Staff Interpellation of Drug Testing in Youth Substance Use Treatment: Enactments of a complex Biotechnological Object

Abstract

Drug testing through urinalysis is extensively used in the treatment system for youth substance use, in Sweden and elsewhere. Still, knowledge is scarce on how treatment staff understand the impact of this assessment method on disciplinary roles, work prioritizations, collaboration with other stakeholders, and meeting service users’ needs. This study aimed to examine assumptions about biotechnology, patients and interventions that professionals in Swedish youth treatment draw on to make drug testing meaningful in their clinical work. Twenty interviews were analyzed with a focus on how urinalysis was interpellated as an object by research participants, and on what subject-positions different interpellations enacted. By drawing on a wide range of narrative forms, the professionals interpellated urinalysis as a multiple and fluid object: it both was and was not: necessary, caring, compulsory, intrusive, a truth producer, and a means to determine treatment progress. These interpellations enacted professional-subjects who were both able and unable to break with clinical protocols and external expectations, but always capable of balancing care and control. They also enacted patient-subjects as vessels of information, youth in need, convicted offenders, citizens with rights, minors under paternal control, and untruthful drug users. The study demonstrates the complexity of urinalysis in youth treatment, and that it builds on and advances suspicion and zero-tolerance towards substance use. The deployment of drug testing appears as the least common denominator among diverse stakeholders with differing interests and ambitions in addressing youth substance use problems, and therefore as a stabilizer of a treatment system that could otherwise disintegrate. In staff interpellations, this biotechnology provides legitimacy as being evidence-based, encouraging between-agency collaboration and representing a shared push towards the same goal: drug-free adolescents. We, however, argue that the centrality of urinalysis in this treatment restrains productive discussions about other ways to address youth drug problems.

Introduction

Globally, drug testing appears in many parts of society, such as in legal systems, sports, schools, workplaces, social services, and healthcare (Campbell, 2004; Hanson, 1993; Paul & Egbert, 2016). It encompasses several techniques to “provide objective estimates of drug use” (Dolan, Rouen & Kimber, 2004, p. 213) as evidenced in blood, breath, saliva, hair, sweat, and urine (Hadland & Levy, 2016; Levy, Siqueira & Committee on Substance Abuse, 2014). This biotechnology has become omnipresent in the treatment of substance use problems as well (Jaffe et al., 2016; Jarvis et al., 2017). The Swedish youth treatment system, for example, is based on a zero-tolerance approach to (illegal) substance use, which necessitates abstinence-targeted interventions and motivates extensive drug testing.

Even if drug testing is naturalized in youth substance use treatment, knowledge is scarce on how professionals who work with adolescents understand its influence on disciplinary roles, prioritization of work tasks, collaboration with other service providers, and meeting service users’ needs. The current study aims to examine assumptions about biotechnology, patients, and interventions that Swedish youth treatment staff draw on when discussing drug testing. We ask: what is drug testing, what does it do, by who, and for whom? The professionals are to provide effective interventions to young service users with heterogeneous help needs, and they must deal with sometimes conflicting organizational demands. In scrutinizing the complexities of drug testing, we show that it is not merely an add-on to youth treatment but that it has a profound impact on service provision.

Critical scholars have described drug tests as “authenticity testing” (Hanson, 1993, p. 176) and as “technologies of suspicion” (Campbell, 2004, p. 78). They rest on the idea that drug users tend to lie about their use, and that biotechnology provides “a forensic means of verifying the truth-claims of those suspected of illicit drug use” (Campbell, 2004, p. 79). Within this framework, the body becomes a “source of instant ‘truth’” (Aas, 2006, p. 154), and biotests are developed for what is considered “socially problematic” substance use (Campbell, 2005, p. 377). The definition of socially problematic is obviously context-dependent, but there is a broad consensus that adolescents should not use drugs with known health and developmental risks.

Here, we do not approach drug testing as one essential “thing,” but rather as a local practice being performed differently by different people. The analysis takes inspiration from Science and Technology Studies (STS), which posits that a phenomenon such as drug testing comes to be, or is enacted, through interaction between subjects (e.g., test givers and takers) and objects (e.g., urine tests, treatment manuals) in specific settings (e.g., outpatient agencies, treatment philosophies). According to this, drug testing can “become” many things depending on how it is known, administered, legitimized, talked about, and so forth. We draw on Law's discussion of how the “knowing subject” and the “known object” constitute each other in mutual processes of interpellation (Law, 2000, p. 15). When we as subjects know, engage with, and talk about (interpellate) objects, “we are being made or remade as particular subject-positions, made to constitute our objects” (Law, 2000, p. 16). For analysts, this means concentrating on how interpellation of subjects and objects orders reality in specific ways with specific effects. If, for example, drug testing is interpellated as an object that detects previous drug use more accurately than verbal accounts, this positions those who are exposed to testing as untruthful subjects. To uncover what object-positions and what subject-positions that are enacted through different “versions” of the known, we analyze how staff interpellate drug testing in research interviews, and with what potential effects for those involved in youth substance use treatment.

The theoretical approach section below outlines in more detail how subjects and objects are typically interpellated through specific narrative forms that constitute different “versions” of reality (Law, 2000). We will argue that by drawing on these narrative forms, the professionals interpellated drug testing as a multiple and fluid object that enacted complex and sometimes conflicting subject-positions, for service providers and service users alike.

Youth Substance Use Treatment in Sweden

Adolescent substance use is associated with several negative outcomes (Gray & Squeglia, 2018; Levy, Siqueira & Committee on Substance Abuse, 2014) and is generally considered as concerning (Rahmandar, 2023). The Swedish drug political strategy for 2022–2025, for example, endorses penalization of personal use of illegal drugs, and specifically emphasizes the importance of “protecting children and young people from the harmful effects of alcohol, narcotics, doping, tobacco and nicotine products and gambling” (Socialdepartementet, 2021, p. 42). Congruently, crime statistics in Sweden show increased testing of adolescents over time (Estrada, Bäckman & Nilsson, 2022).

The most common response to adolescent drug use in Sweden is “drug use assessment with brief intervention,” which entails weekly urine tests and psychosocial counselling during normally six to eight weeks at designated youth outpatient facilities (Glad, Berlin, Bäckman, Forkby & Wallin, 2025, p. 69). These assessments are often initiated by the social services when investigating youth care needs, but can also be requested by schools, parents, and other service providers (such as child and adolescent psychiatry) when there is concern about ongoing substance use and further interventions are deemed needed. The Swedish National Board of Health and Welfare recommends laboratory-analyzed urine tests (urinalysis) as best practice to detect “suspected ongoing or recent drug use” (Socialstyrelsen, 2019, p. 106), and this is the testing used in dedicated youth substance use treatment.

At the time of writing, there are numerous youth outpatient treatment facilities in the country, and more than 25 in the Stockholm region (so-called Maria clinics). These employ healthcare staff and psychosocial counsellors, with urine testing being performed by the former occupational group. Available data indicate that the majority of the patients at these clinics are boys, the average age is 17 years and many report mental health and criminal problems in addition to drug use (Anderberg & Dahlberg, 2023; Anderberg, Dahlberg & Wennberg, 2022; Boson, Anderberg, Melander Hagborg, Wennberg & Dahlberg, 2022). Almost 80% of the patients use cannabis as the primary drug (Anderberg & Dahlberg, 2023).

It is rare for adolescents to enter substance use treatment at their own initiative (Christie, Bavin & Wills, 2018), and in Sweden they are usually pushed to it by penal or social authorities (if drug use has been detected) or persuaded by parents or other stakeholders (to regain trust, access services). Once in treatment, patients must typically engage in a urine testing regime, and the desired treatment trajectory starts with positive tests and ends with negative. Representative Swedish statistics on the form, length and content of Maria clinic treatment are scarce (Karlsson, Ekendahl & Lindner, 2025). Previous qualitative studies, however, show that drug use assessment with brief intervention, but also more elaborate and extensive treatment contacts involve urine testing combined with psychosocial counselling and information about the harms of drug use (Ekendahl, Karlsson & Månsson, 2018; Ekendahl, Kvarmans & Karlsson, 2024; Ekendahl, Månsson & Karlsson, 2020).

Drug Testing as a Study Object

As stated in the editorial for a special issue in Contemporary Drug Problems on the materiality of drugs, “drug control and prevention practices are increasingly technologized” which warrants STS-approaches to understand this practice (Paul & Egbert, 2021, p. 302). This entails to “examine how images of order are constructed, and look into the symbolic and the social behind the veil of the technological” (Aas, 2006, p. 155–156). Acknowledging this, we have previously studied how young people in the Swedish treatment system understand urine testing as a socio-material object (Ekendahl, Kvarmans & Karlsson, 2024). Our analysis showed that the testing influenced several aspects of the service users’ lives. It made visible drug use as a demarcated and treatable problem, and at the same time suppressed the complexities of adolescents’ drug use and their strategies to evade social control.

Drug testing can hold many functions within treatment and penal systems, such as screening for problems, identifying chronic users, monitoring and deterring drug use, and tracking drug trends (Wish & Gropper, 1990). This builds on the notion that surveillance is “deployed in the name of compassion” (Campbell, 2004, p. 82), and “done to people for their own good” (Hanson, 1993, p. 165). Such claims, however, have been questioned by studies arguing that drug testing can sometimes be counter-productive in efforts to help people overcome problems (Sarmiento, Seear & Fraser, 2019; Strike & Rufo, 2010). It has been argued that drug testing includes integrity intrusions and that it should not be a routine procedure (Strike & Rufo, 2010, p. 311). As stated by Sarmiento, Seear and Fraser (2019, p. 296), “[u]rine-testing regimes are onerous, demanding, intrusive, and time-consuming,” from which follows that they sometimes push people towards more harmful drug use with less risk of detection. While this research shows that control comes with costs, Moore (2011) rejects the opposition between care and control, as indicated by her term “therapeutic surveillance.” She discusses instances when monitoring people “is neither technocentric nor dystopic but rather intimate, pastoral and productive” (Moore, 2011, p. 257). At Swedish Maria clinics, urinalysis is framed as “therapeutic surveillance” on the website of Stockholm regional healthcare, which affirms that “results from urine testing form the basis for your treatment so that you receive adequate help” (https://www.mariaungdom.se/fakta-och-rad/faq/).

While there is medical research on the relevance and validity of drug testing in clinical settings (e.g., Casavant, 2002; Dolan, Rouen & Kimber, 2004; Levy, Harris, Sherritt, Angulo & Knight, 2006a & 2006b; Rahmandar, 2023), few studies have critically examined “the everyday practices, immanent logics, and group norms that shape how suspect technologies are developed and deployed” (Campbell, 2005, p. 392). For being such a staple in the care and control of drug problems, studies that interrogate how and with what effects socio-material technologies have moved into the practices of everyday life are important. Some previous research has criticized drug testing for relying too heavily on biotests when producing “truths” about people's drug use (Aas, 2006, Paul & Egbert, 2016), and points to an ambiguity or duality of what drug testing is, according to both service providers and users (Strike & Rufo, 2010). There is still limited research, however, on the social aspects of this biotechnology in the youth treatment that we target here.

Theoretical Approach

Empirical research that draws on STS does not attempt to fixate the ontological status of study objects (Fraser, 2016; 2020). Rather, it assumes that study objects are complex, multiple, and fluid and that phenomena such as drug testing are made “in and through the emergent coming together of heterogeneous materials, forces, spaces, signs and bodies” (Duff, 2016, p. 17). They are enacted, or “come to be,” through the interaction between human and non-human entities in practice. Thus, reality is constantly performed. In Law and Mol's influential piece on how technoscientific artefacts appear to remain stable and unaffectedly move through time and space, they argue that everything from abstract ideas and identities to technologies and bodies can count as “objects” (Law & Mol, 2001), and that they are all agentic in some way. Objects, a drug test, for example, as well as human beings and their practices, such as professionals who perform drug testing, make differences; they “do realities” (Law, 2009, p. 2). Borrowing Althusser's idea that the individual subject comes into being in ideology through being called upon—that is being interpellated by an authority—Law (2000) argues that interpellation is everywhere, in, for example, “speech, subjectivities, organizations, technical artefacts” (Law, 2000, p. 23). Humans interact with reality by calling upon, interpellating, its objects and subjects. Through this interpellation they perform specific “versions” of reality. In Law's reasoning, knowing subjects and known objects are reciprocally related. They impact each other through the distribution of object-positions and subject-positions. Thus, a certain interpellation of drug testing as a known object also affects the knowing subject, as well as other subjects and entities that are enacted through this specific interpellation.

For Law (2000), different interpellations may clash with each other, which potentially generates “conflicting subject-positions” (p. 24). In our previous study, youth interpellated urine tests as both motivational boosts and integrity intrusions, which produced different and sometimes conflicting subject-positions that existed side by side (Ekendahl, Kvarmans & Karlsson, 2024). Understood from the perspective of STS, such diverse interpellations indicate multiple modes of ordering reality (Law, 2000, p. 27; Law & Urry, 2004, p. 397; Mol, 2010, p. 264).

Engaging with this multiplicity, critical drug studies highlight that addiction-related phenomena are best approached analytically as “messy objects” that tend to be interpellated in multiple and often conflicting ways (Law & Singleton, 2005). This includes the concept of addiction itself (e.g., Dwyer & Fraser, 2016; Fraser, 2016; Fraser, Moore & Keane, 2014; Lancaster, Duke & Ritter, 2015), people who allegedly suffer from it (e.g., Ekendahl & Karlsson, 2021; Fomiatti, Moore & Fraser, 2017; Karasaki, Fraser, Moore & Dietze, 2013) and solutions to fix it (e.g., Moore & Fraser 2013; Rhodes, Azbel, Lancaster & Meyer, 2019; valentine, 2007). These studies have drawn on insights from STS to analyze how subjects and objects come to be through material-discursive practices (Law & Singleton, 2005; Mol, 2010).

In discussing how discourse and materiality are always intertwined, Law emphasizes that interpellation is performative, that it works to stabilize different “versions” of reality as “facts.” He also argues that interpellation is typically structured according to “five separate discourses, five distributions, five styles of narrative, five modes of interpellation” (2000, pp. 20). These modes of interpellation include (Law, 2000, p. 20–23):

the “plain history,” which is a detached chronology of events into historical trajectories which produces a “narrative landscape of facts”;

the “policy narrative,” which is similar to the first, but considers that facts have policy implications and that “praise, blame, and responsibility” can be distributed;

the “ethical narrative,” which enacts subjects and objects through considering what is ethically right and wrong;

the “esoteric narrative,” which includes specialists and excludes the general public and performs reality as “specific, local and analytical”; and finally

the “aesthetic narrative,” which highlights qualities that can be experienced, felt and enjoyed, for example, a pilot who is “in awe” of an aircraft.

The analysis below demonstrates how the interviewed professionals deploy such narrative forms when they interpellate drug testing and so distribute object-positions and subject-positions. At the end of this article, we discuss what implications this has for youth substance use treatment.

Data and Methods

A total of 20 professionals who work at Maria healthcare clinics in the Stockholm region or at municipal social services directing adolescents to these clinics participated in this research on youth treatment in Sweden (cited as P1-P20 below). Staff employed by regional healthcare were invited to interviews through a newsletter within the organization. All who showed interest were interviewed. Staff employed by municipal social services were identified through snowball sampling and given the same information as clinical staff already interviewed. The sample is self-selected, meaning that only those who felt they had work experiences worth sharing were interviewed, but it includes representatives from ten different regional and/or municipal facilities that are all specialized in assessing and treating youth drug use. Seven clinic managers, four counsellors and five nurses from different Maria clinics (some run by healthcare alone, and some run as collaboration between social services and healthcare), plus one unit manager and three social workers from municipal social service units agreed to participate. Three of the participants identified as men and seventeen as women. The research was approved by The Swedish Ethical Review Authority (2022-02494). All participants provided written informed consent, and no information except professional roles was included in the analyzed data. While sensitive information that could be used to identify people was omitted from data transcripts, it would have been futile to pseudonymize the Maria clinics since they hold a unique position in the Swedish treatment system.

The interviews were conducted by one of the authors at the participants’ workplaces, over the phone or with digital video. They lasted almost an hour each. An interview schedule was used that covered themes such as target groups, working methods, good practice, and between-agency collaboration. We did not specifically ask about views on drug testing or urinalysis. This issue was instead spontaneously raised by all participants, and we therefore regarded it as important and worthy of a targeted analysis. The interviews were audio-recorded and transcribed verbatim. Extracts presented under results were translated to English.

The analysis started with a content-based coding of the full material, in which all mentions of urinalysis (including related terms such as “test/-ing,” “urine,” “peeing,” “piss,” “wee,” “sample,” and “drug test/-ing”) were pulled out. These extracts were then searched for recurring themes, which revealed that the participants reported a plethora of experiences, perspectives, methods, and ambitions related to urinalysis. In an effort to advance this basic understanding, we analyzed the themes with a focus on different modes of interpellation (Law, 2000). In this phase, we recoded data to pinpoint sections that were structured according to unavoidable events in temporal order (plain histories), how things could be done otherwise (policy narratives), what was considered right and wrong (ethical narratives), and professional discretion and local knowledge (esoteric narratives). The fifth mode of interpellation, the “aesthetic narrative” was not visible in the material, probably because the participants were interviewed as professionals and not private citizens, which should prompt formal rather than emotive discourse. The results are structured around four modes of interpellation that distribute different object-positions and subject-positions.

Plain Histories of Treatment as Usual

The first narrative form we will analyze is the plain history which approaches unfolding events as chronological and unavoidable (Law, 2000). Previous research highlights a lack of consensus on how, why, and when drug testing of adolescents is adequate (Levy, Harris, Sherritt, Angulo & Knight, 2006a & 2006b; Levy, Siqueira & Committee on Substance Abuse, 2014). Despite such controversies, the data include plain histories in which urinalysis is interpellated as an obligatory and naturalized part of a youth treatment trajectory. If administered correctly, it transforms ambiguous concerns about drug use into a treatable problem. A social worker explains the rigor needed for it to work as supposed to:

We call it addiction mapping slash substance use assessment. They have to provide six urine samples, see a doctor on one occasion and talk to the counsellor. So, it includes, sort of, conversations and testing. (…) Once there was this youth who provided, what was it, four samples, but there was a significant gap between them, and I felt that it wasn’t reliable. And they [Maria clinic staff] felt the same, but they were not allowed to continue and extend it. (P14, municipal social worker)

In this narrative form, drug testing is a crucial “part of a series of linked dates and events” (Law, 2000, p. 20) that determines the effectiveness of treatment provision. The patient first enters treatment, is assessed for “addiction” or “substance use” through interaction with professionals and a series of urine tests, and is either discharged or transferred to more interventions. There is also an assumption that testing can be unreliable if too much time has passed between sessions (which would allow substance use to go undetected), but that organizational regulations rather than professional judgments determine the duration of the testing. This version of urinalysis enacts the professional-subject as a detached observer of what a routinely used biotechnology can do to help untrustworthy patient-subjects in need of treatment. The observer does not evaluate practice, but follows protocol. Below, a clinic manager describes how this detachment is built into referral procedures as well. She highlights differences in opinions and ambitions between those who perform testing and those who interpret results and decide what adolescents need:

Now, this is a legal sanction, and this is how we can help you complete it. We do not judge whether your positive test results work against you or not. That's for your [municipal] social workers to assess together with the district attorney they report back to. But, of course, it would be good…we can talk about the health aspects of drugs, but we don’t think that you have to become drug-free within a certain time frame in the same way as the social services might. (P3, manager at Maria clinic)

The clinic manager distances her professional role from that of social workers and district attorneys who demand that patients immediately become “drug-free,” and enacts urinalysis as an impartial penalty rather than a therapeutic intervention. In this plain history, the professional-subject can distinguish between crude and temporally demarcated measures to make young people quit using substances, and more process-oriented and communication-based approaches endorsed by the Maria clinic. The test results are in this interpellation either “positive” (drug use) or “negative” (no drug use), and this guides treatment planning. Or as stated by a Maria clinic counsellor when discussing patient queries about the length of treatment (P19): “I usually say that I can’t promise anything in that regard, because if a bunch of [positive] samples appear, I’m unable to say that I can discharge you now.” Thus, the plain history enacts drug testing as a chore that must be completed by someone. It consequently enacts professional-subjects as having limited power to break with professional boundaries and organizational routines, and patient-subjects as vessels of information about ongoing substance use. In the next section, we discuss a narrative form suggesting that things could be otherwise.

Policy Narratives of Conflicting Interests

The policy narrative gives a less neutral depiction of practice and enacts a professional-subject that distributes “praise, blame and responsibility” (Law, 2000, p. 21). This is exemplified by a nurse who concludes that Maria clinics are exploited by other stakeholders to straightforwardly judge whether young people use drugs or not, which she criticizes as flawed:

You get somewhat narrowed down there, because maybe it's the social services requesting a urine sample just to check if something is present. But that really doesn’t say anything, because it's just a single occasion. The entire psychosocial situation, other aspects are more telling, sometimes. But regarding that…I actually think that…we talk quite a lot about the development of addiction and many want to use regional healthcare [staff at Maria clinics] only to check that nothing is there. But that's somewhat wrong because we assess if there is a need for care. We see it differently, whereas many others just want to check: am I drug-free or not. (P1, nurse at Maria clinic)

This narrative form distinguishes between one-off urinalysis and more broad-coverage assessments of youth problems. On the one hand are external demands on easy-to-use information on “if something is present,” which enact testing as the answer. On the other hand are professional thoughts about more thorough assessments of youth substance use, in which this testing can merely provide one out of several important answers. Urinalysis can identify ongoing substance use, but not treatment needs, which is considered less easy. Still, while these opposing enactments could create friction in cross-organizational collaboration, the professionals were tolerant towards other stakeholders’ imperatives to initiate testing. The nurse, for instance, hints subtly at difficulties (“other aspects are more telling, sometimes,” “it is somewhat wrong”), and appears to regard these oppositions as marginal differences in approach. This interpellation concerns not if testing is needed, but what can be learnt from it and by whom, and it enacts some professional-subjects as apt and others as inapt in dealing with drug testing. Next, the current drug testing practice is problematized by a clinic manager:

I think urine tests are incredibly important but it's equally important that regional healthcare owns the urine tests. By this, I mean both how they should be interpreted and what to do with the information, how it should be understood and all that. We have schools that want urine test results because they will expel students who show positive results, and I think that is using it the wrong way. (P9, manager at Maria clinic)

Here, urinalysis is interpellated as biotechnology that needs to be regulated by policy and handled by professionals with accurate knowledge and fair motivations. It becomes a public good that can be appropriated by both adequate and inadequate stakeholders, which in turn impacts how young people are met by the adult world. The example given by the clinic manager is that those who perform testing—healthcare staff—should also have the prerogative to draw conclusions. Using drug tests for other purposes than establishing treatment needs is rejected as faulty, such as in demanding negative tests for “school clearance” (Levy, Siqueira & Committee on Substance Abuse, 2014, p. 1801). The allocation of tasks to different professional roles is further discussed by a counsellor who does not fear becoming redundant in the future, if substance use treatment were to be re-organized from a shared responsibility between healthcare and social services (as is the case today in Sweden), to being the former's sole responsibility (as has been proposed):

The risk is that my professional role would become sort of less significant, perhaps, but I don’t think so considering what I’ve seen my regional [healthcare] colleagues do and not do, what they did ten years ago and what they do today. Huge difference. Before they engaged in real family sessions, now they’re caught in a urine sample trap sort of. (P17, counsellor at Maria clinic)

This counsellor concludes that urinalysis has become so prevalent in youth treatment during recent years that those with competence (nurses) must prioritize it. The administrative routine of having other stakeholders (such as social services) request testing has, according to this, resulted in a “urine sample trap” for healthcare. This has given psychosocial counsellors the opportunity to do the work today that was assigned to nurses before. A potential change of responsibility allocation would yield fewer external test requests, and hence better control over who does what in the treatment system. In this interpellation, the need to consistently monitor and control patient-subjects necessitates ample drug testing, which in turn determines how scarce resources are spent and what tasks are available to different disciplinary roles.

Ethical Narratives of Dos and Don’ts

Here we analyze interpellations by “moral means,” that is instances when subjects, objects, events and circumstances are “linked by means of a particular sense of right and wrong” (Law, 2000, p. 21). A nurse, for instance, discusses how drug testing is a fusion of voluntariness and coercion, particularly when social services refer young people convicted of minor drug offence to treatment at Maria clinics. She states that “you can never get sentenced to urine testing” within the legal framework of healthcare. And further:

…and we just go along with it [in those cases] because we conduct a health assessment and then you get to see a doctor and then we do loads of urine tests. But the patient doesn’t know that it's voluntary, that they get to say yes or no to regional healthcare. They just know that they’ve been sentenced to this, or rather, they often don’t really understand what they have agreed to. One has to start by informing them about what they have consented to. Speaking of informed consent, it doesn’t exist. (P1, nurse at Maria clinic)

Addiction discourse often presumes that subjects are both free and forced at the same time (Fomiatti, Moore & Fraser, 2017; Karasaki, Fraser, Moore & Dietze, 2013). The above interpellation similarly enacts patient-subjects who should be able to avoid testing (because it is formally voluntary in the healthcare context) but who cannot do this (because a series of negatives must be completed). It is here considered unethical to compel young unknowing offenders to engage in outpatient treatment operated by a healthcare system based on voluntariness. This enacts patient-subjects who are unable to safeguard their right as citizens to accept or decline treatment, and presumes the willing participation of professional-subjects who execute these “sentences” without formal authority. This pinpoints how urinalysis becomes a nexus in a treatment system where all stakeholders demand it, but disagree about jurisdictions, rationales, and goals.

The balance between what should and what should not be disclosed to patients is picked up by a counsellor who talks about adolescents who cheat and use substances between testing sessions:

If you suspect that you have one with an ongoing use and who is a bit shady and all, then we have secret appointments. Is that ethical? No. Can you do that to a 14-year-old? Yes, that can feel fine because then the parents have more say, considering the 15-year age limit. But if you’re over 15, I mean, it's uncertain. We still do it, but I’ll have to say it's dubious. In those instances, afterwards one maybe has to say kind of, “Sorry, but it felt like we had to do it this way.” If you have the connection, you can say that. But, yeah, it's dubious. (P17, counsellor at Maria clinic)

This testimonial concerns sidestepping the general rule of “transparent drug testing occasions” (P17) and summoning patients to spontaneous tests without noticing them in advance (Hanson, 1993). The counsellor concludes that this way of preventing false negatives can be ethically appropriate for children under the age of 15, but that it gets more “dubious” with older age. This assumes that drug testing is part of a system of adult control over young people, with paternalism and gradual loosening of control as the child grows up. Urinalysis is interpellated as a therapeutic intervention that can be made more effective through ethical sensibility and consideration. This, in turn, enacts professional-subjects who can accurately balance different ethical principles, but also patient-subjects whose claims to have their rights accommodated are considered more (“over 15”) or less (“shady,” “14-year-old”) valid.

Professional competence and sensitivity are further highlighted by a clinic manager who talks about how drug testing can be made less uncomfortable for young patients:

Of course, it's super weird to have a lady standing there to watch me take a wee, or an old man or whatever. But, how to make the best of it anyway and what are the advantages? Most of the time, it's about having something up your sleeve that you don’t want to reveal. But it can be uncomfortable. Then you might ask, “Is there a guy who can monitor?,” if it is a boy or vice versa. It has to be done, but the question is, what's the best way for you? But I think that, if you are to work with young people, then you’ll have to be flexible enough. You have to get them motivated in the moment and make them understand why you’re doing it. I think we are quite good at that. (P2, manager at Maria clinic)

Urinalysis is here interpellated as an ethical object that can be performed in better and worse ways, which enacts professional-subjects who can adjust and motivate testing procedures in accordance with patient needs. It also enacts patient-subjects who can feel discomfort when being forced to urinate in front of adults. This underscores the difficulties of performing testing without integrity intrusions (Hanson, 1993).

A similar appreciation of work well done is described by a nurse who talks about differences in commitment across professionals, and how this impacts patients’ treatment experiences:

But then there are people who more or less go out of their way for their kids. I know social workers who exercise with their patients several days a week, kids they have investigated. Those social workers … it's incredible. Not everyone does that. One social worker woke them up, drove to their homes and just, “You know that you’re due to go to [name] for testing?” “Ahh, okay” and then he brought them to me and we talked, that was his social worker. He came every day, because his parents were … had limited time. (P8, nurse at Maria clinic).

In this interpellation, drug testing becomes “therapeutic surveillance” (Moore, 2011); an event involving concerned adults, social interaction and youth in need of “talking.” It enacts professional-subjects who are willing to sidestep protocol, and patient-subjects who benefit from extra attention.

Esoteric Narratives of Provisos

In this final section we analyze a narrative form that covers issues that are “specific, local and analytical” (Law, 2000, p. 21), and that are generally silenced in more mundane treatment discourse. These esoteric narratives paint a more complex and negative picture of what drug testing can do than the website of Stockholm regional healthcare, which talks about how it safeguards the provision of “adequate help” (https://www.mariaungdom.se/fakta-och-rad/faq/). These interpellations question the capacity of urinalysis to determine ongoing substance use and stress the importance of competence, discretion, and local knowledge when interpreting test results. A unit manager at municipal social services, for example, declares that a “positive” drug test does not always necessitate further formal contact with the social services, if “everything else works optimally, the parents do their best and they have things under control” (P13). In addition to nuancing the significance of detecting ongoing substance use, the manager suggests that it can become superfluous if the adolescent is exposed to other forms of social control. A clinic manager explains in more detail when drug testing is unnecessary:

I mean, when we’ve been audited, sometimes it's been that we’ve taken too few samples, even if it wouldn’t make a difference. Because in my opinion, if the young person says “I smoked the day before yesterday,” why should that person provide a sample to prove that? Instead, we want to see negative tests, which I think gives us something to work with. It's easier to build alliance if you talk to them instead of merely testing them. (P6, manager at Maria clinic)

This account juxtaposes the administrative routine of performing a set number of tests with professional considerations of when this is therapeutically sensible. The ambition is not to identify drug use, but sobriety. This rids the positive test from its prominence in determining treatment needs, because it does not involve “something to work with.” Urinalysis is interpellated as biotechnology that can be used to monitor progress, but not if the patient lacks motivation to stay sober. This enacts patient-subjects who feel safe enough to admit having used drugs before testing and professional-subjects who valorize alliance-building more than surveillance.

Another clinic manager goes into more detail on how to solve the potential conflict between care and control. The following section of the interview is about a patient who risks being placed in out-of-home care by social services if he does not provide negative samples, which is difficult since young cannabis users are prone to have difficulties with handling stress and other feelings, prompting them instead “to smoke even more”:

I understand their intention [cannabis use under stress], but we can help by saying that this [using] will have consequences. And as expected, at his next appointment, this guy tries to cheat in a very clumsy way. And of course, it's no good that he tries to cheat, but on the other hand it informs us that he is getting the message. He must show negative tests, he is super stressed about it. And [for us] to be able to see that, and communicate that something is happening here, and that we should not increase the level of stress any further. Of course, we have our obligations, but at the same time, we cannot continue to boost his stress because it won’t, then he’ll be unable to act instead. (P9, manager at Maria clinic)

Here, it is emphasized that healthcare professionals at the Maria clinic, as opposed to social service staff who request negative samples, have the competence to understand the event of cheating and to adapt services accordingly, so as not to “boost his stress.” With the appreciation of “he is getting the message” and “something is happening here,” the clinic manager acknowledges that the drug testing has spurred the patient's will to comply with treatment (Wish & Gropper, 1990), despite indications to the opposite. Thus, positive tests and cheating are not considered indicative of lack of motivation, failure, and the need for more interventions. This interpellation of urinalysis enacts some professional-subjects as having local knowledge and expertise in understanding young patients, and others as not having it, and patient-subjects as justifiably “stressed” and “unable to act” due to surveillance.

The same manager continues to lament other stakeholders’ naive belief in urinalysis as trustworthy in detecting whether young people have used drugs or not. He talks about “overreliance on urine tests” as “always being the truth” among “those who are not in this business”:

It's only through them [urine samples] that we can know what's going on. At the same time, we also need to be aware of what we actually know. The only samples we know anything about are the positives. Then we know how it is - or how it was at the time of the testing. But negative results, actually don’t tell us much. We can’t take a negative test result as guarantee that this young person doesn’t use narcotics. Rather, this is a young person who didn’t have narcotics in the system at the time of the test. And we are spoiled with cannabis, because we can trace use about one to six weeks back in time. So, what we find is cannabis. The question is, does it mean they only use cannabis or that we are unable to catch all else? (P9, manager at Maria clinic)

The clinic manager underscores the importance of knowing “what's going on,” thus approving of testing in principle, but doubting its ability to fully uncover this in practice. According to this, urine tests can merely detect use in prior demarcated segments of time, and leave the rest as “pretty much a void” (municipal social worker, P15), meaning that negatives do not indicate that the patient is necessarily drug-free and has made progress. Moreover, the interplay between the chemical properties of certain drugs (the long half-time of THC metabolites, see Jaffe et al., 2016) and the weekly testing regime discloses some use and conceals other use (“unable to catch all else”). This interpellates urinalysis as a flawed “evidence machine” (Paul & Egbert, 2016, p. 100), which enacts patient-subjects as potential cheaters and professional-subjects as aware of the limits of drug testing.

Discussion

Considering the abstinence-oriented approach to substance use that permeates the Swedish youth treatment system, we can understand why urinalysis has become pivotal. This biotechnology is legitimized as providing truths about previous drug use (Paul & Egbert, 2016), and as a means to guide and improve treatment (Jaffe et al., 2016, p. 29). Still, the circumstances of its deployment (time gaps between testing, staff discretion in frequency, preplanned testing regimes, cheating) and methodological limitations (easier to detect drugs with long half-time, testing must be supervised) obviously work against this capacity. Our study's depiction of such threats to the validity and reliability of urinalysis demonstrates “the social behind the veil of the technological” (Aas, 2006, p. 155–156), which entails other realities than the one in which it is fixated as evidence-based best practice (Socialstyrelsen, 2019). While our theoretical approach rejects clear boundaries between discourse and materiality (Law, 2000, Law & Mol, 2001; Law & Urry, 2004), we want to acknowledge the limitations of interview data when studying embodiments of youth substance use treatment. Ethnographic research on the everyday practice of drug testing is clearly needed.

This study aimed to examine assumptions about biotechnology, patients, and interventions that staff in Swedish youth substance use treatment draw on when discussing what drug testing is, what it does, by who, and for whom. Our results show that urinalysis was multiple and “messy” (Law & Singleton, 2005). By using different narrative forms, the professionals interpellated it as an object that sometimes is and sometimes is not: a necessary part of treatment; a consumer of resources; caring and therapeutic; a compulsory intervention; an integrity intrusion; a producer of truths about substance use; and a way to plan treatment and determine progress. These distributions of object-positions authorized specific subject-positions for service providers and service users alike. The professionals were assumed to be able to both follow and sidestep administrative routines, treatment protocols and external stakeholders’ expectations. The young patients, in turn, were variously assumed to be vessels of information, in need of treatment, convicted offenders, citizens with rights, children under adult control, and drug users hiding their use.

If different modes of ordering reality “perform themselves alongside one another” (Law, 2000, p. 23), drug testing does not appear as a singular and uniform part of youth treatment. Rather, it consists of numerous complex practices in which human and non-human entities assemble under differing preconditions and with differing effects. For Law (2000), interpellation is always multiple, and can lead to conflicting object-positions and subject-positions. This study highlighted some conflicts and social dynamics that surface in staff interpellations of drug testing. For the professionals, the various ways that urinalysis could be enacted implied demands to balance care with control to reach desired treatment outcomes, and to differentiate reliable and important testing from unreliable and unimportant. Similarly, different “versions” of urinalysis enacted several different patient-subject positions. Adolescents were youth “in need” when the testing was “therapeutic surveillance” (Moore, 2011, p. 255), citizens with rights when it was ethically problematized, and untrustworthy drug users “at risk” (Goddard, 2012,) when its treatment relevance was underscored.

This diversity in object-positions and subject-positions can obviously be expected in research interviews with participants who have different disciplinary roles, varied work experiences and who meet a heterogeneous patient group. Our analysis, however, suggests that this diversity is shaped by and also shapes the naturalization of drug testing in the Swedish youth treatment system.

In a previous study of adult substance use treatment, the interviewed professionals thought that their supply of interventions (primarily based on cognitive behavioral therapy) was suitable for clients with a wide range of differing characteristics. Our interpretation was that a reasonable match between services and users could only be created if the users’ traits were enacted as “diverse and flickering” (Ekendahl & Karlsson, 2021). We see similar processes at work in the present study: the multiplicity and inevitability of urinalysis in Swedish youth treatment appear to demand diversity among patients. Even if this testing has limitations, the professionals cannot wish it away (“it has to be done,” as one participant said). Based on the heterogeneity of patient problems and needs, urinalysis can be made relevant in at least some phases of treatment and for at least some patients.

By using different narrative forms, or modes of interpellation, participants could enact particularistic rather than holistic realities. They associated urinalysis with demarcated but solvable organizational, administrative, ethical, and methodological problems and not with principal discussions about its relevance in therapeutic work. Drug testing, at least some “version” of it, could remain a sine qua non of treatment despite concerns about integrity intrusions, disturbances in alliance-building, misuse by other stakeholders, and uncertain reliability. The participants had much to say about “treatment as usual,” but not about interventions that do not require urinalysis. This professional stance stabilizes the use of biotechnology in youth treatment, but also the abstinence-oriented system it belongs to.

The one-size-fits-all approach that urinalysis implies rests on the ideas that young people should be protected from the harms of drug use (Socialdepartementet, 2021) and that drug tests can uncover facts about drug use not evident in their verbal accounts. There should be consensus about these ideas among treatment stakeholders that otherwise might dispute how to best help young people with substance use problems. Our data demonstrated that urinalysis appears to work as a least common denominator that holds together a treatment system with multiple agencies and disciplinary roles. In this professional discourse, it provides legitimacy as being evidence-based (Socialstyrelsen, 2019), encourages between-agency collaboration and symbolizes a shared push towards the same goal; drug-free adolescents.

As a final note, we want to stress that the interviewed staff were faced with the difficult task of helping young people with various substance use problems. In addition to building rapport with oftentimes unmotivated patients with chaotic situations, and collaborating with actors in their networks, they were tasked with promoting seized substance use (including others’ concerns about it) and provide for abstinence-targeted interventions. The participants considered urinalysis necessary, but that alliances and trustful relations were easier to achieve through conversations. Their diverse interpellations of drug testing illustrate how they made sense of a complexity that probably follows from a lack of guidance on when in youth treatment this testing is adequate (Jaffe et al., 2016; Levy, Siqueira & Committee on Substance Abuse, 2014). We wonder what would happen with the discourse and materiality of youth substance use problems in Sweden if other, potentially more productive ways of addressing them were imagined; without mandatory use of biotechnology.