Undoing Drugs

[Jaunty Guitar Music]

Mike: Welcome, everybody. This is Avoiding the Addiction Affliction, brought to you by Westwords Consulting and the Kenosha County Substance Abuse Coalition. I'm Mike McGowan.

Mike: You know, for me, the best thing about doing these podcasts is having thoughtful conversations with thoughtful people who know what they're talking about and have real life experiences and ideas for improving the way we approach problems in our culture.

Mike: Well, today our guest meets all of that criteria and then some. Maia Szalavitz is the author, most recently, of Undoing Drugs, the Untold Story of Harm Reduction and the Future of Addiction, which is the first history of the movement aimed at focusing drug policy on minimizing harms. Not highs. Her previous New York Times bestseller, Unbroken Brain, a revolutionary new way of understanding addiction, wove together neuroscience and social science with her personal experience of heroin addiction.

Mike: It won the 2018 Media Award from the National Institute on Drug Abuse. Maia is a contributing opinion writer for the New York Times and has written for numerous other publications including Time, Wired, Elle, The Nation, and Scientific American. Oh, I'm tired. Welcome, Maia.

Maia: Thank you so much for having me.

Mike: Well, I want to start with the New York Times part. I want to ask you, you recently wrote an opinion piece and the first paragraph, okay, I want you to take the story. You're getting oral surgery. You're going to be prescribed opioids, and you were at one time in your life, addicted to heroin and liked it.

Mike: Take it from there.

Maia: So, yeah, so I was I was anxious about you know, having to take strong opioids. I was anxious about the dental procedure as one is in general. And, you know, but I knew that my dentist is a person in recovery himself. And so, like, I was sort of more scared of not having them than having them, but I wanted to be prepared you know, in case, like, I felt, like, you know, triggered or whatever, which I hate that word, but you know, and so I did have the, it's a, I'm having implants, so it's like a whole procedure, and.

Maia: Different stages of it. So I've had the first two parts so far. And so, yeah, so you know, and I took like five pills over the course of, I guess it's probably two, three weeks because there were two separate surgeries, blah but so anyway and it was nothing like I felt no euphoria, no nothing, no craving.

Maia: You know, it was just like, Okay, I'm, you know, a bit sleepy now, and I'm gonna go to bed, and that's what I wanted to do, and I'm not feeling, you know, too horrible, so I'm gonna sleep. And so, yeah, so, you know, I mean, when I was talking to him the reason that dentists, in particular, tend to use a lot of opioids is because oftentimes the surgery goes into the bone, and that causes, A lot of inflammation and pain.

Maia: So, you know, and we really, the reality is like, much as we want to pretend otherwise, these are in many cases, the best thing we have for pain. And the reality of addiction is that stress and fear and terror are more likely to make you relapse. Then a brief exposure to euphoria. And also when you are in pain, and this will vary widely from person to person, but usually when you're in pain, the opioid kind of goes to killing the pain, not creating (chuckle) euphoria.

Maia: So, and that was my experience at least this time. You know, again, like one of the things that a lot of people don't understand about opiates is that the experience is incredibly varied depending on, you know, your genetics, your trauma history, where you are at the moment in your life you know, the specifics of the drug there's just all kinds of variables and like, around 20 to 30 percent of people find opioids completely aversive. They just do not like them. They, you know, find it numbing or nauseating or just plain bleh. They do not like. And then another third of people are kind of like, well, some aspects of this are good and some aspects of this aren't and then the final third of people, like do tend to really love them. And that group of people is obviously the group at highest risk. But if you look at the percentage of people who try opioids outside of the medical system that become addicted, it's at most 30 percent generally. So mostly what you're looking at there, you know, in medical settings, the risk is way lower, and this is for several reasons.

Maia: The first is that 80 to 90 percent of addictions start when you are in your teens or your 20s. So if you're past that, and you haven't had an addiction, you are at very low risk. And this is why the pharmaceutical companies could say, Oh, the risk is less than 1%. If you screen people for past addictions, and they are over those ages, which, of course, people didn't.

Maia: And we ended up with the crisis that we had. But the complexity is important because so many times people think, Oh, you know, You get an opioid, and then you immediately turn into a zombie who knows how to find a drug dealer and you know, when, in reality, most people who get addicted to opioids have already been using multiple drugs for a while.

Maia: So the 70, 80 percent have been using either amphetamine or cocaine. So it's not just, oh, they're casual, you know, weed smokers and drinkers. It's like these people, by the time you get to opioids, you tend to be a pretty committed drug user. And so that obviously selects for the most high risk people.

Maia: And then you wind up in trouble.

Mike: Well, you know, we just had a guest on a couple of weeks ago who spoke almost, it's almost like you're saying the same thing, and yet we're restricting opioids for people with pain. It doesn't make a lot of sense.

Maia: No, and I mean, what's really horrifying is that we have paid zero attention to pain patients in this crisis.

Maia: None of the settlement money, almost none goes to, you know, pain patients, none that I can tell goes to pain patients directly for anything. There are some that is devoted to research on better pain medications, but most of the efforts have been like, well, this was caused by the medical supply.

Maia: So we'll cut the medical supply. The problem with that approach is first of all, it wasn't totally caused by the medical supply. What really happened was 80 percent of the people that misuse prescription opioids did not have a prescription for them when they started. So they came from the medical supply, but a doctor didn't prescribe them to that person.

Maia: And so they got them out of their mom's medicine cabinet or a friend gave them to them, you know, and like, so this idea that it's like these pain patients that are getting addicted. Well, that's a nice story because it makes the people innocent and white people need to be innocent, of course, because we're not like those bad crack users that we crack down on.

Maia: Anyway, so yeah, it's just a really stupid thing. And of course, what happens is when you have people who like, say we're going to a pill mill and most people going to a pill mill, we're not paying patients either. They went to the doctor to get drugs because the doctor had drugs, not because (chuckle) you know, like the bank robber goes to the banks because that's where the money is.

Maia: So, you know, you ended up with you had these pill mills, they shut them down, and then what are people going to do? Oh, I have no more drugs. I'm not going to try to get more. I'm not addicted. It's just going to go away because they took the drug. I mean, why did they not think that this was going to cause something like fentanyl?

Maia: I mean, fentanyl was probably eventually going to happen to the American drug market anyway, because it's just so much cheaper and it's just so much easier to smuggle. Like, Prohibition drives you towards more potent and more easily smuggled, smugglable things. And you end up with horrors like street fentanyl.

Maia: And, you know, the plant product was pretty dangerous. You know, heroin is not exactly your safest drug when you're buying it on the street especially. But, you know, there are countries that use it in pain management perfectly fine for decades. Anyway, you know, we've never seen anything like the death rates with fentanyl though, I mean, it's 50 to 100 times stronger than heroin, and it is, you know, some of these forms are 10,000, I mean, it's crazy in the level of potency, and America is nuts to think, and like, I think it's like one or two trucks could supply the entire country for a year.

Maia: You cannot deal with that by policing. You know, it just it's like if you want to shut down international trade sure. But you know, we did that during the pandemic and you know well, there were certainly briefly some shortages... not for long! You know, it is just not the way to deal with addiction.

Mike: Well, let's get into that then because in in one of the reviews I love this. (chuckle) Of your recent books, one of the reviewers, and I quote, "her writings on radical addiction therapies." And I just started laughing when I saw that. And I wanted to ask you, I wondered what your response was to the word radical.

Maia: Well, I mean, the sad thing is that basing treatment on the evidence of what works and treating people humanely is unfortunately radical in the drug treatment world. That should not be the case. But, you know, particularly in the United States, it really is. I have, you know, over the years, occasionally asked experts and just people in the general public. Can you name 10 rehabs in the United States that do not use the 12 steps? And nobody can do it. And I'm talking about asking the people who know. I mean, I know two out of the three that possibly exist, like sometimes they may have it inpatient, sometimes they don't.

Maia: But this is like ridiculous. This is not to say that the 12 steps don't help a lot of people, but you can get them for free in church basements, and we shouldn't be paying taxpayer or insurer money to teach people what you can get for free in church basements. And worse, to tell them that it's the only way, and if they don't comply with this, that they're doomed.

Maia: And also, they should stop taking the medication, which, in the case of opioids, we have two medications that cut the death rate by 50 percent or more, which are buprenorphine and methadone, if you stay on them. They tell you to come off. In this crisis, that can be deadly advice and so it's really, you know, so yeah, so finding evidence based treatment is hard, and being kind and supportive to people with addiction has historically been known as enabling, and you shouldn't do that.

Maia: So you know yeah, it's sad, but it's true that actually good treatment is still pretty radical these days.

Mike: In your bestseller, Unbroken Brain, you suggest looking at addictions as learning disorders.

Maia: Yeah, so, I mean, the idea there is basically that, you know, the most accepted definition of addiction worldwide by the experts is compulsive drug use that continues despite negative consequences.

Maia: In other words, punishment is the one thing we know does not fix it, right? Continues despite negative consequences. There's a whole other rant I could go on about that, but I'm going to say for now that what is that in terms of learning? You are not learning from punishment. And so that is. You know, by definition, a learning problem right there, just in the main definition.

Maia: But beyond that, if you look at the sort of life history stories of addiction like 90 percent of addiction start in the late teens or early twenties. And that's also when other mental illnesses tend to start. You know, there are some disorders that start earlier, some start later, but it has to do with the stage of brain development that is going on at that time.

Maia: And what is developing at that time, but, you know, the whole systems that are about you know, going out and finding a mate, (chuckle) and you know like working to be an adult and be an adult in the world which involves these complex relationships and you know biologically, ideally you know, finding someone to have a kid with.

Maia: And so what happens in addiction is basically that instead of like that system being devoted to, you know, taking care of a kid or taking care of a relationship it is now devoted to the relationship with the substance or in some cases the activity like gambling or something like that. So, you know there's so many aspects of it that are about learning.

Maia: And so your brain kind of learns to love the wrong thing.

Mike: I'm going to invite you to go on your rant.

Mike: What do food stamps, drug tests, and student loans have to do with addiction?

Maia: Nothing. And I mean, it's the stupidest thing ever because like, we do know what are some correlates of recovery.

Maia: Having an education, having a good job being able to feed yourself, having a house taking those things away. It doesn't stop addiction, but it does make it a lot harder to recover. And so, it's just so stupid. I mean, the again, we have tried for the last, you know, a hundred years, pretty much to treat this as a criminal problem and to say that like, okay, you have a condition marked by compulsive behavior, despite punishment, we're going to punish it out of you.

Maia: How well has that worked? We have the worst overdose crisis in history. And we have, you know levels of addiction that are as bad or worse as they've ever been. It is just, you know, people become addicted because drugs seem to solve a problem for them. They learn that drugs work to, you know, make them feel okay.

Maia: And over time, that may not even be true anymore, but at least at 1st, it makes you feel. You know, okay or better. And so, for people who are miserable or feeling, you know, existentially lost, no sense of meaning or purpose, no sense of connection. The drugs can give you a sense of that. And, that's what people really need to flourish and so if you make flourishing harder, you make recovery harder, you don't make addiction better, you know, you often make it worse by making things worse for the person because the more the person feels horrible, the more they're going to want to get high.

Mike: So what, in your opinion, what is the future of drug treatment and recovery look like? And (laugh) I think I know the answer already. Do we have the political will and leadership to get there?

Mike: You know, the reason I'm asking that is that we've treated the same thing again and again and again and again in much the same way. And in addition to what you just said about recovery, our prisons are full.

Maia: Yeah, it's, I mean, you know, we incarcerate the most people in the world. Like now it's possible that China has hidden prison systems that we don't know about.

Maia: But in terms of the you know, developed world democracies, we imprison like ten times more people than most countries do. And we have worse drug problems. We have the worst overdose crisis, and it's kind of like, okay, more of this is going to fix it, you know, there's that, like, I don't know if Einstein ever actually said it, but the, like, idea that insanity is doing the same thing and expecting different results, and they accuse people of addiction, of having that problem.

Maia: Well, I would say more that politicians have that problem when it comes to this, and the problem is, of course, that the negative consequences. Don't hit the politicians, the politicians get the positive consequences of voters think this is a good thing to do. So they get elected by like supporting bad policy.

Maia: That is another whole discussion. But the you know, the bottom line is that what we are doing is a complete failure. And if we actually want to improve addiction and drug problems in the United States, we have to do very different things with both treatment and prevention and law enforcement than we're currently doing. In terms of prevention, most people with addiction have either childhood trauma, incipient mental illness, or childhood trauma has turned and incipient mental illness into an actual mental illness, right? So and then there's another group that just has sort of complete despair. If you aren't in 1 of those 3 categories, or all 3, your risk for addiction is seriously low, like people whose lives are working great and who have good brain health and good coping skills, do not suddenly find a substance and give up a good life for it. Like that almost never happens. What tends to happen is you're struggling, you find something that seems to work, and then you get trapped. And if you want to make it better, you got to figure out what problem is the drug solving for you and how do we find a better solution and get you out of the cycle that you're, you know, currently stuck in.

Maia: That means that what treatment should look like is starting with as soon as possible. Now, when somebody's in withdrawal, this is not the best plan, but, when it is feasible, a complete psychiatric evaluation so that you know what is going on with that person mentally and coping wise and all of these things, you know, are they like on this autism spectrum?

Maia: Do they have depression? Do they have anxiety? Do they have psychosis? Like, what is going on there? Then you have to figure out you know is there a trauma situation here that will need to be dealt with at some point? Now, what you don't want to do is be like, okay, tell me your trauma right now.

Maia: (laugh) Because that can be retraumatizing. But if done right, you can actually treat addiction and trauma at the same time. And people can deal with things like PTSD and addiction at the same time, but it has to be done right. Otherwise you're going to end up making it worse. So, you know, what treatment would look like would be dealing with what the problems are that that individual has.

Maia: And so, It's going to be very different for somebody whose problem is that, you know, they are from, you know oppressed group and don't have an education and are poor and have really not had many opportunities and are traumatized and have. You know, stuff going on in terms of, say, depression, like, that's going to look very different from somebody who's like, say, a CEO of a company and you know, got in trouble from doing a bit of coke.

Maia: You know, one person is going to need very different services than someone else. And so the sort of inpatient 28 day rehab is really not a sensible approach for the vast majority of people.

Mike: And that CEO is going to have access to services that the other group isn't.

Maia: Exactly.

Mike: Right?

Maia: Yes. And, yeah, I mean, it is just ridiculous.

Maia: But, like, we tend to see this very complex condition as being everybody has the same thing and there's one solution. And if you don't like that solution, it's your problem and you're the failure. So treatment needs to be highly individualized, highly flexible you know, as long term as it needs to be for the person to find their way.

Maia: And what I would like to see is a system that, you know, if somebody say wants to be abstinent. They have the supports for that. But if they slip, there's harm reduction right here so that you can not die. You know, I would like there to be options such as. You know, just maintaining people on prescription opioids where, you know, at least they're not dealing with the street supply that is so poisonous right now.

Maia: You know heroin maintenance there's all kinds of interesting stuff going on with psychedelics. Psychedelics are not going to solve this. They are going to help some people just like, you know, Prozac helps some people. They'll help a proportion of people, but like. Assuming that's going to cure everything, bad idea.

Maia: Assuming it might be a new and useful tool. Yes, that makes sense. And. You know, we just, we have pretty good ways of dealing with addictions. We just don't use them. And we just trap people in a cycle of, you know, jail and courts and all this kind of stuff. Now, the other thing, of course, that we really need to have any kind of a treatment system that works is universal health care which again, you know, we may get there.

Maia: But, you know, it's, it's really like, You know, blaming people for not getting treatment when insurers don't cover treatment and then saying we need to, you know, spend more on cops to, like, force them into treatment is really stupid. And this is what we do over and over again. I mean, I'm just so sad about what's going on in Oregon because the whole, decriminalization, like if you look at where fentanyl hit and when it hit, sadly, for Oregon, fentanyl hit almost exactly when they decriminalized. Was this due to decriminalization? No. Could it possibly have been due to, because like if you think about it, okay, so how do you rapidly increase overdose? You have to be doing it among people who are already using, right?

Maia: Because, like, most people who overdose, although there are some exceptions due to this crazy fentanyl world, but the vast majority of people who overdose are regular addicted drug users. And that takes time. You do not instantly go from somebody who uses on weekends to somebody who's homeless and shooting up and at high risk of overdose.

Maia: How that would have happened in three or four months to cause the overdose rate to shoot up the way it did, (chuckle) like, it's not a plausible causal pathway. What's also not plausible is that the people who were already using were like, Oh, wow, this is great. I can do this publicly and I won't get caught. So I'm going to use more.

Maia: You know, if you've ever met someone with addiction. They tend to use as much as they can afford on that particular day. Not more, not less. If they can afford more, they use more. If they can't, they don't. So, unless decriminalization was accompanied by giving people a million dollars, which I can tell you it was not. That would be an interesting experiment because it might actually help, but we will never do it, (chuckle) but because a lot of times people's problems, they can get access to services.

Maia: They can get a house. They could do all kinds of other things. But we're not going anywhere near there. Anyway, the point is that this is not a plausible way that decriminalization could have produced the overdose increase that we saw recently in Oregon. And, oh, by the way, that overdose increase every single place that fentanyl arrived happened when it arrived.

Maia: And so, you know, it's. It's just crazy.

Mike: Well, I think it makes sense, then, to circle back to what you've said earlier in our conversation, you've talked about your recovery was dealing with your emotional turmoil. If I'm getting I'll quote one of your books, with a combination of cognitive techniques, drugs, antidepressants, and, I think importantly, genuine social bonds.

Mike: Yeah, yeah, no, I mean I have been very lucky to find people that I love and be able to connect with them. And since the depression was treated, I was able to actually feel that connection. Because I think, you know, a lot of times people think, oh, you know, all you need is love. And you're, you know, you're saying that, like, you know, if you have a relationship and you have like a strong community, you're not going to get addicted.

Mike: No. Like, those things are. Often essential for recovery, but they're not going to prevent somebody who has depression or has autism or has any of these things and cannot feel that connection because their brain is off you know, or neurodiverse, however, you want to phrase it. And I do like the idea of neurodiversity, because I do think that some of these.

Mike: Differences are gifts as well as curses for many people. That said you tend to need a combination of things. You tend to need to know, how do I live in this brain that I actually have? How do I connect with people? And how do I find something that gives me meaning and purpose? In this world,

Mike: well, okay, I'll give you your walk off then because you said in your article your quote from your dentist, who you said was also recovering, right?

Mike: He told you that the secret for him. Was he was more in love with his recovery than his drug. I thought that was just beautiful. What's what's the key for you?

Maia: I mean that you know that really that really is is true and also just like, you know Realizing that like oh I am this sort of strange person that I am because I'm on the autism spectrum.

Maia: I have you know my dad was a Holocaust survivor. I have a complex history. The, you know, I figured out how to live in my skin comfortably. And for me, that tends to involve, you know, having like, I'm married now, I have good friends, I have my sisters and brother and, you know, people in my life, my mom you know, the So I have like a sense of socialness and that, that, you know, works for me.

Maia: I also I recently started learning to sing, which has been really fun if I'm not going to do it publicly yet, but it is like, I just love, love, love music and like learning music theory and stuff like that has been really, really cool. And you know, I took up weightlifting, which is bizarre, which is something again, I never thought I would do.

Maia: But exercise, I think for many, many people is a really important thing. You just have to find something you like and or are good at. Bizarrely, I am good at deadlifts. And so I can, I just did 275. But I know, it's like, who knew? I did not expect to have this, like, you know, I obviously worked for many years to get up to that, but, like you know, upper body stuff, I'm still not as good, like, it's, you know, anyway, genetics matter.

Maia: But, You know, who knew? So I, you know, I do this and I you know, I work on stuff that I deeply care about. I try to, you know, help other people through my journalism and all the stuff that I do basically. And, you know, so all of that, like, has You know, checked all those boxes for me pretty much and, you know, not perfect, still get depressed sometimes like still, you know, have life, but the, I do have the things I need to sustain my recovery at this point, and I work very hard to ensure that those continue because I know my life depends on it and it is.

Maia: What was really, really difficult for me particularly as a teenager was just like, I really hated myself and I thought other people hated me. And getting out of that way of thinking was really essential. And then I was able to feel the connections that I actually did have. Because like, You know, my parents cared about me a lot, like, I had a good family, all this stuff, like, it wasn't like, you know where a lot of people's situation is, they were abused, they lost people, they, you know, literally didn't have the people.

Maia: In my instance, people were there, but I couldn't feel it. I couldn't connect to it. I felt so horrible in myself that you know, I was just You know, looking for escape and looking for a way to just, you know, feel okay and feel that I was valuable. And it is very strange that you can sort of live in an illusion that keeps you from Feeling good.

Maia: And I do also think that there are chemical parts to this. The cognitive stuff in terms of like, hey, that person over there, who is absolutely gorgeous, thinks she's ugly. Maybe you're equally deluded about some of the things you think you know seeing so understanding that other people had the same kinds of experiencing being able to, you know, get out of those, like, cognitively, that was really important.

Maia: But also, I really needed the medication to not be so, like, overwhelmed by my senses and just experiences in general, so that I could Be able to be present and I think that's really important because a lot of people think oh like You take an antidepressant and it like numbs you and makes you unable to feel or whatever and I'm like Well, what if your feelings are like way up here and it's just trapping you Like, a little bit of turning down that volume is good.

Maia: Now, if you're coming from down here, and you're you know, then you get more suppressed, then you're gonna feel horrible. And that is not the right medication for you. But, just, if you ignore the baseline of where someone's coming from, You are not going to be able to help them appropriately. And if you just say, All drugs that numb you are always bad.

Maia: Or all drugs that like make you feel more intense are always good. Like, no, it depends on the baseline.

Mike: AmazinMaiaaya, you, you said And your clothes there, your work, and your work does help. I mean, that's how I found you, and I just thought the writings were brilliant. And you all know, who listen to this, that there are links to Maia's website, which has everything, all your books, your links to your articles, brilliant and thoughtful.

Mike: You've summarized for us today, probably about I, I was counting up on my hands. I'd lost track, but 25 podcasts we've done, you hit on different topics. So yeah, thanks so much for being with us. And for those of you who are listening, please listen in the next time. And until the next time, stay safe and stay open to new ideas.