The Autonomy Paradox and Performing Dependence—Responsibility and Resistance at an Opioid Substitution Treatment Service

Historically, opioid use has been problematized to serve various socio-political interests. To understand the present construction and management of opioid “dependence,” across 2023, an Opioid Substitution Treatment service was assessed in Aotearoa, New Zealand. This article outlines the day-to-day work at this service, to assess how it is informed by treatment guidelines, and the interests of staff, service users, and policy makers. Using Institutional Ethnography, nine informants were interviewed from these groups, their work at the service was observed, and the texts that were activated through this work (such as treatment guidelines) were assessed. Findings are organized into a map of the treatment institution; informants’ work is connected by the associated texts. This map is described to show the interests that pervaded these, and how they were activated in informants’ work, and informed their understandings of opioid dependence. From these texts to the talk of the informants, there is a persistent understanding of “successful recovery” as requiring individuals to become self-responsible. However, though dominant (responsibilizing) modes of constructing opioid dependence and recovery are identified, these manifest paradoxically in practice, as service user autonomy is both promoted and restricted. How service users described themselves and their opioid use is equally varied, but also leveraged opportunistically by this group. It is argued that there is evidence of a complex performativity of dependence amongst the research informants. Service users understood themselves and their dependence in anticipation of the expectations of the service, but also in resistance to these, despite the service's seeming intent.