Maia Szalavitz, the NYC–based drug columnist for VICE and the author of a new book, Unbroken Brain: A Revolutionary New Way of Understanding Addiction, was in Seattle recently to speak at the Downtown Emergency Service Center’s annual dinner. DESC was and is a pioneer in harm reduction, which involves reducing the negative consequences associated with drug use, and the “housing first” philosophy, which holds that people experiencing homelessness need a place to live first, followed by supportive services and treatment where appropriate.
I got interested in Maia’s work because of a provocative piece she wrote for Scientific American, “Opioid Addiction is a Huge Problem, but Pain Prescriptions Are Not the Cause,” in which she argued that most people who get addicted to opiates start using them illicitly (say, stealing pills from their parents’ medicine cabinet), not as prescribed, as the popular image of a football star who had everything but became addicted to heroin after taking pills for an injury would have it.
I had a chance to sit down with Maia at Zeitgeist Coffee in Pioneer Square late last month. This is a condensed and edited version of that interview.
The C Is for Crank (ECB): As someone who writes about addiction in the context of homelessness, and as someone in recovery myself, I’m very interested in hearing about your theory of how addiction works.
Maia Szalavitz (MS): I think addiction is a learning disorder that affects the way you make choices, and I think the cause of that is a multifactorial mess. For some people, it’s straightforwardly trauma. For some people, it’s self-medicating for mental illness. For other people, it may be existential despair of various types, sometimes economic. Fifty percent of people with addiction have another diagnosis, and it’s probably more like 60 or 70 percent. Two-thirds have a serious childhood trauma history. They have more trauma than the general population.
Learning is really critical, because you have to learn that it is the drug that fixes you. Because if you didn’t know that, you wouldn’t know what to use, so you couldn’t get addicted. This is why some people get physically dependent on drugs and don’t even realize it. You can be in the hospital after having major surgery, you’ve taken opiates for about a month, you come home, you’re dopesick, and you do not know it. And because you do not know it, you don’t go to your doctor and ask for heroin or ask or more opiates.
ECB: So you’re drawing a distinction between physical dependence and addiction.
MS: Yes, and that’s a very, very important distinction, because physical dependence is neither necessary nor sufficient to define addiction. It’s not necessary because cocaine and meth have very little physical dependence. You will be very cranky, you will be very filled with cravings, you will be very irritable, but you will not be puking, shaking, or any of the stuff that goes on with heroin or alcohol withdrawal.
I am on Prozac. I probably will stay on Prozac for the rest of my life. Hopefully it will continue working. And when I am not on antidepressants that are working for me, I am depressed. Addiction isn’t the same as physical dependence. Physical dependence isn’t a problem. What addiction is, is compulsive behavior despite negative consequences. The consequences have to be negative. If they’re not negative, it isn’t addiction.
If you take opioids for more than a month, 99 percent of people are going to be physically dependent. People take opioids to the point of physical dependence all the time in cancer treatment without getting addicted. If you screen the patients carefully for past addictions, for mental illness, for trauma and stuff like this, you end up with less than 1 percent getting addicted. When I’m talking about addiction, I mean the compulsive behavior that ruins your life, not physically needing something to function.
I had days at the end of my addiction when I was shooting up dozens of times a day, literally, because I was dealing, so there was always coke. I would wake up every morning and say, “I’m not going to shoot any coke today. I know it’s going to suck. It will be horrible. It will be a bad experience. I will be feeling like I’m going to die. It will not be good.” And—pfft!—I’m doing it.
ECB: My understanding of addiction is that drugs or alcohol flood your brain with neurotransmitters like dopamine, and your brain stops producing those chemicals, so that you need a steady and increasing supply of drugs to get high and eventually to just stay level. And withdrawal happens when you don’t have the substancebecause your brain no longer produces the stuff that helps you feel normal, so you feel awful until you have the substance again. What do you think of that theory?
MS: What that perspective leaves out is that the reason that you were using the drugs in the first place is that the drugs helped you do that coping. The people I know that have been addicted, something is going on with them, and if you don’t figure out what that something is, they are going to relapse.
The economic thing—when people are despairing and they have no hope, why wouldn’t you use? I don’t believe addiction is, like, a rational choice, but I do think heavy drug use can be a rational choice in that situation, and then you can certainly end up addicted.
I think this is why, in the ’90s, we saw the black community get hit really hard by crack [when] they had been suffering for years with high unemployment and homelessness. And now we’re seeing that in the white middle class and lower middle class. It is not surprising we are having an opioid epidemic in that population, and if you look at the people who are hardest hit by opioids, they’re only being called middle-class because they’re white, for the most part. It’s not to say that there aren’t plenty of white middle class opioid addicts, as I can speak to myself personally, but if you look at the risk for heroin addiction it’s triple in people making under $20,000 than people making over $50,000. There is an economic piece of this.
With opioids, clearly we had an increase in supply, and at the same time we had a massive increase in use, so it’s not non-correlated. But what we also had at the same time was the collapse of the middle class, and what we also had at the same time was 75 percent of people who misuse opioids are getting them from somebody else’s prescription. These are not pain patients who are directly being prescribed these drugs. Most pain patients are not getting addicted, and those who are getting addicted in their 40s or so are usually people who have had previous addictions.
ECB: Long-term “maintenance” for opioid addiction with drugs like suboxone or methodone is controversial because those drugs are themselves addictive, and because people who use them are physically dependent on them—withdrawal from either drug can be just as bad as coming off heroin. But you’re a firm believer in long-term, even lifelong, maintenance. Why?
MS: What maintenance does, when it leads to recovery, is it replaces addiction with physical dependence, so now you’re basically on an antidepressant. If you look at the data, the only thing that cuts the mortality rate 50 to 70 percent is maintenance with suboxone or with methodone, and possibly with heroin. And the thing with methodone everybody gets all freaked out about it is that they think, “Oh, people are high all the time, and they’re not emotionally available, and they’re not really in recovery.” That’s because they don’t understand tolerance. Opioids create complete tolerance to the intoxicating effect. It’s not like replacing vodka with gin, because you will have impairment when you do that with alcohol. You still get tolerance to alcohol, but you don’t get complete tolerance the way you do with opiates, so that that means if you just take your steady-state dose all the time, you’re not high. You can drive. You can hang out with your kids. You can do what everybody else can do.
Some people will probably need maintenance for life. I certainly believe no one should be pressured to come off of it if it’s working for them. If they’re feeling numb or have bad side effects, like sexual side effects or like whatever other kinds of side effects like you sometimes have from Prozac, that’s a different story, but you shouldn’t want to be coming off because of stigma. You shouldn’t want to be coming off because you’re “not really in recovery.” That’s ridiculous.
ECB: In covering the problems caused by addicted people experiencing homelessness, I’ve heard over and over from people fed up with crime in their neighborhoods that addiction is a choice, and since it’s a choice, people who choose to continue drinking or using drugs don’t deserve any help. This includes everything from help getting housing to portable toilets to needle exchanges. What is your counter to that argument?
MS: In San Francisco, they had pioneered [using] bleach [to sterilize needles], and one of the outreach workers from San Francisco happened to visit a friend of mine in New York when I had started just shooting up, and she taught me to use use bleach. [Without that], I would have God knows what diseases at this point. At that time, half of New York’s active drug users were already HIV positive. God knows about the hepatitis C levels because it wasn’t even discovered, and so nobody was doing anything, and about two years before I finally got in recovery, this woman taught me to use bleach. And I was compulsive about cleaning my needles just as I was compulsive about using my needles.
People said, “oh, they wouldn’t bother to use a clean needle,” or whatever, but you know, it’s always been easier to get people with addiction to use clean needles than it is to get men to use condoms. There are two reasons for this. One is that clean needles make the high better, because with a sharper needle, you’re going to more likely hit the vein than not, which is better. But also, you know, condoms can get in the way of the mood or whatever. But it’s just kind of funny, because people have always thought the irresponsible addicted people are never going to do that and they like sharing. That was my favorite, was that people like sharing needles. And I never was able to get this into print, but I always wanted to say it’s like sharing a tampon. Nobody would want to do that. It’s about money.
It’s like when people say, “They just like living that way. They just want to sleep in the park, passed out. You can’t ever get them into housing. Leaving aside if you think they deserve housing, which I think majority of people don’t think [they do], but people seem to think people want that lifestyle, that it’s a lifestyle choice, and that’s something I have never understood. There are some people who will say that they like that, but I always feel that it’s sort of a bravado. There certainly are people who, once you sink that low, it’s liberating in a weird way. You have to worry about lots of other things but you don’t have to worry about being somewhere at a specific time. You don’t have to worry about them coming after you for the rent or all that kind of other stuff. So I can see why some people might actually say that, and maybe some people actually believe it, but for a lot of people, their reality is that there’s addiction, there’s mental illness, there’s mental illness plus addiction, usually, and about 50 percent of people with addictions also have another mental illness, and the drugs did not cause the mental illness. They were self-medicating with the drugs for the mental illness.
I always hate this idea that, like, people were totally fine and then they started doing drugs and then they have a problem. That is almost never what happens. It is rarely the case that someone with some strong genetic predisposition meets just the right drug and they were perfectly going on with their lives [before]. I have met very, very few such people.
I think that treating people with empathy and compassion and respect is the secret sauce of harm reduction. If you think about it, with homeless people, particularly homeless women, the level of trauma, particularly child sexual abuse and adult sexual abuse after they’ve been out there for a while, is huge. An enormous portion have serious trauma histories. You can’t take away their only coping mechanism before doing something. In some cases, they need to get their coping mechanism in place while they’re still using, before they can move toward recovery.
What harm reduction does is, it opens up a safe place for that to happen. If you’re homeless, why wouldn’t you want to use all day? Is [Housing First] a cure? Hell no. Absolutely not. But will it help? Hell yes. Everybody deserves a decent place to live, and frankly, I don’t understand why people aren’t more selfish and just say, like, “I don’t want to see people lying on the street—why don’t we give them houses?”
ECB: They are that selfish, it’s just that instead of housing, they want to give them one-way tickets out of town.
MS: Right, but they’re still going to be somewhere, and extermination is a horrible thing. If everybody had to pay an extra, like, $5 a month and there would be no homelessness, because you’d have housing for everybody, then why not? I just don’t get that. I always feel guilty, guilty, guilty when I see people that I can’t help, and so I don’t understand. I think that homeless people, and people with addictions in general, are not hedonists, generally. Sometimes they might take a hedonistic pose out of defiance and some remaining self-respect, but most of the time what’s going on is they are trying to deal with some kind of serious pain.
They’re not getting extra pleasure. It’s not like, “This is so fun lying on the street, I don’t have to show up to the 9 to 5.” This is just not how it works. There is a minority of people with addiction who do have antisocial personality disorder and who are basically the assholes that give everybody else a bad name, but there are assholes in the general population as well. And it is the case that I don’t think that anybody knows what to do with people with antisocial personality disorder. They’re overrepresented in the homeless population; they’re overrepresented in prison populations.
ECB: We’re having a serious discussion here in Seattle about creating safe injection sites, and possibly safe consumption sites for all drugs. Obviously, if that happens, there’s going to be a huge battle about where they’re located. How do you suggest combating that?
MS: The people who are going to be there—would you like to have them? Not in your sight, most likely, but if they are given a safe space, they will respect that safe space. This is one of the things I’ve seen again and again and again with needle exchanges. They know that this is a fragile thing and everybody hates them, and if they, to put it crudely, shit where they eat, it’s not going to work out so well. So they tend not to. Similarly, methadone programs reduce crime. You cut a methadone program, you get more crime. You add one, you get less crime. That’s the reality of it. People are smart enough to commit their crimes elsewhere. Once you’re on methadone, you are just much less likely to commit crime. When you give people respect and safe spaces, they will typically give you respect and safe spaces back.
ECB: You talk in your book about people “aging out” of addiction or simply growing out of it with time, which contradicts the more generally accepted belief that once an addict, always an addict. Explain to me what you mean by “aging out.”
Looking at the general population, about 50 percent of people who qualified for alcohol dependence in their 20s and teens, by 30, half of them are no longer qualified. About half of them will have moderated. The problem is that basically none of those people show up in [Alcoholics Anonymous] and never show up in treatment because they managed to stop without it, even though they had every symptom to qualify for severe dependence. They stopped without treatment and we didn’t see them.
I think in some cases, a lot of times, it’s life events, like you fall in love with somebody and because you’re just in love with somebody at that moment, you are able to give it up for them, whereas if you fell in love at another time, it wouldn’t work. Or you just got the job you’e always wanted. Or the structure of your life changes. For a lot of people, you can’t really party the way you did in college 30. And that structurally helps a lot of people to recover, just the fact that in order to earn a living, you have to show up somewhere at 9 or 10 in the morning. And maybe those people have less severe addictions.
ECB: A lot of people believe people have to hit “rock bottom” before they get help, and that sometimes going to jail and being forced to go to meetings is the best way to address addiction.
MS: This is what I think is interesting—because addiction is compulsive behavior despite negative consequences, right? So why do we keep thinking negative consequences can fix it? That’s, like, dumb. And that’s why I really hate the idea of “bottom,” because it’s like, if horrible, cruel things being done to people with addiction fix them, we wouldn’t have addiction. So many horrible things have been done to people in the name of pushing them to bottom, and lots of people have died behind that, and lots of evil, abusive treatment centers have done horrible things to people around that idea, and continue in some places.
Locking people in cages for using certainly doesn’t help anybody. There’s no evidence that criminalizing personal possession helps anybody. People with alcoholism get into recovery all the time without having to go to jail for a few days repeatedly, over and over and over.
We could pay for tons of inpatient treatment if we stopped locking up users. [Ed. note: Szalavitz is not an advocate for widespread inpatient treatment, and believes outpatient treatment is more cost-effective in many cases.] Every cent that we spend arresting people for possession, which is billions of dollars every year, we could have luxury rehab for all. It’s insane the way we do this, and I know there’s a lot of really good people, really well-intentioned people, who genuinely believe in what they’re doing in the field and are absolutely helping people. The unfortunate thing is that if you truly believe in what you do and you don’t realize you can be wrong, you can do an awful lot of harm, and an awful lot of harm has been done, because for so many years there was this notion that you can’t hurt people with addiction—the more you attack them, the closer you’re bringing them to bottom, and that’s all to the good. And a lot of people have been, and continue to be, retraumatized by that.