many scholars interested in drugs, Deleuze and Guattari were often critical of drug use. They felt that it was antiproductive and anathema to becoming: drug use results in dependence and forecloses the potential for desiring-production. To use drugs is to reterritorialize the body in negative ways. They bend the body out of shape and draw the subject into a spiral of abject nothingness (Deleuze & Guattari [1980] 2013). However, Deleuze and Guattari also acknowledged the transformative potential of substance use and the ways drugs can reconfigure the body and profoundly transform one's relationship with the world. Drugs shift our capacity for sensation and perception and dissolve the rational, autonomous self (Deleuze & Guattari [1980] 2013). Substance use is a both/and situation: drugs create “active lines of flight” that lead to new heights of perception and they create abject “black holes” of “false perceptions, fantasies, [and] waves of paranoia” (Deleuze, 2006, p. 153). Drugs are not stable material entities but expressive events capable of tracing diverse lines of becoming (Dennis, 2017).

Following some of these lines, there has been a “pleasure turn” in recent critical drug studies (Dennis & Farrugia, 2017; Malins, 2017; Race, 2017, Ritter, 2014, Zajdow, 2010). Race (2017) encourages scholars to “think with pleasure” when analyzing the social life of drugs and the sociopolitical significance of substance use. This approach involves thinking with different ways of experiencing substance use rather than thinking about them; it is about using personal experience and feeling as analytic tools and not viewing pleasure as a representational object. Malins (2017) takes an alternative stance and suggests that Deleuzo–Guattarian desire is a more fruitful mode of inquiry. She writes that “drugs can be used to compile desiring machines—or assemblages—that “molecularize” perception, shifting it away from whole or “molar”forms (discrete subjects, static categories, and identities) and toward a “molecularity” of part objects or haecceities (fragments, colors, sounds, smells and textures, movements and flows)” (2017, p. 129).

We expand this line of thinking by arguing that depot buprenorphine is a technology of becoming situated within regimes of desire. Here, we employ the Deleuzo–Guattarian form of desire which conceptualizes it as a productive force and rather than a form of lack or negation. Malins (2017) highlights the generative force of desire in her argument for using desire over pleasure in critical drug studies. For Deleuze and Guattari, desire is the collection of affective and material forces that produce social reality; it is the connective tissue of assemblages. It has no subject or object but is a free-flowing “abstract machine.” Deleuze writes that desire opposes structure and is a “field of immanence or a body-without-organs which is only defined by zones of intensity, thresholds, degrees and fluxes” (2006, p. 130). Social groups use organized forms of desire to come into being. The force of desire brings everything together and propels social reality forward (Gao, 2013). It is presubjective, nonrepresentational, and immanent. This is to say that desire exists before “us”; it ontologically antedates the emergence of the desiring subject. Instead, subjects create social reality by channeling, blocking, and directing forces of desire. Deleuze and Guattari ([1972] 2013) state that desire is organized into regimes. Different machines or flows of desire have particular shapes that intersect and dance with other machines, creating unique organizations of desire.

Malins (2017) writes that “passions” are the affective drives within regimes of desire. These passions are “the visceral ways our bodies gravitate toward, or move away from, desire, as well as the ways they come to experience it” (p. 128). Desire as passion is what we commonly think of as appetitive, intentional desire—the yearning or craving for something. We shape assemblages by manipulating desire with our passions. This allows for certain bodies, feelings, relations, and experiences to emerge. Pleasure is a type of passion for Deleuze and Guattari; it is one of the affective ways that desire is felt in the body. They do not see it as an overly positive force though and state that pleasure interrupts and blocks the potential of desire because it seeks out the familiar and privileges sameness over difference/creation (Deleuze, [1993] 1997; Deleuze & Guattari, [1980] 2013).

As highlighted above, the concept of health/recovery assemblages is a popular one among Deleuzo–Guattarian scholars in the public health and critical drug studies arenas (Duff, 2014, 2023; Ekendahl et al., 2024; Malins, 2004b; Sultan, 2022; Sultan & Duff, 2022; Theodoropoulou, 2023). We have opted to use regimes of desire within our discussion of assemblages because of the multiple meanings embedded in desire. Our theorization of desire includes Deleuzo–Guattarian desire, desire as lack, and desire as passion/pleasure. The regimes of desire we discuss here involve the desire for pleasure and for drugs; the desire for recovery and stability; and the desire to pursue a new way of being, among other things.

But how do assemblages, becoming, and desire relate to depot buprenorphine? As we have outlined above, various assemblages congregate to produce the OAT experience. These assemblages are shaped by the forces of desire and passion. Positing that depot buprenorphine is a technology of becoming situated within regimes of desire is to say that these assemblages are not neutral forces that randomly coalesce. Rather, they are deliberately shaped and provoked to produce particular outcomes. The participant experiences we present below show how individuals used depot buprenorphine in active and passive ways to achieve a desired outcome. These individuals engaged with the social and material forces around them to procure new ways of experiencing the world. Before canvassing our results directly though, we will briefly note how our conceptual interests framed our research design.

Methods

Open-ended, semistructured interviews were carried out with 40 individuals who were either currently receiving depot buprenorphine (n = 21) or had discontinued treatment or were in the process of discontinuing (n = 19). There was a gender split of 26 men, 13 women, and 1 undisclosed. To be eligible for the study, participants must have been 18 years of age or older and had received at least one dose of depot buprenorphine. Interviews were conducted between November 2021 and January 2022. Ethics approval was granted by the University of New South Wales in September of 2021 (ethics approval number: HC210448). Participants were recruited by posting flyers in community-based organizations in Sydney, Melbourne, Adelaide, Perth, Brisbane, and Canberra that support individuals who use drugs. The majority of interviews were conducted over the phone, with the remaining participants opting to have their interview carried out on Zoom. All interviews were audiorecorded and then transcribed verbatim. To ensure confidentiality, any information that could reveal the participant's identity was removed and pseudonyms were assigned. Interviews ran for approximately 45 min and participants were reimbursed $50 for their time.

The data were analyzed on NVivo using an adapted form of Clarke and Braun's (2017) thematic analysis. Thematic analysis involves systematically reading through transcripts to identify key concepts, ideas, and notable experiences. It is an iterative process, meaning that the analysis of each transcript is informed by the previously analyzed transcripts. This process helps to refine the interpretation of the data and deconstruct the underlying meanings within each participant's experiences. We augmented Clarke and Braun's approach using Timmermans and Tavory's (2022) abductive analysis technique. Abductive analysis is a creative third way of doing qualitative data analysis. It is about looking at data with a bricolage of ideas and theories in mind to produce innovative modes of thinking. Abductive analysis aims to defamiliarize the familiar; it is a method of surprise and permutation. It differs from inductive and deductive analysis in that it does not seek to develop a theory from a blank canvas (inductive) nor does it aim to test or generalize an existing theory (deductive). Rather, it is the process of crafting theory in original ways using preexisting and newly invented styles of thinking (Timmermans & Tavory, 2022).

As individual authors and scholars, we have had a long-held fascination with Deleuze and Guattari's work, and, as individuals, their ideas have shaped a great deal of our thinking over the years. Writing now as the first author, Deleuze and Guattari haunted me while I was conducting the interviews and analyzing the data; they appeared in unexpected places and at unexpected times. As I moved deeper into the data, it became clear there was a relationship between depot buprenorphine and becoming. Participants underwent profound transformations after they came into contact with this treatment. There was also a strong undercurrent of desire in their stories—the desire to create a new way of being; the desire to use drugs; the desire for social connection; the desire to be a better person; the desire to feel more embodied. I was insistently reminded of these concepts of desire and becoming during the data analysis process.

This is the second publication to come out of the present study (see Clay et al., 2023). In the time between the first article coming out and the writing of this one, I meditated on how becoming, desire, and assemblages might apply to our participants’ experiences. We then came together as coauthors and continued to play with the concepts of becoming and desire through conversation. Gradually the notion of depot buprenorphine as a technology of becoming situated within regimes of desire formed. We reapproached the data with this new set of ideas in mind and the narrative below slowly took shape.

Results

Massumi ([1992] 1996) writes about how becoming is a system of immanence that emerges at times of crisis and “catapults” the subject into uncharted territories of being. This was the experience of many of our participants. Depot buprenorphine brought them to a crisis point or threshold that pushed them into a novel state of becoming. These thresholds were either sought out, occurred organically, or were imposed upon the participant by clinicians. Four types of thresholds emerged in our analysis: thresholds of geography, freedom, the body, and abstinence. Each of these thresholds represented a turning point, a juncture at which the participant experienced a major change that affected their whole life. They entered a state of becoming and were transformed in some way. These four thresholds contain accounts of particular types of becoming and yield insights into the ordering and/or disordering of an assemblage of health that will be crucial to our closing discussion of effective OAT treatment.

Thresholds of Geography

Becoming-Clean

Thresholds have a spatial dimension; they signify movement from one space to another. Participants spoke about geographies in overlapping ways whereby physical sites were enmeshed with conceptual places in one's life. Sebastian (South Australia, 44) had been on depot buprenorphine for a few months and found it be to an exceptionally effective treatment. As a result, he felt like his addiction was now “a million miles away.” He spoke about how the addiction experience is constituted by—and reified through—attending clinics and pharmacies. That is, addiction is more than a psychophysical dependence. It is a condition that is constantly reinscribed spatially through daily dosing at pharmacies and being around others who are also managing substance dependence (Fraser, 2006).

When you go day to day to the chemist, you know you’ve still got an addiction, but a month out, I just go to the doctor's and get my medication and that's it. It's sort-of like, out of sight, out of mind. And I’m a million miles away; it's the furthest I’ve been away in my life from anything.—Sebastian

Sebastian had been in and out of prison for most of his life, and prisons were a place where drug use was a norm. However, he entered a threshold of becoming-clean when he went to prison last time:

I was clean for three years and had eight years parole at one stage, and [in] the [final] three months [of my parole], I fucking used crack (methamphetamine) for some reason. I gave a dirty urine and went back to jail and was [in there for] a good three months. It cleaned me up and I just said, “Enough. I can’t do this. I’m better than this … I’m not one of these people anymore …” I hold myself in high [enough] regard to not be a low-life junkie, even though I’ve been one at times.

Sebastian's experience of becoming-clean manifests in multiple ways. He situates his substance use and dependence in prison and the pharmacy/clinic, and by no longer being in contact with these sites, his addiction was now “a million miles away.” Prison was also the place where he was provoked into getting “cleaned up.” It became the site where he resolved to become abstinent because of the drug cultures he saw around him, and the restrictive environment facilitated this process. These sites carry a stigma, so becoming-clean was also about shedding the “dirty” identity associated with the “methadone queue” (Fraser, 2006), “junkies,” and prison. Because he did not need daily dosing anymore, depot buprenorphine had allowed him to get “cleaned up,” gain stable employment, and feel like a more responsible person.

Becoming-Unpained

As Sebastian highlighted, clinics are often experienced as sites that reaffirm addiction. People go to clinics to access support for their substance dependence; being in a clinic can stir up cravings; and you can take on the master identity of “addict” or “junkie” simply by being in proximity to a clinic (Anstice et al., 2009). Oscar (Western Australia, 31) lives with multiple chronic pain conditions. He described the difficulty he experienced trying to find effective clinical support for both his pain and opioid dependence. He sought out depot buprenorphine because he believed it would be an effective analgesic, thereby addressing both conditions, but found the weekly dosing appointments an increasingly difficult experience:

I’m still going for these weekly appointments where you just sit around and you’ve got to discuss how your week's been with other addicts. But it was the wrong place for me because I had been reducing my dose and really cutting things out, and then you go and be around these other people and it would just instigate another addiction because you are seeing these people in these states and you are still in pain and then you are seeing them hanging out and on the nod and it's just like, “I’d rather be in that state than a pain state.”

The intense cravings these appointments provoked ultimately led Oscar to discontinue all OAT. While many studies have highlighted the way stigma and drug-related social networks can create challenges for OAT treatment adherence (Anstice et al., 2009; Fraser, 2006; Johnson et al., 2022; Neale, Parkin et al., 2024; Neale, Tompkins et al., 2019), discontinuing treatment because of cravings triggered by clinic attendance does not appear in the literature on depot buprenorphine. These site-induced cravings also prompted Oscar to wean himself off his other pain medications. He had become so disillusioned with Western medicine that he decided to use Ayurveda to manage his chronic pain and opioid cravings instead and found this to be an effective treatment model because of its holistic philosophy. Discontinuing depot buprenorphine had led Oscar to becoming-unpained through pursuing a different avenue of medicine to better manage his chronic pain and avoid the troubling experience of clinic attendance.

The interaction/intersection of depot buprenorphine and place produced thresholds of becoming for Oscar and Sebastian. Others have noted similar interactions between place and substance use (Dilkes-Frayne et al., 2017; Treloar et al., 2022). Scholars in the health geographies field have written about this phenomenon—the myriad ways that space and place influence our health and well-being. They show how geography is not a neutral, physical landscape: it is a topography of sociocultural and affective dynamics whereby the social, affective, and material properties of a given environment modulate capacities to pursue well-being (Gatrell & Elliott, 2015; Hanlon, 2014). Health geographies have thus contributed to cognate efforts to conceptualize health assemblages, often by elaborating upon the ways space and place are organized within assemblages (see Andrews & Duff, 2019). Consistent with this literature, Oscar and Sebastian's experiences show how desire and the substance of becoming emerge from and interact with assemblages of place, and that these topographical assemblages are directly related to the efficacy and experience of OAT.

Thresholds of Freedom

Several participants spoke about feeling a new sense of freedom and liberation after starting depot buprenorphine. They gained a new lease on life and felt revitalized in ways they had not thought possible when they were receiving other forms of OAT. This is a well-documented experience in the literature on depot buprenorphine (Johnson et al., 2022; Neale et al., 2023a; Parkin et al., 2023). Participants spoke about starting depot buprenorphine as a kind of revelatory experience: after the first dose, their cravings subsided, they could pursue new endeavors, and a whole new world opened up for them.

Becoming-Free

Paul (SA, 49) was one participant for whom depot buprenorphine had completely changed his life and created a sense of becoming-free:

It changed my life completely: not using drugs; waking up and never feeling sick; never having to be concerned of not being able to do anything or go anywhere; [being able to] travel; [not] always having to worry about [going to the] chemist [tomorrow]. “Can I get a takeaway [dose]? Can I do this? I can’t go because I have to go to the chemist tomorrow …” I mean, thousands of things … Just that feeling of freedom of being able to make decisions without being concerned that if I don’t get to the chemist tomorrow, I am going to be sick as hell.

Depot buprenorphine freed Paul from the pragmatic burden of needing to visit the pharmacy every day. But more importantly, it liberated him from the omnipresent threat and onset of withdrawal symptoms. He now had the freedom to do “thousands of things,” go anywhere, and do anything.

Becoming-Liberated

Arthur (New South Wales, 55) had a similar experience to Paul. He spoke about how depot buprenorphine had created space for him to grow in exciting and unforeseen ways:

[It's been] liberating … I have been on methadone, I have been on Suboxone, I have been on Subutex. [These treatments] all involved daily dosing at a clinic or a chemist, and now that I go in once a month, it's [been] liberating. I am not bound by timetables with chemists. I have got the freedom to travel, I have got the freedom to go to uni. I have got the freedom to volunteer in certain things I am interested in. I am very much interested in drug law reform. I have [put] all my energy into many other things … I can forget that I am in treatment for opioid addiction, forget it to a degree where I am not reminded on a daily basis because I am not going to the chemist or I am not going to a clinic.

The liberation that Arthur experienced goes beyond the ability to pursue tertiary education, go traveling, and engage in volunteer work. He had been liberated from the burdens of daily dosing and had been relieved of the stigmatizing identity of someone who is in treatment for opioid dependence. Arthur was channeling this newfound freedom and vitality to fight for social liberation: Arthur was becoming-liberated. The freedom Paul and Arthur described also resonates with Sebastian's experience around addiction being enacted and reinforced through pharmacy attendance and daily dosing.

Desire produces the real, and “within the real everything is possible, everything becomes possible” (Deleuze & Guattari, [1972] 2013, p. 40). The unique regime of desire that emerged after Paul and Arthur received depot buprenorphine opened up unforeseen realms of possibility that continued to unfold into new territories. They felt like they had their “real” lives back. Paul and Arthur's experiences are also an example of how becoming affects movement. Deleuze and Guattari point out how becoming is sandwiched between high and low velocities. Life sped up for Paul and Arthur once they started depot buprenorphine. They were no longer mired in the cycle of daily dosing and became free to pursue new goals. This speeding up was created through a slowing down of dosing, reduced contact with pharmacies and clinics, and a moving away from the specter of OAT.

Thresholds of the Body

Becoming-Straight

The participant experiences presented so far position becoming as a positive event that expands possibility and enhances one's quality of life. However, this was not always the case. Deleuze and Guattari ([1980] 2013) state that becoming cannot be placed into any one category as it is beyond experience and representation. It is a kind of immanence that creates new territory and expands the limits of feeling. Beth (NSW, 51) experienced this expansion of feeling in less than desirable ways after she received her first dose of depot buprenorphine:

I had it and the next day I woke up and I felt like I’d hit a wall of straightness at 200 miles an hour. Like, I was flinching; everything was so real. I was ultra-sensitive, that's the best way I can describe it. It's like driving your car at 200 clicks and hitting a brick wall and feeling it … Having that needle was just horrible, it was disgusting and I couldn’t get over that feeling … [My body] really grabbed hold of it. I was so scared.

The onset of unpleasant and unmanageable adverse side effects is one of the leading reasons why individuals decide to discontinue depot buprenorphine (Clay et al., 2023; Wyse et al., 2024). Nettleton et al. (2011) detail something similar to Beth's experience in their embodied analysis of recovering heroin users. Using the “dys-appearing body” as a theoretical lens, they describe how their participants experienced withdrawal as a “seizing” of the body: their bodies were demanding attention in disturbing and troubling ways. Beth felt her body “grabbing hold” of the depot buprenorphine, causing it to speed up and crash into “a wall of straightness.” Depot buprenorphine had created a disruptive line of flight that led to Beth becoming-straight.

Desiring-machines “continually break down” and “run only when they are not functioning properly” (Deleuze & Guattari, [1972] 2013, p. 45). Beth's account is an example of how this machinic breakdown can be experienced. Her body was no longer functioning in “normal” ways, and this altered state produced a radically new (albeit unpleasant) way of experiencing the world. Beth's description expands upon the relationship between becoming and movement too. Deleuze and Guattari note that “all drugs fundamentally concern speed, and modifications of speed … the mad speeds of drugs and the extraordinary posthigh slownesses” ([1980] 2013, p. 329–330). Depot buprenorphine sped up Beth's body, but the “disgusting” feeling from “having that needle” slowed time down to a painful crawl. This collision of velocities is part of the reason why Beth had had such a poor experience with this treatment: the embodied experience of time no longer made sense (a finding reminiscent of Lancaster et al.'s (2023) study described above), and the medication embedded beneath her skin altered her body in ways that produced a profound sense of disembodiment. As Williams (1998) puts it, “the body in pain emerges as an estranged, alien, ‘thing-like’ presence, separate from the self” (p. 61).

Becoming-Normal

Not all participants experienced the negative side effects that Beth had. Many felt a wonderful new clarity and sense of embodiment after their first dose of depot buprenorphine. This was often spoken about in terms of “feeling normal” again:

I wake up and am not even sick … It's amazing … I feel better than normal, I can’t explain it. I feel sympathy, empathy, caring; I have feelings and emotions. I watch something on TV—if it's emotional, I cry. I haven’t cried in so long it's not funny.—Paul, SA, 49

Drugs alter the body in profound ways. Certain sensations are heightened; the boundaries between other bodies and the environment are thinned; time stretches and contracts; the reflexive experience of ourselves is pushed into unfamiliar territory. Pharmacology produces passional, queer bodies (Dennis, 2020; Florêncio, 2023). The real is comprised of passional regimes of desire that are partially shaped by our drives and past experiences (Deleuze & Guattari, [1980] 2013). Paul's sense of awe at being able to cry and “feel sympathy, empathy, [and] caring” articulates this dynamic. No longer experiencing the emotional numbing effects of opioids and withdrawal sickness, his feeling body became more sensitive to emotion in positive and surprising ways. Depot buprenorphine had opened up an affective threshold that led Paul to enter a state of becoming-normal. The juxtaposition between Paul and Beth's experiences demonstrates the role that embodiment plays in OAT and how successful treatment is contingent upon creating a stronger mind–body connection.

Thresholds of Abstinence

Many individuals seek out depot buprenorphine to help them pursue abstinence (Neale et al., 2023b; Scurti et al., 2023), and this was true for the majority of our participants. While there were some variations as to why they wanted to become abstinent, the underlying motivation was generally the same: they were tired of the drug user lifestyle.

Becoming-Older

Adam (SA, 50) had been receiving OAT on and off for over 30 years. He spoke about how he was becoming-older, and with age came an increasing disinterest in frequent heroin use:

I’ve spent quite a lot of time drug-free—not going out every day scoring and using, you know, heroin or stuff like that. Over the last ten years, I’ve really pulled right up on it, especially [in] the last two years. Before, I might score maybe every couple of weeks or whatever. Now that's become every couple of months, sometimes longer … For me, as I’m getting older, the novelty of [using heroin] is wearing off. I’m just not interested as much anymore, whereas before, I’d use every day, ten times a day. But yeah, things sort-of change as you get a bit older and you get a bit more settled.

Levels of substance use tend to drop with age (Vasilenko et al., 2017). Older users often reduce or moderate their drug consumption over time in response to the cumulative health impacts of long-term, heavy substance use, the user lifestyle becoming less attractive, and a greater desire for life stability (Roe et al., 2010). Adam's experience adds to this research and highlights how changing priorities and reduced pleasure from drug use can play a key role in why older people decide to reduce or discontinue drug use.

Becoming-Carer

Terese (Queensland, 30) was in a similar situation to Adam—the user lifestyle had become untenable and a change was needed:

I have a son who is high-needs … I couldn’t do a withdrawal and look after him, so I decided to do the injection to make things a bit easier … I was just sick of going around in circles. I had been down those paths before (frequent drug use) and I didn’t want to [do it again] and I knew it was wrong while still doing the same thing. Felix is nine now and he is much more of a handful and he requires more [attention] and I just couldn’t give it to him [whilst using regularly]. So, I needed help to actually stop forever.

Terese was contending with multiple needs and desires. She was trying to balance meeting her son's needs with her own. For her, part of being an attentive and supportive mother was finding a form of OAT that allowed her to spend more time with her son, avoid withdrawal, and thwart the temptation to go “down those paths” of drug use again. Prioritizing her son's needs became a type of self-care because it created the impetus for her to break the cycle of recovery/abstinence and relapse. She was confronted with the threshold of needing to change her life to become the mother she wanted to be. This pushed her into becoming-carer—a carer for herself and a carer for her son.

While highlighting the radical possibilities of drug use, Deleuze and Guattari ([1980] 2013) also warn of its dangers, such as dependence, ill health, and personal hardship. Dependence halts the becoming-ness of drug use and creates a “vitrification” of potential and intensities. One becomes stuck and unable to blaze into new territory. Terese and Adam's experiences articulate this well. Both of these participants were tired of the user lifestyle. They were “sick of going around in circles” and used their passional desire for treatment and abstinence to shape the surrounding regimes of desire to create a new future of possibility.

Conclusion

Conceived in terms of regimes of desires and thresholds of becoming, our participants’ experiences help to construct a map of OAT treatment by which assemblages of health and illness are organized according to particular relations, practices, and encounters. Within this analysis, the very image of depot buprenorphine shifts and morphs, appearing first as a familiar pharmacotherapy for opioid dependence, but soon revealing novel thresholds as new subjectivities and ways of being emerge. Considered in terms of lines of desire and becoming, depot buprenorphine may be regarded as a force/tool mobilized within treatment settings to craft new subjectivities of a particular character. These processes are rarely linear and often produce surprising results as lines of desire and becoming converge in an assemblage of health. Sometimes these emergent subjectivities yield opportunities for novel expressions, enhanced capacities, and more freedom, whereas other times they create states of pain and discomfort.

Our participants’ experiences demonstrate how depot buprenorphine is a technology of becoming, not an inert medicine. It is an agentic being that is manipulated in active and passive ways within regimes of desire (Barnett et al., 2024; Neale et al., 2023a). These regimes give rise to novel assemblages, entanglements of place and space, the feeling body, subjectivity, interpersonal dynamics, and social structures. Understanding how these assemblages work according to the forces within them offers some potent new ways of thinking about the methods and goals of substance use treatment and how the efficacy of treatment can be enhanced and made adaptable for the diverse bodies experiencing it.

Conceptualizing depot buprenorphine, and OAT more broadly, as a technology of becoming that sits within regimes of desire represents an important step forward in our pursuit to create better treatment experiences for those seeking to reduce their substance use or stop entirely. It prompts us to consider how far the agentic forces of pharmacotherapy can reach into a person's life, and to think about the hidden and unassuming factors that directly shape their treatment experience. Throughout our analysis, we have identified how the different forces, bodies, and relations can enhance the social, affective, and material capacities of the body in treatment: think of the force of Oscar's experience of “becoming-unpained,” Paul's experience of “becoming-free,” or Adam's experience of “becoming-older.” Within each of these assemblages, within each of these experiences of OAT treatment, we have sought to highlight those forces that create openings for novel experiences of subjectivity according to the regimes of desire that propel the body across a critical threshold of becoming. Another word for this force is care (see Dennis, 2019; Farrugia et al., 2019). Caring for the body in treatment involves the patient work of identifying these thresholds. It speaks to those moments when an assemblage might be made otherwise and tuned to other regimes of desire, such as the desire for freedom, for the absence of pain, and for new modes of sociality. By attending to these moments, this paper adds to an emerging literature within critical drug studies that advocates for an understanding of substance use and treatment as a complicated assemblage of intersecting and overlapping forces that combine in novel ways to express a given assemblage of health or illness (see Fomiatti et al., 2017; Theodoropoulou et al., 2022). These assemblages demand novel regimes of care more responsive to the regimes of desire at work within them and the unique thresholds for becoming they afford.