Maia Szalavitz: When Abstinence-Only Approaches Fail
Maia Szalavitz is a contributing opinion writer for the New York Times and author of two fantastic books about addiction. Her New York Times bestseller, Unbroken Brain, tells the story of her own heroin and cocaine addiction as a student at Columbia University in the ‘80s—she was expelled for dealing and barely escaped prison time—woven together with the decades of work she’s done as a journalist in the addiction space after entering recovery in her early ‘20s. In it, Maia offers a compelling case for why addiction should be thought of as a learning disability, in part because so many people “grow out of it.”
Maia’s latest book—Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction—taught me so much and challenged so many of the stories about addiction I was holding onto. Ultimately, it’s an optimistic book in the face of what feels like an overwhelming cultural challenge, a challenge that only seems to get worse every month—Maia explains why we’re trending in this direction, and more importantly, what we can do to shift our collective fate toward recovery. And what an expanded idea of recovery might mean. Okay, let’s get to our conversation.
MORE FROM MAIA SZALAVITZ:
Undoing Drugs: How Harm Reduction is Changing the Future of Drugs and Addiction
Unbroken Brain: A Revolutionary Way of Understanding Addiction
The Boy Who Was Raised as a Dog
Read Maia on The New York Times
Maia’s Website
Follow Maia on X
Further Listening on Pulling the Thread:
PART 1: Holly Whitaker, “Reimagining Recovery”
PART 2: Carl Erik Fisher, M.D., “Breaking the Addiction Binary”
ADDICTION: Anna Lembke, M.D., “Navigating an Addictive Culture”
TRAUMA: Gabor Maté, M.D., “When Stress Becomes Illness”
BINGE EATING DISORDER: Susan Burton, “Whose Pain Counts?”
TRANSCIPT:
(Edited slightly edited for clarity.)
ELISE LOEHNEN: Thank you for all of your work. It seems like the most compelling work, and this gets into harm reduction, which we'll spend a large part of our conversation talking about, but so much of the work around understanding addiction feels like it has to be from inside the house. The people I know who are most compelling are those who have real experience.
MAIA SZAKAVITZ: Yeah, yeah. I mean, I think especially because it's so stigmatized and so misunderstood and there's so much bad information out there that people with lived experience in this area really have a critical role to play in terms of that there can be some bad sides to that, which is that sometimes people who have a few months of recovery decided they're experts and they don't look at anything outside of their own experience. And that can be problematic also. But I think the way around that is for people with lived experience to, you know, look at the research, read up, talk to people understand some of the science. And then you have this really broad expertise that is incredibly useful because sometimes if you just have, well, this is what I was taught and this is, you know, what I've been told is the only way, when you encounter people for whom something different is true, then that can really cause a lot of problems.
ELISE: Yeah, and some of the other conversations that I've had in this series, Carl Eric Fisher, Holly Whitaker, are about, you know, where there's been a predominant myth or culture around recovery, how that can shut people out who might not resonate with what's presented as the only option.
MAIA: And it's ridiculous. We don't have this in any other area of science and medicine. We don't say there's just no one size fits all. You know, I think we can universally say that smoking cigarettes is bad for you. And there's no counter examples, but with most other things different things are working for different people and the way to understand that is by looking at the broader scope of things and putting your experience in context of that rather than just being like, well, all those other people are wrong. And my way is correct.
ELISE: Yeah. So it's funny, interestingly that you brought up smoking. My dad's a pulmonologist and as a child, the two things that I was not allowed to do, one smoke and two ride motorcycles and anything else, acceptable, including marijuana. But it's interesting, he came to my school and did the whole presentation around chewing tobacco and around tobacco and its impacts on lungs and whatnot. And I remember thinking, as I grew older, I was like, you guys aren't telling a great story here. It's only from the place of like fear and shock and horror and the images that they use are terrifying, but why don't you tell people that they can recover, that their lungs will regenerate because so much of the, I don't even know if I'd call it mythology because it's real, but so much of the way that we deter people from using substances offers no hope and no redemption, right? And so when I would see friends smoking, it was always like, well, I've done it, there's no recourse here. Like, I've ruined my lungs.
MAIA: And I mean, that gets at the heart of things around harm reduction because people are afraid if you don't tell them it's all bad that you know, everybody's going to do it and ruin their health and whatever. And the thing is, like, cigarettes in the form of tobacco are actually uniquely bad. And this comes out in understanding prevention for a lot of things. I mean, long term users of cigarettes, through tobacco, 50 percent of them will die a smoking related death. Even fentanyl doesn't tend to do that at this point. I mean, we don't quite know the numbers on street fentanyl, but historically before fentanyl, most people with other addictions, died of their smoking addiction, because most people with other addictions also have smoking addictions. Although that is less so these days. So, it's really, like, when the truth is that it is actually that bad for you, it makes the scare tactics more effective than they are when that is not the truth. Like, for example, with marijuana. And so when people try to do prevention based on cigarettes, they have a much harder time because if you tell the truth, it's much more complicated.
ELISE: Mm hmm. Yeah. But it's, I think in your book, I'm not sure whether it was Undoing Harm or Unbroken Brain, is it 30 percent of people who smoke will likely become addicted, where it's 10 percent, roughly, for other...
MAIA: And what's interesting, too, though, is that has changed somewhat because smoking cigarettes is so much less socially acceptable now. And so it used to be the case that I think the majority of people who smoked were pack a day smokers. And now the majority of people who smoke are people who smoke while they drink in college. And so they are not addicted smokers and so it is by changing the environment, we change the addictiveness of the substance because one of the things that made nicotine so uniquely addictive is that you could in the form of cigarettes that you could do it anywhere. It was socially acceptable. And so that meant, like, you pick up a coffee, it's a cue to smoke. You talk to your friend, it's a cue to smoke. You have sex, it's a cue to, like, it was just everything. And now the places where you can do it are so limited that those cues are reduced. Now, it doesn't mean that you get stressed and you don't want a cigarette if you are addicted, but, and that can obviously happen anywhere, but the Q related stuff is really reduced in the smoking situation by limiting the times and places where you can do it. And that's a useful lesson for other things. And, like a lot of times we just think that, you know, addiction is just sort of like pure biology, but it's not. It always has to do with set and setting and with your own biology and your history of trauma and all kinds of other things like this and the culture. So it's an interesting area because it is so complicated, but that also means that we tend to overgeneralize and that ends up causing serious problems.
ELISE: Yeah. Well, I thought that that was fascinating in Unbroken Brain, both your own story, but I hadn't heard the theory of addiction as a learning disorder, and I know that that book was published seven years ago, maybe, but that was so fascinating to me and so insightful and in terms of offering hope, I think to anyone who's listening who maybe has a child who is going through addiction, the fact that so many people do out grow it.
MAIA: And again, fentanyl is causing issues because it is so deadly. But thankfully, the good news there is that most young people are not trying prescription opioids, are not trying street opioids are just like, you know, maybe they want to try ecstasy, maybe they want to like smoke some pot, but we have these cycles of drug use in this country where, like, one thing is particularly trendy, and for the generation immediately after that, it's like, nope, not touching that stuff. Might do something different, but not touching that stuff. And I mean, this is how, you know, crack went out of fashion. Now this doesn't mean that people aren't still addicted to it, and there aren't still places where people are despairing and starting to try some of these things, but the sheer deadliness of the current opioid supply has led to a drop in the number of people who are taking that up. And that is definitely good. And this is like a fundamental message of harm reduction, if we can keep people alive, the majority of them will get better.
ELISE: Yeah. No, I think that that's not something that's known. That there's such a prevailing story, which again, and I understand this idea of let's keep people alive, let's focus on you know, needles, syringe, stuff that feels so obvious to us now. You were alive, you were living through, you were surviving through the AIDS epidemic and involved then, was somehow seen as aiding and abetting or encouraging drug use rather than preventing the spread of AIDS. Do you feel like that's shifted? Can you take us back and then sort of explain that central argument against harm reduction?
MAIA: There's this whole concept of enabling, which I think we need to get rid of. And it's this idea that like, another person can control someone's addiction. That if you give people a lot of drugs, you are going to, you know, make sure their addiction continues. Now, obviously, if you have somebody chained up in your closet and you're giving them drugs, you might call that enabling, right? We have many studies now on actually prescribing heroin to people with heroin addiction, and that should seem to people to be like the most enabling possible thing you could do, right? Like, that should make their addiction last longer. That should prevent them from hitting bottom. That should keep them from getting better. It absolutely does the opposite. The longer people stay engaged in heroin maintenance treatment, the more likely they are to become abstinent or to go towards more traditional forms of medication treatment. So, that concept is just false. But, you know, we have this idea, it's certainly the case that, like, drug trends are social and you know that like when celebrities get into cocaine other people might be interested in trying it, that's how capitalism works a lot. Right. But when you're talking about something like addiction, when somebody is addicted to something they're not deciding, every day, today I'm going to continue to use, you know, it's just like, okay, this is what I need today. This is the thing that allows me to feel okay. And so I will seek this. So, you know, providing it doesn't stop that process or make it last longer. The definition of addiction is compulsive drug use that continues despite negative consequences. And this is agreed upon by all the major people who have thought about this for many years. This is not needing something to function, like needing something to function is dependence and we're all dependent on a lot of things like each other. But the idea that like negative consequences is going to fix addiction and make you hit bottom and therefore you will get better like, By definition, that is what works, for one, because by definition, the condition would not exist, but also when you just think about, like, who's more likely to get better, somebody who is rich and has a ton of resources, or somebody who is homeless and uneducated and traumatized and has nothing. I'm going to go with the rich person for that, right? Because they at the very least can get treatment if they want it, for one. And they can be housed and they can have all these things that will allow them to get better. It's not the people on the bottom who get better. You know, it's not to say obviously, there's plenty of poor people who do recover, thankfully.
But what allows people to recover is not giving them more pain and suffering. But actually treating them like human beings. And what allows people to recover is beginning to value yourself again, and that is helped by other people valuing you without judgment and without trying to make you change immediately. And that's why harm reduction is so powerful, because the basic thing is, we don't care about you getting high, we care about you getting hurt, and we just want you to live. And when somebody comes at you with that attitude, it's so much more different than when somebody's like, you gotta stop, this is bad for you, like, you are worthless if you do this, like, you're destroying your life, you're destroying other people's lives, like, it's all stressing that person out, and from the perspective of the person who is addictive, the substance is, or the activity, or whatever they're addicted to, is the thing that makes their life worth living. And so telling them that you're taking that away is not especially helpful, it just sort of shuts down the conversation. On the other hand, if you talk about what do you want. Like, how can we make your life better? That's so different. And that is, you know, with any other medical condition, like obviously sometimes if you have cancer or something like that, and you need to go through horrible treatment, it's going to be painful before you're going to get better. But the whole idea is so that you get better, not that the pain is the thing that is going to make you better. We don't say like, if somebody has chemo that is like horrible and especially, you know, your hair is coming out and you're in pain and agony and throwing up and all this, we don't think that that is what makes it work. Like, we're perfectly happy when somebody comes out with a new genetically tailored thing that causes zero suffering and kills the cancer. We don't think, oh, well, you didn't go through the hard work of recovering because you... you know, but we have this really moralizing and it's so deep, it's so entrenched in the way we think about these issues, that when you actually take the analogy to, you know, other medical conditions, it's like, Oh, wait a minute, you're right. That is not how we treat other conditions at all. There used to be this thing where, you know, Oh, well, God cursed Eve to suffer in childbirth, so we shouldn't believe labor pain. But, you know, we're beyond that now. And we should be beyond this with other conditions as well.
ELISE: Right. And reading about early needle exchange and I loved both of the books, but Undoing Harm was full of so many incredible stories about people who have Worked on this issue and in really stunning ways and many people who have died right, who have been Fierce advocates who have also succumbed which I thought was beautiful in its own way but this idea with needle exchange or with Heroin prescription for example that if you can one that if there's some small intervention of care that people who even though they might be addicted are perfectly capable of choosing or wanting the safer option, right? Because that was one of the arguments, was one, you will increase it, and two, these guys are automatons and they don't care. And that certainly wasn't true. Even for people, for addicts who already had AIDS, if anything, more than any others, they wanted to protect
MAIA: I mean, like, I remember, there was this New York Times story about this where the very 1st needle exchange in New York City that was set up to fail by the city government and like they had this thing at City Hall, right across from the courts and the cops headquarters, which is of course where everybody doing illegal things is really going to want to go. But one of the guys that they interviewed there was like, yeah, I am already HIV positive but I get the clean needle so that like, I won't share with anybody, and I won't hurt them. We think of people with addiction as these like selfish zombie automata that are, you know, they don't care. There are jerks and assholes in every area and profession. There are people who give everybody else a bad name in everything. But among people whose addiction there's also just like among anybody else there's also really lovely human beings and having an addiction isn't doesn't make you a bad person and being a bad person doesn't make you someone with addiction like there's some overlap but the overlap is to do with things that pre exist the addiction, not the addiction now that's not to say that being addicted won't exaggerate your negative Characteristics, just like being in love will do if you're somebody's trying to get between you and the person you love. But any appetite is going to stress your moral behavior to some extent. And any sense that this is the only thing I need to live can, you know, put you in under that kind of pressure. But for the most part people with addiction are just people like anybody else. And some of them are absolutely lovely people and some of them aren't.
ELISE: yeah, but it was so interesting and again like this I'm sure is blowing some people's minds as an intervention, But that when you medicalize heroin when you create a stable and safe supply For addicts where they're not, one, sort of driven by that impulse, like am I gonna get it or am I not? Which only seems to heighten the addictive impulse, when you can neutralize that and then ensure that people aren't taking something laced with fentanyl and, you know, obviously, I think it's in Canada, injection sites where they take the drugs on site in case they need to be revived. Absent that daily struggle to feed the addiction and what might be required in order to do that, they're suddenly left with time, energy, and maybe the idea that their life could be more.
MAIA: Yeah, what's really interesting to me about this is that we just dehumanize addiction and make it such this alien thing that it's like no other experience. And that's not true. That's not true of mental illness. That's not true of anything like, you know, it's like certain mentally extreme states are not common and most people don't experience them. But things like anxiety, we've all experienced that. Not to the degree of having an anxiety disorder necessarily, but we can all know what fear is like and can imagine that if it was, you know, ramped up to a thousand, that that would be a horrible experience. But that doesn't mean that you're no longer human if you have the ramped up to a thousand version. But with addiction, we tend to think that it does. And so like, you know, think about when you get that thing that you've always wanted that you think is going to fix you. It might be a boyfriend. It might be a job. It might be a certain level of success. It might be a kid, whatever it is. You get that thing and it does not fix you. Whatever it is, it doesn't. That's just not the way human life works. And that's also true of heroin. And so when people are not in that I just have to chase this all the time, and all my life is basically a career of chasing this thing that gives me purpose, you suddenly have to look at some other stuff.
Now this doesn't mean that people don't be like, okay, well, now I've got the heroin sorted. I'm going to chase cocaine or something. You know, people can do all kinds of things that are unhealthy. But for people for whom opioids are that central thing, giving them a safe supply often allows them to stabilize the rest of their lives. And a unique property of opioids is that if you take the same dose at the same time every day you will be completely tolerant to the high. So, you know, this is how methadone and buprenorphine work so basically, like, I could be on some massive dose that would maybe kill you and you wouldn't know it because I would have that complete tolerance. Now, that does not happen with alcohol, which is why We don't do alcohol maintenance, I hate the term medication assisted treatment because it's like we know that the medication is actually what like causes the reduction in mortality associated with it, but we don't have alcohol assisted treatment. We do have, there are some places now that are doing sort of supervised drinking sites for people who are you know, severe alcohol use disorder, and while this does not leave them entirely unimpaired, it again can have this same kind of stabilizing effect for people who are homeless, and it allows an opportunity to reduce harm.
ELISE: Yeah. Well, and like methadone, et cetera, there are a lot of medications for people who have addiction to alcohol. There are a lot of drugs. I don't think that they've received the same PR
MAIA: I mean, the thing is, because opioids have that unique tolerance effect that isn't the case with, say, alcohol or stimulants or benzodiazepines, it is so much easier to stabilize people with something like methadone or buprenorphine or heroin itself than it is to do with alcohol or other depressants or you know, stimulants. Now, stimulants, it's interesting because people are starting to look at like, well, what happens if we give people methamphetamine, you know, there's actually a prescription form of methamphetamine, what if we just give this to people who are addicted, because there was this fear originally when you give opioids that if you give heroin maintenance to someone, you're always going to have to up the dose and et cetera. That does not happen. Stimulants sort of have more of a tendency to for that to happen because like they escalate like wanting so much they escalate that desire, So it's not satiating It's kind of like if you think about the pleasure of sexual desire versus the pleasure of sexual satisfaction, infinite satisfaction can always be satisfying, but infinite desire is bad after a while if it isn't satisfied.
But, that said, there are people for whom stimulant maintenance does work. I tend to think that what that means is that You're probably treating ADHD. But those people stabilize and do not need infinitely escalating doses, because if you give very high doses of stimulants people don't become tolerant. They just can be psychotic. So obviously you do not want to get into that level of dose escalation, but that doesn't seem to happen for a select group of people. And there's more research on this going on to try to find this. And there are also some medications for alcohol use disorder. Most of them are not like the idea that we would find something that just stabilizes you, that kind of gives you the same effect. But there's something called Baclofen, which helps some people and has that kind of stabilizing anxiety reducing effect. Benzodiazepines have their own class of issues related to severe withdrawal afterwards for some people. You don't get that complete tolerance to the impairment thing. So it's interesting though, but yeah, we don't have as good medications for other conditions as we do for opioids.
ELISE: Yeah. Well, and there's just such a need for psychiatrists who really understand, a friend of mine is a functional psychiatrist who you should know if you haven't met him, but his whole thing is like, there are so many nutraceuticals. What is ultimately the cause of severe brain damage with...
MAIA: oh, thiamine, yeah.
ELISE: So essentially he's like, there are just these core magnesium stores, like so many things that are depleted that need to be restored that also can help with cravings, etc. Like it's a complex, we're talking about a very complex system. The other thing that I thought was so fascinating, going back to Unbroken Brain, briefly, but you talk about the, not the causation, but the correlation between, one high IQ and addiction, but also how there's typically some sort of other mental illness present. I know you write about a self diagnosis of being maybe on the autism spectrum disorder. I don't know if you've since been formally diagnosed.
MAIA: I was like, I was considering it and then I decided I got so many wrong diagnoses in the past, why am I suddenly going to think that somebody pronounced difference. If you want to look up the criteria and look up my childhood, they match.
ELISE: Yeah, but it's so interesting that whole conversation that you get into about both sort of the shadow and the potential redeeming factors of identity around diagnosis, I think, is so Fascinating, right? One, to be seen or embraced or to recognize yourself in those pages as an explication for how you feel and then also, obviously, it can be contained...
MAIA: yeah.
ELISE: It has its downsides.
MAIA: yeah, cause I think this is one of our difficult questions of our times, you see kids online, they're embracing these diagnoses and stuff like this. And If they're embracing it as like, okay, this explains a lot about, you know, why I behave the way I do and it helps make sense of stuff that didn't make sense to me, that's great. If you then take it and then be like, well, this means I can't do. X, Y, or Z, if you put it as a limitation on yourself, it's a problem, but if you see it as like an explanation that can allow you to find workarounds for the things that you find difficult, then that's helpful. And so it depends on are you taking on this identity as a stigma and a limitation, or are you taking this on as like, oh, okay, this explains why I can't deal with loud noises. Let me see what I can do to Make that better. And I think it's especially complicated when you're talking about teenagers, because teenagers are so socially influenced by each other and also so malleable still at that point. So it's really important to, if you are self diagnosing, really think the whole thing through and be sure that you're not Limiting parts of yourself that don't need to be limited, don't say well, I'm aspy, so therefore I am never going to be able to have friends. You know, instead it's like, okay, I'm on the autism spectrum, like this is difficult for me, but I also know that I really need this. So how do I find ways to make it work where I can connect with people, but I'm not masking myself too badly. And I'm also just being able to be in a space where I can deal with my sensory whatever's, you know, because We do define ourselves. We also define ourselves in the context of others and how people see us. And that complicated feedback loop makes understanding and avoiding limitations difficult.
ELISE: Yeah. No, that makes a ton of sense. All right. So I want to ask you to go into two things. One, for anyone who's listening who has a loved one, a child, a partner who is in an active addictive phase, what is your best advice? And then I want to talk about culture and I want to talk about harm reduction and what you see for as our path forward. But let's start with the personal.
MAIA: So I think the you know, people who have active addiction are struggling and it's really important to understand why they behave the way they do. And one of the things that a lot of people told me that they got from Unbroken Brain who were like relatives and loved ones of people with addiction was like, Oh, now I understand like their perspective. And this is not like aimed at me, sometimes teenagers will do rebellious behavior to piss parents off. That's not what addiction is, you know, once you're addicted, what you're doing is trying to be okay in yourself. And so, you know, what is it that makes you not okay? Like, why is it that you need this extreme form of relief? What is it that you were trying to get from these substances? Not, what are these substances doing to you? Because when you look at it that way, then you can help them find healthier ways of dealing with it. And, this may not happen immediately, and you have to really realize that you can't make someone want to change. You can invite them to do it and you can be welcoming and you can be supportive and you can help them see why changing would help them, rather than why they're changing would help us.
So, the more you can do that, the more you can sort of ally yourself with that person and really empathize and understand Why they're doing what they're doing, then the easier it will be to help them find better ways of doing this because like, nobody wants to be, you know, shooting up in the street, like, it's awful, like, first of all, you're not even going to be enjoying yourself at that point, you're going to be worried about somebody like stop, you know, it's just going to be terrible. And then, you know, with fentanyl these days, You get high for all of three seconds and then you're asleep and then people are robbing you, this is not about people wanting extra pleasure and being irresponsible and like they're having so much fun doing this, like, this is desperation. And so what is going to make somebody less desperate, not more desperate, and how can we connect to them? Because so much of addiction is about feeling like, even when people are trying to show you that they care, not being able to believe that they really do. And so it's complicated, it's slower than you would like there definitely are people with addiction who are gonna behave terribly, and you know, and that's really difficult for family members, if you have somebody who, you know, actually you know, is a very callous person, such people exist, and they may steal from you and do things In ways that like You can't comprehend why they would be able to behave that way.
And so, you know, if you're dealing with people who basically have personality disorders as well as the addiction, that gets much harder, because for them to get better they're going to have to address that. And it may be difficult for that to happen. Thankfully, this is not the case for most people with addiction. And you you know, oftentimes the bad behaviors directly associated with the addiction and you resolve the addiction. And that resolves the, you know, stealing from you or whatever kind of thing. But people who have been very severely traumatized or who have just severe mental illness and personality disorder, that is just a much more complicated path to recover from and it, you know, my heart goes out to people who are just facing that because it is just really, really hard.
ELISE: I think that the point to, unfortunately, as reductive and essentialist as we've tried to make this as a culture over time, it's complicated, right? There are unknown genetic factors, there might be trauma, you know, and there's obviously a really big trauma story right now, which is, I'm glad that everyone is becoming trauma literate. But what I also hear from people who have a child or a partner, specifically a child who is struggling with addiction, that that creates on its own stigma, right? Where suddenly they're like, wait, now the prevailing cultural ideas that I've traumatized my child.
MAIA: I think it's very important to say that trauma does not mean child abuse. Like, trauma could mean your mom died. Trauma could be like a hurricane hit your house or you got raped by somebody outside of your family. So I think it's really important for people to realize that you can totally be an absolutely excellent parent of a traumatized child and the trauma had nothing to do with you and you couldn't possibly have prevented it. So I think, you know, assuming that there is trauma in somebody's addiction history, which is not always the case, but if there is, you should not immediately assume that it was bad parenting because sure, that could be the case sometimes, but again, there's so many different ways that people can be traumatized by so many different people. And it's also the case that so much of addiction has to do with people's temperament that will set them up for things. So, if you are incredibly sensitive to stimuli, something that wouldn't traumatize someone else might traumatize you. And again, that's not your parents fault. That's just how you were born. And I think it's really important for for people to recognize that, like, when somebody tells a story of addiction with trauma, that it's not always their parents fault. And that this is a really complicated disorder. And that, you know, in order to get better, it is often essential for people to have much better and richer social connections. But that doesn't mean that people didn't love them while they were addicted. They may not have been capable of taking that in the way they should have done because of these temperamental or traumatic or whatever kind of other experiences that might have caused issues.
But, you know, a lot of people want to be like, oh, well, you know, all you need is love to recover and that's not true. Like you definitely do need love and connection to recover, but you might also need antidepressants and you might also need housing and you might also need education and you might also need any one of a million things because what allows people to recover is like feeling connected and having a sense of meaning and purpose. There's no way to just provide that for somebody, because I can't, like, make you fall in love with me or something, or I can't say, okay, you're gonna love the oboe, so, you know, I'm gonna prescribe you become an oboe player, it's just, we don't know what it is going to be that somebody's gonna really get into, But that is the thing that often allows people to get better. And of course, we all know great musicians who still managed to be addicted. It is complicated. It is not just the one thing. And it's not just trauma. It's not just. loss of connection. It's not just loss of meaning. It's just like a whole combination of different factors. And so this is why it's so hard to give people advice on like, okay, what do you do if your person is addicted?
And so, you know, what you want to do is like, be open to the possibility that It's going to take a bunch of different things. And I mean, this is really true for most chronic conditions anyway, like you talk to people with like long COVID or with any of these things, and it's like 20 different small things are essential to like, allowing that person to be able to function again. And, you know, It's annoying because I'd like to be like, here, you just like do this and you're fixed. You know, and I should also say that for opioid addictions, we have two medications, methadone and buprenorphine, they cut the death rate by 50 percent or more if you stay on them. So if that is the addiction that's going on there, people should really be on medication these days because the the supply is so deadly that one relapse really can kill you and, you know, we make it very difficult for people to get medications in ways that are livable, but, you know, this is the data. It dramatically makes you more likely to stay alive.
ELISE: Yeah, so as someone who's spent your career, I mean, 40 years covering this intimately, I don't know if anyone has your encyclopedic understanding of this landscape. Let's just say you have that crown. So when you think about culture and where we are, and you know, I have friends who live in Portland, I understand things are, and it's unclear how that's going....
MAIA: want to say something about that, actually. So Portland decriminalized possession of all drugs. It did not legalize anything. It just means you're not arresting people for, you know, okay, you've got a bag of heroin or okay, you've got like some methamphetamine or weed or whatever it may be. Like they happened to do that just at the moment when fentanyl was spreading into Oregon, and so right when they did that, overdose deaths increased. It had zero to do with the decriminalization, because if you look at how when fentanyl becomes dominant in a local drug supply, you see exactly that same uptick regardless. So, who has the highest overdose death rate in the country? It is West Virginia.
They do not have alot of homelessness Why? Because it's cheap to live there. They do not have a lot of street drug use. Why? Because it's cheap to live there, so people use indoors. Because if you think about it for two seconds, like, do you really think Somebody who was like not going to use opioids said, Oh, I'm not going to get arrested and put in jail for 10 days for it. I'm going to try it now. Like, that is not what, you know, or I'm going to suddenly become, you know, like, homeless people, wherever they are, tend to get arrested for low level crimes over and over and over. Like you talk to anybody who's, who's been through that and it's like loitering and shoplifting and like the same things they go into jail for 10 days, they don't get treated. If you were to actually arrest all the people for doing that stuff, the jails would be filled full so quickly that it wouldn't function.
And when in New York, we did, you know, all these low level drug arrests in the 80s and 90s. And we, of course have absolutely no drug problem now. It's amazing. It's like, you know, if you just look at it in any of the statistics, like you just look at like, okay, what's the correlation between the rate of arrest for drug possession and the population level drug use? Zero. No correlation. It's like, this does not work. This has absolutely nothing to do with what is going on there. What is going on there is that they have had a pandemic, they have high housing prices and they have fentanyl, that might sound like, oh, well, look at this correlation is huge, it's just like they did this and it went up. Well, the places that didn't do it went up the same amount when fentanyl came in.
It's just a ridiculous thing, and if you just think about it for all of two seconds, like, okay people for possession. A lot of people have this assumption that, oh, we arrest people for possession and they get treatment. Well, who gets arrested the most? Black people, right? So black people must have the highest rate of treatment in the country, right? No. Because arresting people is not a good way to get people treatment because if you think about it for five minutes, if you get arrested, you go into jail, it's a bureaucracy, you're already, let's say you're a diabetic and you're on medication, you may not get that medication for three or four days because they have to sort out all the bureaucracy and they took all your stuff off you, right?
ELISE: Mm hmm.
MAIA: It's not a good way to treat any illness. Like, nobody thinks that the best healthcare is available in jails and prisons. Otherwise we would see rich people going there for treatment.
ELISE: Right.
MAIA: Like, this is just not what happens. And when you look at the rates of treatment for people of color, they are less likely to get treatment, and they get it later in their addiction careers then white people but they definitely get arrested more. So you tell me arresting people is good for the treatment of addiction and how pushing people to the bottom is like a successful way, you know, I mean, what does arrest due to people, it stresses them out. I think there's this crazy statistic, but it's something like maybe 20 percent of all the COVID in the country was spread via people coming in and out of jails. If you look at the effect of jail on life expectancy and prison on life expectancy, every year you're inside takes two years off your life expectancy. It's associated with the spread of every disease that you can imagine, it's associated with more death from cancer, more death from suicide, more death from pretty much any condition you can imagine. So, this is good for people's health? It's just basically what happened is some politicians understood that if you scream drug and crime, you can get elected. And, you know, Portland dared to like try to do, you know, or Oregon in general dared to try to say, wait a minute, you know what, this hasn't worked for 50 years. Why is it going to work now? And they stopped doing it. And so suddenly they're like, oh, stopping arresting people without instantly providing treatment for everybody is dangerous, even though Arresting people itself makes people less likely to recover because it makes you more likely to be unemployed and more likely to be homeless.
ELISE: Yeah. How do you see it evolving? I know people are watching Oregon. Do you think that in time it's going to sort of stabilize?
MAIA: I just hope politically they don't reverse it, because first of all, they're everybody's like, okay, well, okay, we need to start arresting people again, and then put them in treatment. But oh, yeah, we just used funding from not arresting people to form to fund treatment. So where's this money supposed to magically materialize from to start arresting people again and pay for treatment. You know, Portugal is such a good example in a lot of you know, that was the example that Oregon's Decrim was based on. And, you know, there was this ridiculous campaign by people to say that, well, what Portugal did is was arrested people and forced them into treatment. That is not what Portugal did. What Portugal did was give people traffic tickets, essentially, if they got them for possession. And, you were supposed to appear before a commission that would invite you to treatment. If you didn't show up, you didn't go to jail. If you didn't, if you said, I don't want treatment, you didn't go to treatment. First period of time they show dramatic reductions in overdose death increases in recovery, and you know, all the good things. Then they cut the money for treatment, and surprise, surprise things start to get worse again. But it was not that they suddenly stopped arresting people and that it made things get bad.
ELISE: Right. That makes sense. If you could write policy, again another huge question, or even just like three things, you know, everyone should have a Narcan prescription in their house and know how to use it or, I mean, what do you want to see?
MAIA: Certainly, you know, now naloxone is available over the counter in the United States, so, but it's stupidly expensive. But yes, certainly everybody should have it, should know how to use it, any first aid kit that you have, it should be in there for if, you know, a kid gets into something or a teenager gets into something or a grandmother takes it twice, you know. It's a useful drug. It doesn't do harm, like obviously it's not going to solve someone's heart attack, but it's not going to make it worse either. So, yes, absolutely that. I just also really think that we need to make medication available for people who are addicted. So, and including things like Dilaudid or Oxycontin or whatever, like our biggest mistake is We had this overprescribing issue. Now, most of the people who were overprescribed actually were getting the drugs from somebody who was having it in their closet and not actually taking it. Because most of the people who got addicted were not pain patients.
And now we have this whole situation of pain patients who actually need medication, not being able to get it, even if they're dying. what do we do? We cut the medical supply in half since 2011. What happened? Fentanyl. Street fentanyl, not prescription fentanyl. Why did that happen? Because we cut all these people off without, like, providing any help for anyone. We actually made the overdose rate double since we, you know, more people now died from overdose when prescribing was going down than died when it was going up. And so, you know, is even actual prescription fentanyl safer than street fentanyl? A million times, yes, this is the point of having an FDA so that you know what's in the stuff you're taking and if you want to avoid overdose, you know what the actual dose is.
So, you know, being legally able to prescribe for people who are addicted a safer supply would make an enormous difference is still all kinds of huge barriers to prevent, you know, and obviously we do not want marketing of this, like the difference between supplying people who are already addicted and making money by telling people that these pain medicines don't cause addiction in anybody. That's a huge difference. There are people who are already addicted and there's people who are not exposed. These are two different classes of people. They need different. approach. This is not really that hard, but if we would do that we could really dramatically reduce the death rate. And even if we could just like do things like make methadone available by prescription from ordinary doctors just stop restricting opioids to people who are already addicted because what you end up doing then is pushing them to a street supply. You don't end up helping them and stop it away from pain patients. So safer supply. And just really like we need to completely redo our treatment system like our treatment system is based on old ideas that are not helpful. And, you know, 12 step programs can help a lot of people. They are free and available 24/ 7 in many communities. You do not need to give somebody a pretty place to live and spend 10, 000 of my taxpayer money teaching them the 12 steps. When you are creating a treatment system, it should be based on stuff that people cannot get for free. This is not complicated, but really, really difficult to achieve because of cultural barriers. And because of, you know, so many people have made a living doing this for so long, and we're just about to pour tons of money into the system that already exists. And we know does not work very well. But if we were to, you know provide safer supply for people and really make it accessible. That would make a huge difference. And ultimately, of course, we need to tax the rich, basically. We need a much more equal much more equal society so that there is a middle class. And so that people Do not despair and have hope and are not, you know, replaced by robots and have nothing else to do.
ELISE: And so for people who aren't aware, the Minnesota model of rehab is built off of 12 step ideology primarily, right? And what you're suggesting is that we need something that's more science based, CBT Loving Intervention.
MAIA: We also need to understand if we actually are arguing that addiction is a chronic condition, treating it by 30 days inpatient does not make any sense. Like, we need to separate the treatment part from the dwelling part. Some people just need housing, and they may need sober housing, or they may need non sober housing, depending on where they're at. But you know, you shouldn't have to get your medical care in the place that you live to get addiction treatment. You need a safe place to live, that is clear and you need individualized medical care, which is very difficult to give in a residential setting where one size fits all works a lot better. So creating systems where people can like, oh, this person has depression, so we need to get them to a psychiatrist. Oh, this person has a high school education, or less than a high school education, they need job training. Like, they're not the same person, necessarily, and putting everybody through job training and everybody through depression treatment is not helpful.
ELISE: Makes tons of sense. Well thank you for your work and and I can't wait to read everything that you do.
MAIA: Thank you so much.
ELISE: We could have gone in so many different directions because Maia’s books are so encyclopedic in her examination and explication of all the different facets of this space. And her own lived experience, being addicted during the aids crises, saving herself most likely by learning about bleach, which is not the best harm reduction technique but was the only one available and was the impetus for her career. So, I think she is one of the people who is still alive and with us who really intimately understands all the facets and more importantly, the science, that’s what I loved about her book is that she examined what she took as face value early on in her career, or as some sort of essential truth that couldn’t be teased apart, including stories about who she was because she was an addict. So, she’s very careful, really fastidious in terms of looking at for example what she was saying about Portland and how there’s a spotlight on what’s happening in Oregon as not an example for the rest of the country, but that when you look at the rates and all these other factors, nobody should be surprised about what’s happening with unhoused populations. I highly recommend her work, you can find her with great frequency in The New York Times and other places. Alright, I’ll see you next time.
