Undoing Drugs

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0:00:07.3 Trevor Burrus: Welcome to Free Thoughts. I’m Trevor Burrus.

0:00:10.2 Aaron Ross Powell: And I’m Aaron Powell.

0:00:11.3 Trevor Burrus: Joining us today is Maia Szalavitz, a reporter and author who focuses on science, public policy, and addiction. Her new book is Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction. Welcome to Free Thoughts, Maia.

0:00:23.7 Maia Szalavitz: Thanks so much for having me.

0:00:26.0 Trevor Burrus: A good place to start would be where you start your book with your discovery of harm reduction, a term that you didn’t know at the time when you discovered it.

0:00:35.8 Maia Szalavitz: Yes, yes. Well, it was really not even… It was just being developed basically at that time, but what happened was, I was injecting drugs, and I did not know I was at risk for HIV, even though in New York where I was, all of the… Half of the people who injected drugs were already HIV positive. So I was sitting with a friend of mine, or in his apartment, ’cause he went out to buy the drugs, and I was sitting with who I… The woman who I later found out was one of his girlfriends. Anyway, I’m there with her, she says, “Wow, if you’re gonna share needles, you better use bleach because you are at high risk of HIV.” And obviously, she would have preferred for me either not to share, or to have a clean one for every injection. But everything was heavily criminalized, and bleach was legal, so she taught me to use bleach and basically as a result of that, I managed to survive my active addiction and I’m here to tell about it.

0:01:42.3 Trevor Burrus: And the interesting story of you tracking her down, because it matters that she had been visiting from San Francisco, in terms of what she knew about bleaching for harm reduction purposes.

0:01:56.1 Maia Szalavitz: Yes. In fact, she worked in part of the consortium that developed the San Francisco bleach campaign, which they did much better at addressing HIV early on, among drug users, than New York did. And in fact, they actually had a late night TV campaign with its own superhero called BleachMan who came to our planet to teach people about bleach in order to prevent HIV. And it’s like… It’s hilarious, the guy looks really funny, he’s got a crooked smile and a jug for a face, a jug of bleach. And he was very beloved in the communities in San Francisco where he would go out and actually demonstrate with a giant fake syringe, how to use bleach to clean your needles. And since basically, so many people really didn’t care if IV drug users lived or died, and many would prefer that we had died, this was… This just sort of created a lot of love for this character among the people who were injecting out in San Francisco.

0:03:01.4 Aaron Ross Powell: I have to ask about this, because it seems that drug culture in New York was happening at a time when we were aware of the germ theory of disease, and it just seems… Why weren’t people already cleaning needles? It would just seem like they… Our natural instinct would just say, like, “This thing that I’m going to stick into my body was in someone else’s body, I should probably clean it first.”

0:03:25.5 Maia Szalavitz: Well, yeah, but water alone doesn’t do the trick. And so basically, people with addiction, heavily criminalized, thought that any moment, the cops could come in and get you. This tends to lead to a lot of unsafe practices, and in fact, we were seen as being so incorrigible that even if we were given instructions about using clean needles and ways to get clean needles and bleach itself, that we just wouldn’t care and would still share needles, because somehow, we were supposed to be very generous with needles, when we were, in the rest of our lives supposed to be evil, selfish jerks.

0:04:09.7 Trevor Burrus: Well, I think that’s a really important point for the whole book, and something that I’ve written about too. If we set the scene in the ’80s, with people who use drugs, especially people who use IV drugs, and the dehumanization of those users at the time, which it still goes on, but it seems like it was way worse back then.

0:04:33.2 Maia Szalavitz: Well, it was astonishing to me, because basically, people would prefer that we died of AIDS in order to teach children not to use drugs, and maybe we took down our lovers and maybe our own babies with us in the process of doing that. They would prefer that to happen, than to “Send the wrong message” by saving our lives. Because they were afraid that if they saved us, young children would suddenly decide that it’s a fabulous thing to be an IV drug user, there’s no risk to it whatsoever, and it looks really great. I can see these people on the street and they look fabulous and healthy, and this is what I wanna be when I grow up. Yeah, but that was the theory. It was basically using people who use drugs as a kind of instrument to send a lesson to children who of course, are not looking at people dying of AIDS anyway.

0:05:28.0 Aaron Ross Powell: Why this different treatment than alcohol? Because that’s not the way that we have dealt with, culturally, alcohol addiction. We looked down on drunks and whatnot, but it wasn’t this, almost punitive, “They deserve it.”

0:05:40.8 Maia Szalavitz: Actually, during prohibition, the government actually forced manufacturers of industrial alcohol to poison it so that people would die, to show that prohibition was working. So yeah, we just have this puritanical streak, even when it comes to the substances that we actually consider not even drugs, they’re just alcohol and caffeine and tobacco, which are… We don’t talk about them when we talk about drugs. So yeah, it’s like this idea that sending a message about the immorality of certain substances should even extend to letting the users die or actually deliberately killing them, is unfortunately still with us.

0:06:27.7 Trevor Burrus: Now, we get to the term, “Harm reduction,” which thankfully, has become common enough that it’s well known in public policy circles, at least. There is sort of a specific birth date of that, but it’s also sort of a specific birth country, I guess, to Netherlands and the UK, where this kind of radically new way of treating people who use drugs like human beings that we don’t want to die, kind of came out of Liverpool, especially.

0:06:52.2 Maia Szalavitz: Yes, yes. And what was going on there, basically, was that Edinburgh, which is only about 200 miles away in Scotland, had this horrific HIV epidemic among young people in the mid-​80s, and they had all of these things going on like de-​industrialization, loss of jobs, lots of youth unemployment, lots of despair, and lots of heroin that was coming in from Afghanistan and Iran at the time, so they had lots of injectors. And their first response to this problem was, Okay, we’re gonna cut off the needle supply, we’re gonna cut off the… We’re gonna arrest people for drugs as much as possible. And let’s get rid of that methadone stuff because that only encourages people to use more.

0:07:41.9 Maia Szalavitz: And so this created the perfect storm of having more active drug users with fewer clean needles in a time when HIV was introduced into the population. And so, 50% of the people there were infected before they even knew that they had a problem. And Liverpool had basically the same socioeconomic and drug access situation going on, but they didn’t have HIV yet. So they were like, “We don’t want this happening here. We have a chance to prevent this.” They knew that in the Netherlands, a drug user named Nico Adriaans had created a needle exchange which gave clean needles and people returned their used ones, and that this had been effective there. So they wanted to bring that over and copy and replicate that.

0:08:32.0 Maia Szalavitz: And they also… Because the UK never outlawed the medical use of even heroin itself, or morphine or other opioids, and cocaine, to treat addiction, we outlawed this in around 1919, but they didn’t. They had something known as the British system, and so they were able to prescribe these things when people were very high risk, when AIDS became a threat there. And so they expanded methadone prescribing, they expanded prescribing of these other drugs, and they basically made it a lot easier for people to get help, even if they had no intention of stopping the drugs. Because the goal here is, reduce the harm associated with AIDS, which at the time, was a deadly disease, and still is, without treatment. So people were just horrified. Also, it’s communicable, unlike IV drug use.

0:09:28.1 Aaron Ross Powell: It seems though that this… Does harm reduction work at cross-​purposes with drug criminalization though? That if the goal is to… We don’t want people using drugs. It’s an illegal activity. We declared it illegal. That basically, making that illegal activity easier or less deadly… It would be like we… Manufacturing drugs is illegal, but if we came along and said, “Okay, we know you’re manufacturing drugs,” and say, “Cooking meth is dangerous,” so we’re also going to give you the resources to protect yourself against explosions if you are cooking meth, that those seem like those might be at cross-​purposes. So does harm reduction, I guess, require giving up some sense of how criminalized the thing should be?

0:10:14.8 Maia Szalavitz: Well, yeah. The whole point of criminalization is to stigmatize a behavior so people don’t do it. The problem with using that as a way to treat addiction is that addiction is defined as compulsive behavior that occurs despite negative consequences. So negative consequences aren’t actually deterring it. In fact, you make somebody hate themselves and stigmatize them and isolate them, they’re gonna be more likely to use and more likely to use in destructive ways. So Harm Reduction kind of blows up all that. And it says, Wait a minute, what are we doing here, guys? Isn’t the thing we want for most people to stay alive and be as healthy as possible? And so shouldn’t our focus be on stopping harm and we shouldn’t really care about stopping highs? And that is why it became incredibly threatening to prohibition, because it does send the wrong message. And to me, it sends the right message, which is that even if you use drugs that we as a society don’t like, you have the right to live. And the idea that we will, “Enable” people to have alcohol and tobacco, which are as deadly in the cases of severe addiction, that we’ll allow you guys to have a safe supply or a safer…

0:11:35.7 Maia Szalavitz: Well, tobacco is a complicated question, but let’s say alcohol for now. We let you have a safer supply, but the other ones of you need to die to serve as an example to kids that these other drugs… And so, what this brings up very quickly, is that our drug laws are irrational, that they are not made on the basis of, Okay, this wise Committee sat down and they said, Okay, alcohol is much safer than marijuana, therefore it should be legal and marijuana should be illegal. Because you couldn’t scientifically do that even in the 1900s. So what our drug policy is a result of is a series of racist panics and anti-​immigrant panics. So it just… Until you understand all of these pieces of it, the fact that these laws are not actually health laws, that they are moral panic laws, the fact that what they do really well is enforce racism and classism, but don’t do anything about stopping people from either becoming addicted or recover… They don’t drive people into recovery either.

0:12:45.5 Trevor Burrus: It’s interesting you’re talking about the nature of addiction, it was on one level, as you defined it, it’s compulsive use despite negative consequences. But we also have to have this… We have to have an understanding of what the behavior of a person who is addicted is like. And of course, your previous book, Unbroken Brain, gets into that, where on one level, you could say addiction is always a choice, so if you are chemically dependent and compulsively using something, you could always stop using it if someone said, “I will kill your family if you use heroin one more day.” And so even though the consequences are really high, you can stop using it. Or you could go to the other side and say that addicts are completely compulsive and will not stop under any circumstances. And it seems that our understanding of what addiction is, is very important in terms of how we deal with public policy and whether or not we think they will even… People who compulsively use drugs will stop under any circumstance whatsoever. And in the ’80s, they described them as essentially animals who wouldn’t stop under any circumstances. And then sometimes, they go back to the other side and say, “It’s always a choice.”

0:13:56.9 Maia Szalavitz: Yeah, the truth is clearly in the middle. People with addiction don’t generally shoot up in courtrooms, for example. [chuckle] They generally try to avoid police, so they generally try to wait to use till they’re in a circumstance in which they can actually appreciate the use, if possible. So yeah, there’s certainly some choice involved. But what I argue is that it’s a learning disorder, and you have basically learned to love the wrong thing. And when the systems in your brain involved in love, which are the same systems that are basically Darwinian to keep you surviving and reproducing, those are strong motivational systems, and when they go in the wrong direction, they’re gonna set your priorities in ways that are really extreme. So yeah, so if you do tell somebody who’s addicted, “You can’t have any more heroin or I’m gonna kill your family,” probably at that moment, they will not do any heroin and they will completely comply. But the question is, what happens later?

0:15:03.5 Maia Szalavitz: And it is really… The thing that we tend not to understand about addiction is that it’s not this fun, pleasure-​seeking, happy-​go-​lucky thing. It’s really about, the person has found that the drugs do something that they can’t do without it. So for example, for me, I’m quite socially awkward, and I found that being involved with drugs gave me something that people were interested in hearing me talk about, and felt made me feel more socially connected and all that good stuff. So if you just take away the drugs, I’m still gonna be not in a healthy state until I get the coping skills that I need to be able to manage either without those drugs… Either without certain drugs, and get the legally sanctioned ones that are okay for me to have for my depression and my complicity.

0:15:57.9 Aaron Ross Powell: How does harm reduction fit into that model then, because if you could… So you’ve got this need and it could be met in a number of ways, and right now, it’s being met or addressed in this unhealthy way, or this personally destructive way. And then, we make that way less destructive or easier than it might otherwise have been under the current regime, that would seem to make it… Give you fewer incentives to look for solutions in other places.

0:16:33.7 Maia Szalavitz: Well, see, this is what… This is where people get things really wrong. You’d imagine that if you enable somebody by giving them free heroin and free healthcare and lots of social support, that they would just stay on that forever and never stabilize their lives or do anything else to like… ‘Cause they’ve got what they need, it’s all there, now they’re all good, they don’t have to spend their life chasing it. But that is the issue, because once you take away the cops and robbers and the 80% of your day spent getting the money or doing the thing that you need to do to get the money, and then the rest of it is spent actually trying to obtain the drugs, when you take that all away, there’s a whole lot of space in people’s lives, and that space is where change can happen. The other thing that people don’t get about harm reduction is, when you treat somebody kindly and respectfully, they tend to want to treat themselves better.

0:17:27.8 Maia Szalavitz: And treating yourself better generally does not involve shooting massive amounts of drugs. [chuckle] So what happens is exactly the opposite of what you would predict, by the enabling and tough love theory. There is actually no data that supports the idea that if you give people the drugs they want, they will just never get better. What happens is people kinda get better when they get better. And the… Harm reduction has a saying, “Meet people where they are, but don’t leave them there.” And so the idea is like, right now, you may not be ready to give up injecting, but you’ll probably be happy to use a clean needle. And okay, now that you’re using a clean needle, you see that you’ve made a positive health change for yourself, maybe you can inject a little bit less, or maybe you wanna switch to smoking instead, or maybe you just want to try abstinence, maybe you wanna be on methadone.

0:18:29.7 Maia Szalavitz: It just gives people space to actually make change. Because we think that if we just push people into a corner and coerce the heck out of them, that that will force them to change. And that might work if people weren’t actually addicted, but when you’re actually addicted, the drug serves the most important purpose in your life, it is the thing that gives you emotional comfort, it is like your lover. [chuckle] And when you look at the way people behave when they’re in illicit affairs, it’s quite similar to the way they behave when they are addicted to drugs. So they’ll lie about the affair, but they’re not gonna suddenly start lying about everything else unless they’ve always been that way previously. So it’s really, we just need to get out of the mindset that punishment is what’s gonna fix this.

0:19:21.7 Trevor Burrus: It’s also interesting that when you understand, if you can make… ‘Cause in your story, all… Many of the stories you tell in your book, this is usually a grassroots effort with people who had been users or currently were users who understood where other users were coming from, not from public health officials necessarily although sometimes they got on board, and in some of the characters in your book, you can be a compulsive user for 30 years in a stable way, if you get your 9:00 AM injection and your 9:00 PM legal injection, and then you kind of make drugs boring in some weird way, in a good way. It’s like you’re not going out for the adventure, ’cause I’ve read that for compulsive users during prohibition, when you’re trying to alleviate anxiety, and you’re looking for supply, and so you wait three hours longer and four hours, so you finally hook something up and then it feels just even better to finally get over that, that it actually helps make the compulsive use even stronger because it’s irregular, whereas if it’s regular, it could be kind of boring. Yeah.

0:20:27.9 Maia Szalavitz: Right, and that’s the thing that people don’t understand about opioids and maintenance in particular, and it’s an important point because basically if you take the same dose of Methadone or heroin or Buprenorphine or OxyContin at the same time every day, you will end up having a complete tolerance to the intoxicating effects of the drug, so in other words, you won’t be impaired, you can drive, you can do all of these other things. So but people think like, their reference point is alcohol, and yeah, I can maintain somebody on alcohol and they’ll be less impaired than they would be if they were taking it irregularly in varying doses, but they’ll still be impaired, but this is not the case with opioids, and this is why you can have somebody who’s on heroin for 40 years and you can’t tell them from anybody else.

0:21:21.6 Aaron Ross Powell: It seems then that we have this problem of effectively cultural pictures of addicts because… And I wonder how much this is driven by the lack of legality, that with alcohol, we know what an alcoholic looks like and the person who just is constantly drunk and violent and non-​functioning alcoholic, but we also know about all sorts of other people who use alcohol because it’s not illegal, and people use it openly, publicly, regularly, and have a glass or two of wine each night and are fine, and we know what alcohol use looks like across that spectrum, but the illegality of the illegal drugs means that basically we’re only aware of the people who are at the extreme of just dysfunctionality from it, the functional ones are hiding it.

0:22:20.7 Maia Szalavitz: Yes, exactly. And so what you have is this paradox where people… When you look at harm reduction, like you see a lot of people shooting up and you see this craziness and people are handing out needles and they’re like, they don’t look so good in all of this, and you think, Oh God, this is terrible. This doesn’t work, and then you go to an abstinence treatment center and everybody’s happy and they look good and they’re healthy. Yeah, ’cause those other people dropped out and they’re not in services anymore, so the same thing with criminalization, the people that are functional and doing well under our criminal system are gonna be hiding themselves, and the people who can’t hide themselves are the ones you’re gonna see. And criminalization will sort of re-​capitulate and reinforce the negative stereotypes we have about, say, people with addiction being criminals in general, because the prices are so high that it’s very hard to support your habit without being a criminal under criminalization, and so then… Yeah, so then of course, you see all of these people must be criminals in a way that you wouldn’t see if you simply had a safe supply basically.

0:23:27.8 Trevor Burrus: It’s one of my favorite things about your book is it’s all the stories, but the people who got out there and started treating people who use drugs as supposed to be like human beings. And it made their day. John Parker was my favorite story, and in the story of the passing out of needles, you were there for that event at least for the civil disobedience one, but also just the way he did it for years and years and years, and how much that was appreciated by people who use drugs.

0:23:58.8 Maia Szalavitz: Well, yeah, and I mean, all of the early needle exchangers had that experience because the people… This is like the height of the drug war, and drugs are bad and drug users are evil, and we should let them all die, and AIDS is out there and crack is out there, and everybody’s just focusing on these people are the enemy, and then somebody comes up to you like John Parker and says, Hey, I’m gonna give you a clean needle, I don’t want anything from you. If you have a dirty one, that’s great, I’ll take that back. But you don’t have to do that. All I want is for you to protect yourself from HIV. And here’s some condoms. So that just blew people’s minds because they knew he was doing something illegal, he was risking his freedom to help people that everybody else wanted to just step on and avoid. So that was just so powerful and you could just see it when you went out with him to the places where he did his work and with the other needle exchangers, like the ACT UP folks or the people out in San Francisco or wherever it happened, this thing happens because it’s criminalized in most places, and so you would just see people just responding.

0:25:11.0 Maia Szalavitz: Because when somebody tells you that they care about you and they don’t demand anything from you, that’s kind of like unconditional love in a way. And that’s very rare, especially if you’re a person who’s unhoused, you end up being… Everybody is crossing the street to avoid you, you smell, if you go anywhere first they want you to say a prayer or they want you to do this, and they want you to commit to abstinence, they want something from you, they want you to change if you are going to get anything or be of any value to them, and in this, that’s not the case. It’s just like, Hey, AIDS is out there, we don’t want you to get it, clean needles are actually more fun to use ’cause they’re not dulled by repeated use, so you have no incentive not to use them, so why… And we are risking our own freedom to try to help you, and yet it’s just like it is very powerful, and it’s kind of funny because making it legal in that sense makes it slightly less powerful, but it’s still better for it to be legal.

0:26:16.0 Aaron Ross Powell: What was the public health officials response like to these ad hoc community needle exchanges?

0:26:23.5 Maia Szalavitz: Well, it’s interesting, it’s sort of varied regionally, but public health people tended to get it, the people who didn’t get it were people in addiction treatment, and they were like Phoenix House, and a lot of the abstinence treatment places were just hugely opposed to needle exchange, and it was just like, I just found this horrifying because why would you ever wanna go to a treatment center that is basically like, Oh, you should die if you don’t get help, and also at the same time acknowledges that 90% of the people are gonna relapse and that there isn’t enough treatment for everybody, but let’s just not let them have the clean needles because it’s a message. Yeah, no, it’s just gross, but the public health people, they had done sexually transmitted diseases and they were sort of… It tends to be a more radical kind of… There’s a lot of people in public health who were kind of activists, more so than I’ve seen in traditional rehabs, and so they were definitely much more open to it. The problem was the politicians.

0:27:33.3 Trevor Burrus: There is an interesting character who shows up in your book, Anthony Fauci, not to… Who’s the, let’s say been in the news to say the least recently, but he didn’t get it at one point because of his concept of what an addicted person is.

0:27:50.0 Maia Szalavitz: Well, yeah, no, and he kind of indirectly inspired ACT UP’s needle exchange because Richard Elovich went to hear him speak. And at that point, Richard was involved in the treatment and data committee, which was like doing all this great work around the science and getting better medications and developing drugs and all of this, and so he wasn’t… He was kind of put off a little bit by needle exchange ’cause he thought like, Oh, I don’t know if I can deal with… He’s a recovering person, he’s like, I don’t know if I can deal with triggers and seeing needles and all that, and I don’t wanna relapse and all of this, but Fauci basically said to him, Ah, we can’t do anything for those drug users, they’re a non-​compliant population, we won’t let them in our clinical trials and that made Richard furious.

0:28:42.8 Maia Szalavitz: So he just… He went back to ACT UP, and he had been sort of thinking about whether or not they should get involved with doing illegal needle exchange because the Mayor in New York had shut down the pilot study that he had allowed. So anyway, so Fauci pissing him off was a big spur for Richard Elovich to do the activism that he did, and he ended up becoming one of The Needle 8, the people who got arrested along with John Parker, to try to challenge the laws that criminalizes syringe possession in New York.

0:29:18.8 Trevor Burrus: Do 12-​step programs work?

0:29:23.5 Maia Szalavitz: I think they work for some people. And I think that what we need to do is recognize that for every medical condition, there are cases where faith healing kind of things work, and especially if you are talking about a condition like addiction, where what you really need to recover is a sense of meaning and purpose and hope. And for some people, 12 steps certainly provide that. The problem is that you shouldn’t put it into a medical addiction treatment system, so right now, something 70%, 80% of our treatment system is focused on teaching people the 12 steps, teaching people that the only way to recover is going to meetings and being totally abstinent from all substances other than caffeine, sugar and cigarettes.

0:30:20.6 Maia Szalavitz: So this is the thing, it never should have been part of professional treatment because for example, if I go to treatment for depression, I don’t get told I have to get on my knees and take a moral inventory and make amends to the people I’ve harmed. If somebody told me that when I was in depression treatment, I would think that I was seeing a quack, and I would think that they’re blaming me for having depression, but when it comes to addiction, this suddenly is the default mainstream treatment. And so, while I think all human beings could benefit from moral inventory and making amends to people they’ve harmed and all that good sort of spiritual work that you can do, if you single out people with addiction to be the only people in medicine and psychology, that get a moralizing treatment, how is that not stigmatizing them? How is that not saying addiction is not a disease? Even though people in 12-​Step insist over and over that they believe addiction is a disease, but they also believe it’s a disease that has the only moral treatment in medicine.

0:31:28.9 Maia Szalavitz: So in order to get rid of this controversy and yet let people benefit from the fact that as mutual aid, as help in the community, it’s free, it’s available 24/7 in most places, and it provides social support, which is essential for many… For most people’s recovery. So it’s like this thing where I am being seen as either way too 12 steps or way too anti 12 step, but what I’m trying to do is say in the community, 12 steps can be a wonderful source of social support, and for that reason, treatment providers should say, Look, if you’re gonna recover, it’s really important to have some social connections and support, that might just be your family, that might be a 12-​step group, that might be your exercise group, that might be your church, that might be your temple or mosque, or whatever, but you genuinely are going to need something that makes you feel connected and makes you feel like you have a purpose.

0:32:35.2 Maia Szalavitz: Employment is also helpful but basically, that is essential to recovery, people need to be able to find pleasure, meaning and purpose in something other than drugs, and relief. For some people, 12 steps can do that, for other people, they can be really harmful because when you look at the chapters, for example, on taking moral inventory, one of the things you’re supposed to do is look at your own part in the harm that happened, and so if you’re the survivor of child sexual abuse, you did not have a part in causing that, you should never be told to think that you might have, but that is kind of implicit in some of the literature there. And people have made it explicit in some of these abusive treatment centers where it’s like, Oh, you seduced that adult, and that is one of the most damaging things you can tell somebody who’s survived sexual abuse, so you really need to be careful with 12 steps also with people who have historically been oppressed, women, people of color, telling them that they’re powerless and that the only thing they can change is themselves. No, no, you can change a lot of other things, and seeing yourself as powerless is not a good political stance.

0:34:08.5 Trevor Burrus: It seems like in some context, I’ve known some people who were addicted and recovered, and obviously one of the most important points you made is, one thing is not for everyone, it’s a different thing, obviously, some people can use 12 steps, but I had friends who were very much into the disease model, and it made them think… It made them not take some amount of ownership aside from adverse childhood experiences or something like that, some amount of ownership of the choices they made that led them to being a compulsive user, and it was helpful for them to actually re-​conceptualize it as not exactly like depression, ’cause you can become depressed through just because your brain changes, but you do have to start using substances at some point to become compulsively, or a compulsive user of those substances, and so not taking ownership of your trauma, that happened to you, but taking ownership of the decisions you made that led you to the compulsive use, does that make sense?

0:35:12.4 Maia Szalavitz: Yeah, I just don’t think of that as being really important. I feel like you make a lot of choices that get you depressed too, for example, you decide to stay inside instead of seeing people ’cause you’re scared of seeing people, and then you get into this whole avoidance cycle, there’s all kinds of choices you make in all kinds of things. I think it’s a kind of red herring, let’s not worry about that, let’s look at what we can do now to get better, and regardless of its depression or addiction.

0:35:44.5 Aaron Ross Powell: What role do the courts play in addiction treatment, because it seems like a lot of this is you go in front of a judge and they tell you to go to this program.

0:35:53.3 Maia Szalavitz: Right, and I think that is just ridiculous. I think that if you’ve committed a crime, like a real crime, like say hurting somebody else, or like grand larceny, or burglary or whatever, and the driving force behind that crime is your addiction, it is perfectly reasonable for a judge to say, Okay, we are not going to let you be free until you get that addiction taken care of. The thing that then becomes a problem with things like drug courts is they mandate specific treatments, and that causes a real problem for one, they tend to mandate abstinence treatments that do not cut the risk of dying from opioids, so Methadone and Buprenorphine, if you stay on them they cut the death risk by 50% or more, and then they’re mandating people into treatment that doesn’t cut the death rate at all, so that’s deeply problematic.

0:36:49.7 Maia Szalavitz: Also, when you mandate people into treatment, you become the client of the treatment provider, not the patient, in other words, you are now giving these treatment providers all of these free customers, and they don’t have to serve them, they have to serve you. And that just makes for incentivizing punitive and harsh care because there’s no reason to improve the quality when all your customers are coming to you. It’s kinda like Allan Marlene once said to me, imagine yourself like a car maker and you’re making lousy cars, what you should do is make better cars, not get the government to mandate that you have to buy these cars. But that’s what we’re doing with addiction treatment through the criminal justice system, and so we’re propping up a harmful and often abusive system that is expensive and really doesn’t work for a lot of people.

0:37:48.5 Trevor Burrus: Now, in the pandemic year, when we got the numbers in early August, we found out that 93000 people died of drug overdoses in 2020, which was a 29% increase over the previous year, which I think is the largest percentage increase since we’ve been measuring this. You have a couple of chapters on this being, this should be seen, in my opinion, as the biggest harm that we should be trying to reduce, it’s sort of akin to the AIDS epidemic where this is death, people lose jobs when they become users of drugs and a lot of bad things can happen to them, but dying should be at the top of the list, so what is going on there?

0:38:30.8 Maia Szalavitz: Well, part of the problem is that we just looked at this graph that showed, Oh, look prescribing is going up and overdose is going up in sync with that, so if we cut prescribing, that will solve the problem, in fact, so we’ve cut prescribing by 60% since 2011. During that period, overdose death rate doubled, so obviously this was not a very effective solution, why didn’t this work? Because if you cut off somebody’s supply of drugs, you are not treating either their pain or their addiction or both of them, if they happen to have both. And so what we did was we drove people from a safer medical supply to an extremely unsafe street supply and just assumed, Oh, we cut them off that solves the problem. I don’t understand the thinking there, it’s like when you had a pill mill, you had a list of every single patient, because in order to get a prescription, you need ID.

0:39:25.6 Maia Szalavitz: They could have immediately offered them access to methadone and buprenorphine or to other kinds of pain care if they had pain, but we didn’t do any of that. We just threw them out. We detected them and threw them out, thousands and thousands of people, and now what’s happening with chronic pain is that research is coming out showing exactly what the pain patients have been saying, which is that cutting off opioids is often disabling and often leads people to either suicide or overdose, so just cutting off the medical supply, if you’ve been on opioids for either pain or addiction or both for several years, now, if somebody just cuts you off or tapers you down involuntarily, you have, I think it’s twice the risk of dying of overdose and four times the risk of dying of suicide, so yay! Very, very effective policy. No, our policy has done more harm than Purdue Pharma.

0:40:22.3 Aaron Ross Powell: But that focus and a lot of the focus we’ve had in the conversation today has been on the impact of these policies good or bad, on existing users, how to get them help, how to prevent death or suicide for them and so on. But it seems not controversial to say that cutting off supply might limit the number of new users in the future. Like it…

0:40:47.5 Maia Szalavitz: Well, except for the fact that people who are going to be… Who have high risk for addiction actually seek drugs, you kind of assume passive exposure by just saying, Well, if we just get rid of the dental opioids, then like these kids will not do drugs, these kids who end up being addicted to opioids are already using cocaine or Methamphetamine, heavy drinking, lots of marijuana, lots of different… Maybe some, they are… Most of the people who became addicted to opioids during this crisis did not get the opioids from a doctor, even though they were medical opioids, they got them from, 80% got from friends, family, random medicine cabinets, drug dealers. So yes, if you cut that medical supply, those people will not have access to it, but you’re still not cutting the fentanyl supply, and so those people are gonna… Those kids who are just experimenting are actually gonna be starting with something more dangerous, now, I think that there is absolute value to reducing overly large prescriptions for new patients.

0:41:57.8 Maia Szalavitz: And if the person actually needs a large prescription, there’s a lot you can do by having lock boxes and other ways of managing the supply so that the kids don’t get into it, that is a much more effective and humane and compassionate way of dealing with the problem of leftover medical opioids, which by the way, I should stress, if these drugs are addicting everybody, why are there so many leftovers all over the place?

0:42:26.1 Trevor Burrus: Yeah, I try to make that point all the time, it was back, it was 2008, when you got 200 opioid pills because you got your wisdom teeth out and then you just kept them there for the rest of the time, and then your kids went into the medical cabinet and took 100 of them and sold them on the street. That is the diversion that led to the “opioid crisis” it wasn’t getting people hooked, and I love your point, and to steal from your previous book, you know this idea that drugs are not the primary cause of drug addiction, the drug itself, otherwise we wouldn’t even give heroin in hospitals, which they do all over Europe, they do it all the time, as just a pain relief, just like we do Dilaudid here.

0:43:04.7 Trevor Burrus: So what can we do? It seems like we’re back in a drug scare of a different sort, so we still have these prescribing limits, we still have these pain patients who are pain refugees, and we’re still afraid of drug use in a really interesting and dangerous way, so what can we do going forward to try and get back out. It’s like we keep going back down these different troughs and we’re back down a different one where we have more overdose deaths than ever before, we’re prescribing fewer opiates, so people are in pain and people are dying, so we just did the worst of both. So what can we do better?

0:43:40.4 Maia Szalavitz: Well, first of all, I think we need to change the law so that it is legal for doctors to treat addiction with opioids or stimulants, right now under a series of Supreme Court decisions and the Controlled Substances Act, basically, if a doctor is prescribing to someone with addiction for their comfort, that is not a legitimate medical purpose and they can be arrested, and there’s no… The definition of addiction according to the DEA and all these old laws is that you’re physically dependent, so this means cocaine is not addictive, and all pain patients who are taking opioids long term and all people who are successfully using methadone and buprenorphine and have got their lives back and are functional and all of that, all of those people are still actively addicted and are just in as much trouble as somebody shooting heroin on the street, which is a ridiculous thing, you should not see addiction that way.

0:44:44.8 Maia Szalavitz: So we need to change the law such that maintenance prescribing is allowed. And what this would do is allow doctors to treat patients without having to cut them off if they suddenly decide they’re addicted because that’s what’s killing people now, just like cutting people out like saying, Oh look, we found a report on you, you’re getting from different doctors, we’re just gonna cut you off. Okay, so now that person goes to the street, that is not a success. If we want to actually have seen opioid prescribing, we need to train people better, and we need to have people recognize what the actual risks are, and to take precautions with the high risk patients, which isn’t what was done in the past, like you shouldn’t just give people 90 OxyContins ’cause they have their wisdom tooth out, it’s ridiculous, but that doesn’t mean when you have open heart surgery, you should get three codeine, just swing from one extreme to another, and it’s not helpful.

0:45:50.8 Maia Szalavitz: We need to recognize this is a complex problem, and that if you don’t make people with addiction into the mortal enemy of doctors, because if you’re accidentally supplying them, you can accidentally be a criminal, then we should know this is not a sustainable way of dealing with this problem, if doctors don’t have to be policemen around addiction, they… And you can still get rid of bad doctors this way, it’s not like you can’t say, Oh look, this guy is giving out 100 Oxycontin to everybody who walks in the door, okay, if he’s doing that, take away his license, like it’s not that complicated in terms of that kind of stuff, you know, and he’s not gonna be any harm to anybody without his pen.

0:46:51.3 Trevor Burrus: Thank you for listening. If you enjoy Free Thoughts, make sure to rate and review us on Apple Podcasts or on your favorite podcast app. Free Thoughts is produced by Landry Ayres. If you’d like to learn more about Libertarianism, visit us on the web at www​.lib​er​tar​i​an​ism​.org.

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