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Maia Szalavitz is an author, neuroscience journalist, and a contributing opinion writer for The New York Times who most recently published Undoing Drugs: The Story of Harm Reduction and the Future of Addiction, the paperback of which is available now. In her columns for The New York Times, she has written extensively about all things opioids, drugs, policy, addiction, and treatment. She is oft-published in other media outlets and has published several books. Her own experiences motivated her lifelong studies, which she chronicles in Unbroken Brain. She is a leading authority on addiction and harm reduction.

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Undoing Drugs by Maia Szalavitz

I interviewed her about drugs, mostly. Her latest book is the first comprehensive account of the history of the harm reduction movement, which is finally gaining support after decades of pushback and many decades of research showing the successes of the interventions. While the harm movement began in the early days of the HIV epidemic, Szalavitz follows it all the way through the present-day overdose crisis that is gripping the nation. Sensationalist reporting can lead to concerning response, such as what happened during the crack epidemic. How far has the media come in the interim years? To conclude, she discusses potential solutions and evidence-based approaches.

This interview has been edited for length and clarity.

Intro to Harm Reduction

Morgan Godvin: What is harm reduction?

Maia  Szalavitz: Harm reduction is the idea within drug policy that we should try to stop people from getting hurt, rather than stop them from getting high. Outside of drug policy, it’s just the recognition that people are going to be engaging in risky behavior, regardless of whether you want them to or not. So, let’s focus on reducing the risks rather than trying to eliminate the behavior.

Can you give me some examples? Would this be like condoms and sex?

Condoms and sex are a great example. Seatbelts and airbags in cars are another one. Any kind of equipment you use for any sports for safety, like a life jacket. There are other examples such as the designated driver with alcohol, although presumably it could be used for other substances. Masks for COVID. All these things are recognizing that a risky activity is going to take place. Let’s minimize the risk that somebody will get hurt.

The History

Is there a recalcitrance with this concept when it comes to illicit drugs versus most other risky behaviors?

Yes. Harm reduction, historically, the movement of it comes out of the HIV/AIDS crisis. The movement started in Liverpool with a bunch of people who were faced with the fact that they had a ton of IV drug use in their city and a city not far away from them, Edinburgh, Scotland, had similar economic and drug-related circumstances, lots of unemployment, especially among youth, lots of despair. Then came the HIV epidemic.

The Shreveport, Louisiana ACT UP group at the NIH.
The Shreveport, Louisiana ACT UP group at the NIH via Flickr

Edinburgh responded by cracking down. Their government shut down needle sellers, they arrested users, they closed their methadone program. They basically did everything HIV would have wanted them to do if HIV could want and want to spread. The first time they ever tested—actually, they were trying to test the HIV test—they were horrified to discover that 50% of those who inject drugs were already positive. These were 20-year-old IV drug users, very young people. They were white. It’s different racial contexts there between there and the US, which still unfortunately matters.

Liverpool was like, “We have everything that Edinburgh has but we don’t have HIV in our population yet.” They decided to do what the Dutch had started doing in a much more pragmatic way (before it was a movement) which was giving out clean needles and getting the unsterile ones back. The UK had a long history of allowing doctors to maintain people on substances. If you got addicted to a painkiller there, they would tell you to stop faking the pain. “Here’s the drug, you can have it for addiction.”

Literally, Peter McDermott (who began as a drug user activist from Liverpool) describes having that experience. He used to do what they called “blagging doctors” to get Diconal, an opioid that people seemed to love. The doctor said, “just stop faking it, here’s the script.” And he was able to get on with his life. He eventually wound up on injectable methadone and was one of the founders of the Liverpool harm reduction movement. Him, Allan Parry, Russell Newcombe, and John Marks who was the physician providing the prescriptions—all from Liverpool or the surrounding area.

Marks was an interesting character in many ways. He said he wasn’t originally interested in drugs, he just took over some guy’s practice. That other doctor had medically maintained people on substances since the 1920s or 30s. The patients were old people at this point, but they just looked like everybody else. They were just picking up their heroin prescription, picking up their cocaine prescription, and doing their thing. He asked the guys, “aren’t we supposed to be getting people off of these things?” That’s how he began his education in harm reduction, and soon became a very provocative spokesperson for it.

They decided that they’re going to expand prescribing, to do outreach to people who were using drugs as well as sex workers, who often were the same people. They would be giving clean needles and doing everything to keep those populations safe, even the ones who were not wanting to stop using.

Comparing and Contrasting the US with the UK

Where does the phrase harm reduction come from, even?

Russell Newcombe came up with the phrase harm reduction. He published the first article with that title, “High time for harm reduction,” in 1987. They began a journal, they began having conferences, they began influencing people in the United States, and thus the global harm reduction movement was born.

In the United Kingdom, they recognized very early on that if they didn’t stop the HIV spread among IV drug users, they were going to have HIV positive babies, and HIV positive young women who didn’t know that their partner was using, and they were going to have a spread into the general population. So, Margaret Thatcher said, “Okay, HIV is a bigger threat than drugs, proceed.”

Well, it was her commission that actually said it. It was interesting, because she was friends with one of the upper-class people who helped support harm reduction in Liverpool, and if they hadn’t been friends, it may not have gone that way. But this was a person who was a Lord or something. And apparently, she would pick up his phone calls, which, presumably, the Prime Minister rarely does. They founded harm reduction. It came over to the United States largely via Alan Parry who actually came and testified before Congress about it. Not that Congress paid any attention at the time.

The US, in contrast to the UK, ended up being like, “No, we are going to crack down on it. We’re not going to allow federal funding for harm reduction. We’re going to try to stop people from even giving out bleach to prevent HIV in this population, that’s sending the wrong message that it’s okay to use drugs.”

Undermining the War on Drugs

Harm reduction was a response to the drug war that also incredibly undermines the drug war. When your focus is reducing harm, rather than measuring the number of arrests, or the amount of drugs seized, or any of those metrics, if your metric is instead, “are people staying alive? Are people getting help? Are people staying healthy?” Then your interventions are going to be different. You might just think, “Why aren’t we focusing on reducing harm in all our policies?”

If the drug war is demonstrably doing harm, and it’s not demonstrably producing good results, why are we doing it? Immediately, drug warriors were incredibly threatened by harm reduction. The United States even sent people all over the world to these UN conferences, where they would try to take harm reduction language out of international documents.

That is the kind of broader overview and why harm reduction is so controversial. Because if you see harm reduction and the moral goal of saving lives as a better moral goal than stopping euphoria, suddenly, the good guys and the bad guys switch places in terms of the drug war. This is a very powerful message. This is why people have tried to stomp out the phrase literally, and why people are so threatened by it, because it really undermines a lot of the myths that America tells itself about addiction.

For example, the idea that when you are addicted, you are a zombie who has no control over anything. When you see that people will actually use clean needles, and some people can actually cut back on their use. All of this undermines these fundamental ideas, like the disease concept, which is complicated.

From AIDS to Overdose

Harm reduction was born out of the HIV crisis, we now find ourselves in an entirely different crisis. HIV is still with us. But according to the latest CDC numbers, we had over 107,000 overdose deaths in 2021, which is record breaking, far greater than the HIV fatalities at its peak. But overdose is not exactly contagious. Do you see us responding differently to the overdose crisis compared to HIV, when it comes to implementing harm reduction?

Narcan nasal spray
Narcan nasal spray

Well, what’s interesting is that we’ve done better than we would have done had this happened in the 90s. The Biden administration explicitly supports harm reduction. That is hugely different. People are working really hard to distribute naloxone [the opioid overdose reversal medication] all over the place.

The US Government Shifts its Tone

Now the CDC says, syringe service programs work, we want to fund them, do not shut them down, unless you want an HIV or Hepatitis C epidemic. The media, although still problematic in some ways, is much more on board and much more understanding. They’re more likely to cite research that shows the attacks being launched against syringe exchange are nonsense, simply untrue. Syringe exchange makes people several times more likely to get treatment, not less likely. It improves people’s health, it certainly is a dramatic intervention to end HIV epidemics. Because the opioid problem initially was seen as a “white” problem, it has led to a much kinder, gentler, approach. We see people with addiction as valuable, and we’re investing more in life-saving interventions than we did when we saw people using crack, when racism framed the problem as “Black.”

Part of that is a terrible framing of the opioid issue, which is like, “Oh, these were innocent pain patients who were turned into addicts by the evil pharmaceutical companies,” when the reality is that 80% of people who misuse prescription opioids didn’t have a prescription for them in the first place. But that framing led to a notion of innocence, which led to more sympathy for the people who were affected. So, it was both whiteness and white innocence.

Where Peer-Review and Policy Intersect

How have contributions of science and peer-reviewed research moved the needle in this field?

We had all the data we needed on needle exchange in the 80s. The data was strong even then, all you had to do was look at Liverpool versus Edinburgh. And Liverpool still hasn’t had an HIV outbreak. That is pretty impressive, right? There are now countless studies showing the same thing, that if you add syringe exchange and expand medication treatment, you will reduce HIV. If you do the opposite, you will increase it. If you do needle exchange with no medication treatment increase, it’s not as good as if you do both. And if you do maintenance without needle exchange, it’s not as good either. The research shows you really do have to do both. But it’s very clear that by bringing those things together into community you can end an HIV epidemic.

Because harm reduction was always so beleaguered and the ideas were always seen as so outrageous, they had a research tradition very early. If you were going to be doing these outrageous things, it would be good to have studies that show that they actually help and that they don’t do harm. Obviously, if your goal was reducing harm, you would want to know this, too.

It has been important for the movement, that there has been this strong empirical tradition of having research components in whatever is done. Showing over and over again, that no, this enabling thing isn’t a thing. No, you don’t have to hit bottom to get better. And knowing there are many pathways other than 12-steps. 12-steps work for some people but that is not the only way, and saying that it is harmful.

Medication-Assisted Treatment

Can you explain what medication treatment is?

I don’t like the term medication assisted treatment, because it’s clear from the data that the medication is what is lifesaving in that intervention, it is not the “assistant.” Yes, many people are also helped by counseling, but if you give counseling alone, there is no reduction in death rates. Whereas if you give methadone or buprenorphine alone, you have a 50% reduction in the death rates as long as people stay on them.

A heroin user holds suboxone near where John Jay College of Criminal Justice students are interviewing heroin users as part of a project to interview Bronx drug users in order to compile data about overdoses on August 8, 2017 in New York City.
A heroin user holds suboxone near where John Jay College of Criminal Justice students are interviewing heroin users as part of a project to interview Bronx drug users in order to compile data about overdoses on August 8, 2017 in New York City. Getty

Methadone and buprenorphine are both opioids themselves. Buprenorphine has a little bit of a tricky action where it acts as an opioid blocker at certain doses. But the doses that people are using for buprenorphine, medication treatment generally are in the agonist, i.e. they act as opioids. This is not a bad thing.

What you have to realize about opioids is that people get complete tolerance to the intoxicating effects if they take the same dose at the same time every day. And if you do that, people can drive, love, and do all the things that make up living a full life.

OxyContin and Big Pharma, Narrative vs. Reality

Back in the day when oxycontin was being overprescribed, there was a massive availability of these prescription opioids in people’s medicine cabinets in ways that there hadn’t been previously. Now, let me reiterate here that most of the people who ended up addicted to prescription opioids did not have a prescription for them. They were using leftovers from other people’s prescriptions. That’s important because it’s super addictive, and everybody gets hooked, why are there all these leftovers?

This is not saying they are not addicted. But when you exaggerate that you end up with policies like we wound up with, which is we have cut the prescribing rates for opioids. The amount prescribed has gone down by 60% since 2011, and literally the per capita amount available is back to the pre-Oxycontin days. Back in the day, there was 15-20,000 overdose deaths per year. Now that we cut the medical supply, over 100,000.

We cut the medical supply without providing more treatment to those who needed it. Yes, there have been expansions of treatment. But what we didn’t do is make the connection for the people who were getting cut off, whether they had pain or addiction. The “treatment” was we’re taking away your drugs and we have seen a major increase in suicide among people with pain. We now know that cutting them off triples the risk of suicide, and probably about the same increase in risk for overdose.

Given that there are 5 to 8 million Americans who use opioids regularly for chronic pain, and that amount may have shrunk over the years because of all these cut offs, that means that a significant proportion of these overdose deaths are going to be in the group of people that were cut off, just given the numbers.

Again, this is not to say that it was acceptable that Purdue marketed Oxycontin like they did. Safe supply is very different than marketing to gain new users. Marketing to gain new users is tobacco company territory. Safe supply is kind of like nicotine replacement. You have to really understand that if you focus solely on the idea that the drug is the problem, you are never going to solve this.

What is Safe Supply?

Can you tell me what safe supply would mean in this context?

It would be similar to the old British system where, as I described, where McDermott was feigning pain to get opioids until the doctors told him to stop scamming and just gave him opioids because that’s what he wanted. Now, that is a little bit too loose in terms of prescribing.

In the Swiss heroin prescribing system, you have to use the drug on site. I think that might be a little too tight. But the idea is you just provide people with a safer supply of the drugs they’re already using. You bring them into the health care system, and you offer them other things, and you help them to realize that they can get their life back. One of the interesting things I think about heroin maintenance is that people who have been using street drugs spend at least half their day, often more, just trying to get the drugs or get the money to get the drugs. It’s a real occupation.

When suddenly you just have the drugs that you used to spend your days seeking, you have a whole lot of time on your hands to think about your situation, to think, “Maybe I should get a job. Maybe I want to try to get my kids back,” whatever it may be. You also have this phenomenon where sometimes when you get exactly what you want—let’s say your book on the bestseller list or something—it doesn’t fix you, you’re still just exactly the same. Yes, you can be happy over your achievement or whatever, but that idea that, “If I just get this, if I paint my masterpiece, my life will be perfect,” that is just not the case. People who are using drugs think, “Oh, if I just had all the drugs I wanted, my life would be perfect,” and that does not turn out to be the case. And when you see that, that can help you move towards recovery.

Dignity or Brutality?

What harm reduction does is it puts this whole spectrum out there of different things you can do to move people towards healthier lives. The whole idea is just meeting people where they are at and being kind. This works really well in many other circumstances.

Unfortunately, we historically have this same concept that the only way you can stop people with addiction is by being brutal to them. Getting rid of that idea is a lot of work. I’ve been trying to do this work for a very long time. But there is this tough love concept and this whole idea that we should disable people with addiction rather than enable them. For what other condition do we want to disable people?

Surprise, surprise, when you treat people with dignity and respect, they start to respect themselves more. When you have expectations that people can do better, people live up to those expectations. If you have expectations that they’re always going to fail, people will live down to those expectations.

All the stuff that we’ve learned painfully about parenting is recapitulated in this because we have infantilized people with addiction. We have seen them as either criminals or animals or children. None of that has led to effective approaches, because we know that throughout psychological treatment for any condition that people’s motivation is what matters. Forcing people to do things is generally not the best approach.

Is Addiction a Brain Disease?

We often hear addiction is a chronic progressive brain disease. Could you speak on that?

The idea that addiction is a, “chronic, progressive, frequently fatal brain disease,” is falsified by many things. First of all, most people with addiction overcome it without treatment. This is true, even with heroin addiction and prescription drug addictions.

Again, fentanyl is causing many deaths. So, presuming you live through it, most people do eventually get better and often do so without any self-help or any treatment. That means that it is definitely not, “chronic, progressive and frequently fatal,” because most of the time it is none of those things.

Now, are there cases where people have severe addictions that last decades, and they never get better? Yes, there are. Do we know a little bit about what causes those problems? Yes, we do. The things that lead to addiction, the more of these factors you have, the more likely you are to have difficulty and have a chronic course of the condition.

I see addiction as a learning disorder. What I mean by that is that it comes on typically at a certain time in development, something like 90% of all addictions start in the teens or early 20s. But the thing is, in order to get addicted, you have to find something that works for you to do a specific thing, and then repeat it enough that it becomes ingrained in your behavior. The process is kind of like falling in love. The way people with addiction behave is just the way that besotted lovers often behave. They do crazy things, you know, people rob banks for love. There’s a whole genre of songs about it.

When you think about it, it’s not an elimination of freewill, it’s an impairment. This doesn’t make people into animals or children or less than human in any way. It just makes them similar to a new parent or someone in love, who has this very narrow focus on in the parent’s case, making sure that kid is loved and stays alive and taken care of, and in the case of a lover it would be being with them and sustaining the relationship. When your brain falls in love with the wrong thing, that is a learning problem. Because, while love at first sight and love at first drug certainly exists, without the repetition, it doesn’t get ingrained.

Drugs and the Media

Can you speak more about the shift on drug and drug policy coverage in the media?

You can see that they’re still trying to get their head around it. But historically, one of the real problems with media coverage of drugs is that it’s been covered as a crime issue by crime reporters who don’t know to even look, “oh, is there a study on whether this works or not,” because that just isn’t in their framework. When it starts to be covered by health reporters, you start to get a lot better reporting, because they think, “Oh, this rehab says they have a 90% success rate. Let me look in PubMed and see if that is accurate and backed up by research,” which is something that still doesn’t happen as often as it should. But again, because we have started seeing people with addiction as people more, we have moved away from the rhetoric of criminalization.

Beyond strict reporting, it seems to me that most media (like TV shows and movies) still reflect a particular version of “drug treatment” and “recovery,” and very rarely show anything beyond inpatient and 12-step. Would you agree?

One of the things about addiction and media is that what makes horrible therapy makes great TV. The confrontational, humiliating attack therapy is dramatic. You want to watch because it’s just so horrifying. It makes it look like there’s this very linear process of change you confront, you hit bottom, you maybe relapse once, and then you’re good.

If you were to portray addiction recovery as it really occurs, and as it should occur in treatment, it would be boring as hell. Because it’s a slow process of people making changes. It’s rarely linear. It’s iterative.

So, pop culture has continued to support old fashioned models of addiction treatment for teenagers and adults. Look at Celebrity Rehab and these kinds of things, they’re all about reinforcing the idea that 12-step is the only way and medication is bad. Celebrity Rehab had a 14% death rate as a result. And this guy is still called upon as an expert!

Part of the reason that the portrayal of addiction in films and TV is historically bad is because the bad therapies make better drama. The other reason is that, since so much of American addiction treatment has focused on 12-Step as the only way, basically, from the 50s through now. The celebrities who got into recovery are often 12 steppers themselves.

There’s a layer of things that contributes to the fact that the media is more backwards on this than you would otherwise expect. Especially in the 80s, and 90s, when journalists (just like everybody else) were doing lots of coke and at the same time, saying, “This is bad, we must crack down.”

What percentage of the total population had ever done coke or smoked pot or whatever? A lot! But you wouldn’t know that by the rhetoric. If more people came out about their own experience with substances, we couldn’t maintain these policies.

The Social Context

Frequently people come up to me with this and say things like “oh, yeah, I had surgery, and I had Oxycontin, it was the best thing ever. Therefore, I knew that I better only take it as prescribed and not mess with it,” which is the most common reaction. Well, there’s another common reaction, which is, “yuck, this feels awful.” But even among the people who do get euphoria, most of them have a life worth living. Whereas if your life is awful, for whatever reason, or you are feeling isolated and alienated, this might become the only source of joy in your life, then yeah, you’re going to go for it. Knowing the context is so critical, and almost all of our coverage of addiction ignores it.

Coverage focuses on how drugs make people into horrible people, or “hijack the brain.” A lot of that comes from our racist stereotypes and the racist history of our drug laws, which always must be mentioned. People have it in their heads that the drug laws are rational, and that drugs that are illegal are super dangerous and the ones that are legal are safer. And that’s just not how it happened. It happened in a series of panics. There would be no rational way for some FDA like organization to sit down and say, “Okay, we think cigarettes should be legal, but marijuana should be illegal”. One of these things kills half of its users. The other one has far less association with a reduction in mortality. So, which one should it be legal?

Hooked on Politics

So then why are our drug laws what they are? Speaking of lawmakers, US senators had a freak out about crack pipes a few months back and tweeted about it.

I should just say this, our drug laws are not irrational if the purpose is locking up Black and brown people. Our drug laws are very rational if the purpose is getting politicians elected. They’re completely irrational as policy for reducing harm, or for managing addiction, or for making people’s lives better.

The reason that the Republicans and some Democrats immediately jumped on CRACK PIPES law is because a lot of these people who are making these decisions are older, and they were there back in the day in the 90s. Back then, the Republicans and Democrats were out bidding each other on who could be tougher. There was always this fear, if you were soft on crime, you’re going to lose your reelection. Some of these people are still living in the 90s. They think that this will stir up the voters the way it did back then.

“Slightly Better”

Now, we’re slightly better. I hope that this backlash attempt does not work. And at least the media is getting that this is a political ploy. This is not about actually making drug policy in a way that’s effective. I think that stuff has rung hollow lately. Now that we are seeing an increase in violent crime that is associated with the pandemic. We had crime decreasing, decreasing, decreasing, suddenly, we have a global pandemic, and it’s increasing, so “obviously, crime increase must be due to drug policy reform.”

I wrote about how reforms and moral panics often inspire backlash and punitive policies. Do you see that?

“It’s failed reform! It’s the progressive DA!” But the thing is that these increases in violence are happening in places with no reforms, and in places with no progressive DA’s, and in places that have prosecuted the drug war every bit as harshly all along. So, to say that this is a result of anything other than a pandemic is just dishonest.

Path Forward

We’re in the midst of an overdose crisis. What should our what would a path forward look like?

For one, stop cutting people off from the medical supply, stop torturing pain patients. If you discover that somebody is addicted and in pain, or addicted and not in pain, be able to maintain them, or at the very least, instantly get them access to methadone or buprenorphine. It is insane that we cut the supply and then assumed that a black market would not happen.

First of all, stop doing the harm. Stop cutting people off. It’s not helping. We know that for pain patients, it is increasing their risk of dying of suicide or overdose. You can’t kill the patient to save them. That is ridiculous. Stop doing that.

Work out ways that we can provide a safer supply and make things like methadone and buprenorphine more accessible. The research is quite clear that they are a form of harm reduction. Should people have the right to counseling if they want it? Absolutely. But should they be forced to take counseling they don’t want in order to get lifesaving medications? No. Those are things to start with.

Decriminalized possession everywhere would improve outcomes. That measure is supported by the director of the National Institute on Drug Abuse, the chief federal agency funding drugs and addiction research. Take the hundreds of millions of dollars that we’re spending that is not doing any good and is actually doing harm and spend it on evidence-based treatment that is welcoming.

We need to completely overhaul the treatment system, such that we’re not paying for the 12-step meetings that people can get for free and so that we are paying for cognitive behavioral therapies, motivational enhancement therapies, things that are proven to help people get better.

Do we need housing for people that are actively using? Yes, and that will save lives and help some of them move towards abstinence, and often towards stability wherever they’re at in their journey. We should have a system of care that is a spectrum so that people can receive the services they are seeking.

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