The following is a conversation between Maia Szalavitz, author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, and Denver Frederick, the Host of The Business of Giving.
Denver: Drug overdoses now kill more Americans annually than guns, cars, or breast cancer. Yet despite this, our understanding of addiction is stuck with ideas from a bygone era. My next guest has explored new ways to understand addiction from viewing it as a learning disorder, as she did in her groundbreaking book Unbroken Brain, to the idea of harm reduction, which will be central to her new book coming out next year titled Undoing Drugs. She is Author and Neuroscience Journalist Maia Szalavitz, who’s with us now.
Welcome to The Business of Giving, Maia!
Maia: Thank you so much for having me.
Denver: So, Maia, how do you define addiction?
Maia: I like to use a very simple definition that most people agree on, which has taken a very long time. But as of this moment, the National Institute on Drug Abuse and the DSM, the Diagnostic Manual of Psychiatry, both agree that essentially, addiction is compulsive drug use or other sorts of behavior that continues in the face of negative consequences.
Denver: That’s a good definition. is addiction caused by any one thing, or have you found it to be a combination of elements?
Maia: No, it’s definitely multifactorial. And that confounds a lot of people because they just want to say, “Oh, you just expose the person to the drug, and they get addicted.” Well, 80% of the time, even with something like heroin, that doesn’t happen. So you have to start looking at other factors.
Denver: Many look at addiction, Maia, as either a moral failing or a disease, but you say, as I alluded to in the opening, that it’s a learning disorder. Expound upon that a little.
Maia: Sure. Basically, what happens when you’re addicted is that your brain falls in love with a substance or a compulsive activity, as opposed to a person, or as opposed to the love that you have when you have a new baby or a new child. So, you are not a zombie who has no free will, as a sort of disease view would have it– where once you pick up the first drink or drug, you are just completely under the control of that, and you are powerless.
Instead, what happens is that you learn that this substance fixes a problem for you, and then it comes to seem as important in your life as the love of your life, or as your child. And you end up setting priorities in ways that seem really weird because you are doing that in relationship to a drug; whereas if you change your whole life and change all the things you’re interested in and do all kinds of other strange things when you’re in love, people understand that.
Denver: Right. You’re writing in part from firsthand experience because you were addicted to cocaine and heroin from about, I think it was age 17 to 23. Tell us a little bit about that journey, and maybe starting with your childhood.
Maia: Sure. Basically, I trace my addiction to a sort of temperament, combined with environment. So I had a very oversensitive temperament. Lights were too bright. Sounds were too loud. Emotions were difficult to control. These days I’d probably be diagnosed as Asperger’s, although now they’ve taken that as autism spectrum disorder. So, I would basically just get overwhelmed by things, and I couldn’t socialize very well and was very isolated; and then I got bullied, and then I felt like I was worthless.
And when I discovered drugs, they seemed to reduce the overintensity of my experience, particularly heroin. And it gave me an obsessive interest. People on the spectrum tend to have obsessive interests. So, when my obsessive interest was drugs rather than, say, science fiction, many more people were interested. And it was not just the substance itself, but it was the social context of it, where I could feel like I had literally brought something to the party.
Denver: You became popular.
Maia: Yes. Certainly, when there was cocaine.
Denver: I’ve always been curious about this because you see so many people who turn to drugs, let’s say, in the age range that you did that 17-, 20-, 23 years old. Is it because the opportunity is there at that time? Or is there something about our brain development that makes us even more susceptible at that age?
Maia: I tend to think that it is both social and due to brain development because at that time, your brain is getting you ready to be an adult. And so, you become interested in sexual things, and you become interested in peers rather than your parents. And your dopamine system changes. All kinds of things change.
And basically, the systems that are going to prepare you for mating and child rearing are gearing themselves up, and the adults are not very happy about that generally. And the risk-taking behavior that tends to be seen among teenagers, obviously, drugs can fit in with that. So, you have a situation where both socially and biologically, you are at risk. And 90% of all addictions do start in the teens or early 20s.
Denver: Dig a little bit deeper into this, but what happens to a person when they become addicted? How do those priorities really get reset?
Maia: Basically, you come to see the drug as essential for your emotional survival. And over time, it becomes more important than your actual relationships, or your work, or the things that people normally get pleasure and purpose from.
Denver: You hear all the time stories of addicts who hit bottom. And that’s what shook them up and got them on the road to recovery. Is there anything such as hitting bottom?
Maia: Retrospectively and in a narrative, yes. Scientifically and in the real world, no. Because the problem with the idea of bottom is that you can only define it retrospectively because let’s say, I say I hit bottom and then I relapsed. OK, now I’ve got a new bottom. And I relapsed again; now I’ve got a new bottom. Unless I’ve already died sober, you can’t tell what the actual bottom was, so it’s not a useful concept. It can’t be predictive.
It’s also deeply problematic because if you think that negative consequences… things getting worse and worse and worse and worse are going to solve addiction, you have a real incentive to make things bad for people with addiction so that they force them to hit bottom. And that has killed a lot of people, and it’s done tremendous harm to a lot of people’s relationships and to many other kinds of things. And the reality is: if negative consequences worked to stop addiction, by definition, it wouldn’t exist.
Denver: Yes. That’s right. That’s why prison would work. And that’s why prison doesn’t work. What are some of the main barriers that prevent people from getting help?
Maia: I think criminalization is a huge one. I don’t think that if we genuinely believe that addiction is a medical disorder– whether a learning disorder or disease, or whatever medical or public health problem… we don’t solve public health problems by putting people in jail. We don’t need a hammer to get people to get treatment for depression. But we think that we need this for addiction because we still secretly see it as a moral problem… or sometimes not so secretly.
Denver: But what’s the motivation that gets people such as yourself onto the road to recovery?
Maia: You know, it varies tremendously, but having hope that there is some other way is really, really important. And having somebody believe in you, whether that’s another recovering person, or whether it is a parent or a partner or a friend or many people, just somebody thinking that you’re worthwhile. This is actually where harm reduction comes in because a lot of times people think, “Oh, you give somebody a clean needle, or you prescribe them heroin, or you do these harm reduction-y things, and that will enable them, and they’ll never hit bottom, and that will be bad.”
But what happens in actual practice of harm reduction is you give somebody a needle, and they’re like, “Wow! Somebody cares about me, regardless of if I continue to use.” They’re not saying you must change to be acceptable. They’re saying: I want you to live, even if you’re still using. And that’s a really powerful message because especially like if you’re homeless or just very, very addicted, you will generally have lost most of your social contact, and people will often just walk across the street so they won’t have to deal with you. And that’s just a horrible thing to experience.
And so, when somebody says, “Hey!”… like if you’re homeless or just so marginalized, the only people you encounter will be people who have an agenda. “I want you to get into recovery, and I don’t care about you if you’re not.” So when you encounter somebody, who’s just “I care. I think you’re worthwhile. I think you deserve to live,” your eyes open and you start to think “This person thinks I’m worthwhile. Maybe I can make some other changes,” and “That person is doing amazing things. Maybe I can be like them.” So, having examples and just unconditional, non-judgmental compassion, love — all of these things can be very powerful in motivating people to recovery.
Now, sometimes, obviously, that’s not going to be enough, and a lot of people with addiction have either childhood trauma-related issues or mental illness, or more typically both. So, you’re going to need to deal with the symptoms that the person is self-medicating if you’re going to take away this self-medication. And so, a lot of times, that doesn’t happen, and we end up just taking away the medication. And people completely lose it, and they just relapse immediately.
…the idea that people with addiction are just having so much fun, that they will never stop if you don’t force them, that is just not true. By the time you’re addicted, most of what you’re doing is definitely not fun, and you’re just trying to get back to normal.
Denver: What do you say to people who say that harm reduction — that whole idea, that concept — is really enabling people to stay on drugs?
Maia: The reality is if you look at the data, that does not seem to be the case. Like you imagine you give somebody prescription heroin — that’s the ultimate in enabling — but oftentimes, people stay on it a few months, and then they go to abstinence treatment, or then they go to more conventional medication with methadone. They don’t stay actively using any longer than they do if you, say, force them into abstinence treatment.
So the idea that like, “Oh, you just give them what they want and they’ll just never want to recover,” it’s based on a fundamental misunderstanding of addiction because the idea that people with addiction are just having so much fun, that they will never stop if you don’t force them, that is just not true. By the time you’re addicted, most of what you’re doing is definitely not fun, and you’re just trying to get back to normal.
The other thing about heroin prescribing that’s so surprising to some people is: just imagine that you hit the greatest success of your life, and the best thing that you’ve always worked for for years and years and years, and you suddenly get it. A lot of times, people are surprised that they just aren’t immediately fixed of all their flaws that they thought would go away when they were happy and had this thing that they were seeking.
Similarly, when you give somebody this drug that they’ve been seeking obsessively, and then they’re sort of like, “Wait a minute. That’s all this is?” And they have time because they’re not chasing after it all the time, and they don’t have to worry about the cops. And suddenly, it’s like their life opens up because they have room to not be stuck in that compulsion all the time. So, it actually is more likely to lead to recovery because of this kind of normal human feature of assuming that if we get this thing we’re obsessed about, it will fix us, and then finding that it does not.
Denver: It’s really interesting because I had a recent guest on the show, Rosanne Haggerty, who is from an organization called Community Solutions, and what they’re trying to do is deal with the homeless situation. And in looking at the homeless problem, there was this thinking that a person had to become somewhat self-sustainable and get a job before you could give them a home that they could afford. But they found out that when you put them in the home and gave them some housing, lo and behold, they went out and they got a job. So, there’s a little sense of this chicken and egg.
Maia: Well, yes. That is called” housing first,” and it comes out of harm reduction. Because if you think about it: You’re homeless, you’re chaotic; your life is really awful. How are you going to stop using drugs before you have a house?
Denver: Absolutely. Absolutely.
Maia: That whole thing never made any sense. And the funny thing about harm reduction is a lot of it is just common sense once we get away from the illusions we’ve created around people who use drugs.
Denver: Where do we stand in the field with this idea of harm reduction? Has it been widely accepted, or is it still debated quite a lot? Where are we?
Maia: We’re way better than we were in the ‘80s or ‘90s when it was seen as evil and enabling, and we can’t do needle exchange because that will send the wrong message. It has advanced tremendously to the point where there’s government funding for harm reduction programs. There’s thousands of jobs that harm reduction may be in the title or in the duties. We’re hearing a lot about it in relationship to COVID. So, it has become incredibly more mainstream.
That said, there’s still a really long way to go, particularly within addiction treatment, which unfortunately, because a lot of people in the field were trained that their way of recovery is the one true way, and everything else should be ignored and is wrong; that is proving a real obstacle to improving treatment. And I think in order to deal with that, we have to A) pay people more and B) make sure they’re more highly educated, which they will deserve the higher payout. Therefore, they will be able to… and I think we need to prioritize people in recovery for those jobs because personal experience can be really helpful. But it needs to be leavened with expertise. Genuine expertise, not just your own experience.
Denver: In speaking about those traditional ways of treating an addiction, I think you were alluding to the 12-step program, which is, I think about 80% of treatment centers are still using it. Give us your opinion of the 12-step program, the good and perhaps the not-so-good of it.
Maia: So, I first want to say that 12-step can be a wonderful self-help for many people, and many people find meaning and purpose and connection and all manner of good things that help their recovery within 12-step programs.
But 12-step is not treatment. And for too long, basically, you pay, $20,000, $30,000 a month for residential rehab, and 90% of the time is spent teaching you what you could learn in a church basement. And that’s a real problem. The other problem is that if we’re going to argue that addiction is a medical condition, it cannot be the only medical condition for which the treatment is confession, prayer, turning over to a higher power, and moral inventory.
Now, all of those things are wonderful for many people. Some people are not into them, but I generally think that most human beings could benefit from taking moral inventory and from making amends where they’ve done harm. But if you say that only people with addiction have to do that, then you’re saying we are worse people, and I’m not going to stand for that because that’s just not accurate. There’s certainly some jerks among people with addiction and jerks are probably overrepresented, but the…I will say–
Denver: Plenty of jerks to go around, we know that.
Maia: Exactly. And so, we would never let anybody get away with saying the things about any other group of people that they say about people with addiction.
…it’s so important to recognize that relapse is common in addiction. It doesn’t mean that you failed… in order to learn a whole new skill like recovery, you’re going to make some mistakes. What you have to do is learn from them and improve your technique so that you don’t hit those wrong notes.
Denver: So why do some people relapse? Do you have any research on that?
Maia: So that, obviously, that’s a complex question, but most often, it has to do with some kind of stress.
Now, if you look at the research literature, you will think that most often it’s because they saw a needle and had to run out and shoot up because they saw the needle and it was a cue. That’s because it’s easier to, in a laboratory setting, expose people to cues than it is to expose them to stress, which would be… certain kinds of stress would be very unethical to expose people to.
And those are generally the kind of stresses that lead people to relapse. So, you lose your partner, you lose your job, you get disappointed. And it’ll be very individual because people are self-medicating different things. So if you’re self-medicating for everything being too much, and you’re using a depressant or an opioid to chill out, you may have very different reasons for using than somebody who’s primary drug interest is stimulation, and they don’t have enough excitement in their life. It’s really varied.
But what you have to do, and this is why it’s so important to recognize that relapse is common in addiction. It doesn’t mean that you failed. If you just imagine you’re learning to play the piano, you’re going to suck at first. You’re really going to suck for a while. And so, in order to get better, you’re going to have to make a lot of mistakes, and they’re going to sound bad. Similarly, in order to learn a whole new skill like recovery, you’re going to make some mistakes. What you have to do is learn from them and improve your technique so that you don’t hit those wrong notes. But until you have done it wrong, it’s sometimes hard to do it right.
Denver: It’s a journey as you say, and sometimes we bring a finality to things. “Oh my goodness! I relapsed, therefore, it’s all over.” If relapsing is in part caused by stress, what have you observed with COVID, the lockdown, the economic uncertainty, with people who have been addicted?
Maia: It’s just a nightmare for everybody and probably slightly worse for people with addiction and mental illness. In some senses, because we’ve had to learn to manage stress, we might be just a little better off. But the reality is that human beings need social contact to relieve stress. That’s how we’re wired. Like when you’re a baby, if your mom doesn’t… or your caregiver, whoever it is, if they don’t regulate your stress system by holding you and cuddling you and being, saying those motherese kind of squeaky little things–
Denver: You’re going to hear about it.
Maia: Yes. But if you don’t have that, you will… like one-third of babies will literally die if you don’t hold them enough. And fortunately, this happens very, very rarely. But there have been settings where people, kids in hospital beds were just left there and they… you know, that stress system goes out of control, and you get all kinds of diseases, and it’s bad. So being in a situation where social contact is highly limited and where that fundamental thing is often inaccessible to you is going to be a huge stress on anybody, and people with addiction especially so.
Now, fortunately, you could have meetings online. You could do Zoom. You could talk to people on the phone. You can get a pandemic puppy or kitten, whatever. But you have to be able to realize that this is an extraordinary stress, and we need to do harm reduction because some social contact is essential.
Denver: Maia, how do you believe treatment should change? And also, with the advances in biology and exponential technologies, do you think we’re going to see a lot of dramatic change in the way we treat addiction over the course of the next decade?
Maia: I would certainly hope so. But I think that because it’s a complex bio-psycho-social problem, lots of people will be like, “Oh, look, psychedelics. You’re going to take it once, and you’ll be cured.” That is rare. I think they’re a useful tool for some people, and we should certainly research them. But the thing about most human behavior change is that it doesn’t happen instantly. It happens in a slow learning process.
And so, there’s going to have to be, like for example, you give a homeless person a wonderful psychedelic experience, and they feel whole and connected, and then they go back to being homeless. That doesn’t solve the problem.
Denver: No. Not at all.
Maia: So, we need to recognize not just the biological, but the psychosocial aspects of addiction. I think the biggest thing we could do to fight addiction would be to reduce inequality dramatically because inequality places extreme stress on humans. And even at the top, there are these social factors that will need to be dealt with that make me think that there’s not going to be a massive change.
I would really love to see “Let’s understand that medication treatment does not mean you are still addicted, or you are high all the time or not really clean,” as people say. No. Like it’s just…I’m on Prozac. I’m probably going to stay on it for the rest of my life. Am I high? No, I’m not. Do I think I’m a bad person because my brain happens to need this to keep me relatively chilled out? No, I don’t. I don’t think I’m inferior because of that. And if you do, you have the problem, not me.
So yes. So, I hope we get more acceptance of medications. I hope we can have an amicable divorce between 12-step and treatments. So that in treatment, you learn cognitive behavioral techniques and relapse prevention and all this kind of stuff that’s completely separate. And then, you have the option of going to whatever kind of meetings, if it’s 12-step, if it’s smart recovery, whatever it is. You might want to just go to a gym. Hopefully, we can go do those things again. I think treatment is going to have to be far less residential, far more individualized, far less punitive. And if we can decriminalize drugs, that will be a major, major step.
Denver: All good points. Because sometimes we deal with addiction and the people who are addicted as a demographic, where what you’re saying there is that they’re all individuals, and we need to evaluate them as such because it’s going to be a different road and a different path for every single person.
Maia: And we understand this about most conditions and about most groups of people. Like if I said, “I speak for all white women,” I would quite rightly be seen as ridiculous. But if I say, “I speak for all people with addiction,” people will listen to me, and that’s wrong.
We need to frame recovery as being accessible to everybody, and we need to have ways of marking our progress just for ourselves and for us to see how it’s going, but that doesn’t mean we should erase everything if somebody relapses.
Treatment just has to be fundamentally compassionate, humane, and centered on what the person wants, and that’s really what harm reduction is about.
Denver: Finally, Maia, you believe recovery needs some kind of rebranding. How so? And what difference do you think it would make?
Maia: Within harm reduction, there’s this organization called the Chicago Recovery Alliance, and they came up with a definition of recovery that I like, that is basically any positive change. So, if you go from using dirty needles to using clean needles, or if you go from using 20 times a day to 10 times a day, these small incremental changes are part of a recovery process and should be counted. If we are going to count days of abstinence, we absolutely can’t say that if you have five years and you slip in those five years, go away. That is ridiculous. And that also causes harm because it makes people’s relapses worse.
So, we need to frame recovery as being accessible to everybody, and we need to have ways of marking our progress just for ourselves and for us to see how it’s going, but that doesn’t mean we should erase everything if somebody relapses. Treatment just has to be fundamentally compassionate, humane, and centered on what the person wants, and that’s really what harm reduction is about. They talk about meeting people where they’re at. You’ve got to meet people where they are. You don’t want to leave them there. You want to help them make the kind of progress they want to make. And that is way more effective than trying to get them to do what you want them to do.
Denver: For sure. And I think as you found out, it’s not all the things you necessarily have to give up, but you also gain a lot of things as well. Correct?
Maia: Exactly. Frankly, if you frame recovery as something you have to give up, like as…basically, what I try to tell people who are thinking they have a problem and might need help is that recovery is going to be amazing. You are going to get the things in life that you wanted from drugs, but you’re not going to get them from drugs…and it’s going to be great.
It’s going to suck at first and maybe it’s a hard road at certain times, but in reality, it’s just better because when you’re addicted to something, it means that you really can’t enjoy it anymore. And so, whatever your recovery path may be, whether it’s moderation of drinking or complete abstinence, or maybe psychedelics once a year, whatever it is, you have to determine your path; and it will be better than your active addiction.
If your recovery is feeling constricted and small, and you’re feeling just about “Oh, I have to give up this. I have to give up that,” then there’s a problem. I think initially, it certainly makes sense… like don’t go out to night clubs every night… which you can’t do anyway now. But if within six months, you can’t go out and hang out with people, you’ve got a problem because your recovery needs to be more expansive and less constricted than your addiction. And you need to have many sources of joy and meaning and purpose that will actually work a lot better.
Denver: A positive message to lead us out on. I would encourage listeners to read now Unbroken Brain: A Revolutionary New Way of Understanding Addiction, and then come next summer, pick up Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction. Thanks, Maia, for being here today. It was such a pleasure to have you on the program.
Maia: Likewise. Thanks so much.
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