First, do no harm: An argument for a radical new paradigm for treating addiction

There’s rarely time to write about every cool science-y story that comes our way. So this year, we’re once again running a special Twelve Days of Christmas series of posts, highlighting one science story that fell through the cracks in 2020, each day from December 25 through January 5. Today: why we should replace the punitive approach of the “war on drugs” with a radical new paradigm for treating addiction.

In 1986, Maia Szalavitz was addicted to heroin in New York City, weighing a scant 80 pounds and shooting up as often as 40 times a day. She had just discovered the heady mixture of cocaine and heroin known as speedballs, and had no intention of quitting, even though HIV was spreading rapidly through the community thanks to the practice of sharing dirty needles. But a chance encounter in an East Village apartment likely saved her life.

A woman visiting from California taught Szalavitz how to protect herself by running bleach through a shared syringe at least twice, then rinsing twice with water, as well as washing the injection point. It was Szalavitz’s first encounter with so-called “harm reduction,” an approach to treating addiction that emphasizes ways to minimize the risks and negative consequences associated with substance abuse—not just the risk of addiction and disease, but also social stigma, poverty, and imprisonment. Needle-exchange programs, for instance, supply free clean syringes to addicts, thereby reducing the spread of HIV.

Szalavitz eventually found her way back from addiction through a typical 28-day abstinence and 12-step program. She finished college and became a highly respected science writer, focusing on science, public policy, and addiction treatment. But she never forgot that California woman’s compassionate approach and wondered if perhaps there was a better alternative. Her personal experience, and many years spent researching the science behind addiction and harm reduction, gave birth to two books: 2017’s Unbroken Brain: A Revolutionary New Way of Understanding Addiction, and her latest book, Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction, published in July.

Last year, Szalavitz finally tracked down the woman who saved her life in 1986 and was able to thank her personally. “Ours was a story of how change happens, and how even the smallest things we do can sometimes make a tremendous difference,” Szalavitz writes in Undoing Drugs. “This also brought to mind the wisdom of the Talmud, which says that saving one life is equivalent to saving the entire world. These ideas are at the very heart of harm reduction, which takes the perspective that every life is worth saving.”

Ars sat down with Szalavitz to learn more.

Ars Technica: In your prior book, Unbroken Brain (2017), you advocated for a different view of addiction. We tend to either take the view that it’s morally bad and people with addictions are weak, or it’s a disease and people with addictions are broken in some way. You champion viewing addiction as a learning disorder. Can you explain a bit more about that?

Maia Szalavitz: I see addiction as a learning and developmental disorder. There’s a lot of evidence that supports this perspective because it tends to come on at a specific time in brain development: adolescence and young adulthood. Ninety percent of all addictions start in the teens and 20s. That doesn’t mean that you don’t see it developing in older people. It’s just much more rare.

Addiction requires learning because if you do not learn that this drug does something for you, you cannot find it and crave it. It requires you to learn that this fixes something for you. And that learning process is very similar to the one that you experience when you fall in love with someone, for instance, or when new parents fall in love with their baby. It completely shifts your priorities. Addiction changes your priorities in ways that may end up compelling you to do things that you wouldn’t ordinarily do.

Ars Technica: The traditional focus in the “war on drugs” has been on disrupting supply lines and reducing demand by discouraging use. Why has this approach been such a colossal failure?

Maia Szalavitz: Teenaged brains are wired to take new risks and to try to push away from their family because otherwise they would never get out of the nest. If you tell them, “Don’t do this,” they are quite likely to do it. So, the most sensible approach is to say, “Okay, we really don’t want you to do this. But if you’re going to do it, let’s make sure it doesn’t kill you.”

Scaring kids off of drugs doesn’t work. The reality is that, if you are a kid who is traumatized or beginning to develop a mental illness like depression, or who just cannot connect for whatever reason, drugs do help that. We don’t want to admit that. People don’t understand what’s actually going on when people take drugs. They think it’s only rebellion and it just needs to be crushed. Or it’s hedonism that also just needs to be crushed.

It just doesn’t work that way. The people who end up getting addicted are people who have something that is preventing them from being emotionally comfortable in their own skin. At least at first, drugs work for that. When you find something that at last makes you feel okay and warm and safe and comforted, that is going to be very attractive.

I’ve asked people about their experience of opioids in the medical system who admitted, “You know what, I had Oxycontin for some surgery and it was the best thing ever. And I knew I wouldn’t touch it again because I didn’t want to lose my job or my marriage or my kids.” They think they’re the only person that had that experience, the only one who was ever able to resist that irresistible euphoria. In fact, that is the most common experience. It’s not the case that this intense drug pleasure is irresistible to everybody. It’s irresistible when you have no alternative, when the rest of your life is dark.

It’s hard for people to understand that. And so addiction is defined as compulsive drug use despite negative consequences. We spent the last 100 years trying to use negative consequences to fix something that’s defined by its resistance to them. It’s time for something else. That’s where harm reduction comes in. Once reducing harm becomes the goal, you realize, we’re doing harm and it’s not actually helping. And you have a very strong moral weapon against prohibitionists, because their greatest goal is stopping the evil drugs. Your greatest goal is saving lives.

Ars Technica: There seems to be a strong belief in our culture that people must suffer consequences for any behavior that is seen as outside the norm. So your notion of what you call “radical empathy” is something that is quite foreign to many people.

Maia Szalavitz: People with addiction are often homeless, rejected, and marginalized. Many have pre-existing mental issues. Nobody wants to see them. So when somebody approaches them with love and no judgment and says, “Hey, I don’t care if you’re using drugs, I just want you to stay alive”—that changes everything. When people feel valued, they might value themselves more.

Sometimes they find out that drugs are getting in the way of that, and they stop the drugs. Sometimes they cut back, and sometimes they are so traumatized they still can’t get out of it. But at least they’re not dying. To me, it’s a spiritual thing. I don’t generally categorize my experience that way, but harm reduction is so different from the way people with addiction are typically treated: “You’ve got to hit bottom,” or “we’ve got to break your personality down in order to fix you.” Harm reduction is the antidote to that.

There are programs where they prescribe heroin to people with addiction. I mean, it’s free heroin. You’d think those people would never get into recovery because they’re getting exactly what they want. The reality is, when you get free heroin and you’re not chasing, chasing, chasing the next fix, and you don’t have all of that drama, your life suddenly has this massive hole. That’s where recovery can come in, because you actually get bored. People with especially traumatic histories might have to be on drugs for a while and learn ways of dealing with their trauma before they’re capable of stopping the drugs.

Nothing’s perfect. Nothing will work every time. This is why it’s called harm reduction. We want people to change in a flash. That makes for great TV, but that is not how most people change. If you do meet people with addictions where they are, if you do listen to them and hear their concerns, that’s the only way you’re going to be able to affect them. How do we try to change people who have heart disease or diabetes and need to change their diet? We certainly don’t put them in jail for having high blood sugar.

Ars Technica:. The difficulty is that radical empathy runs counter to the worst of human nature.

Maia Szalavitz: Absolutely. I feel radical empathy is the heart of all religions, in the true sense of actually practicing it. I’m Jewish, but when you see harm reduction in action, it is about as Christ-like as you could imagine. You’re providing something to somebody with no hope of them paying you back for it—no hope of anything other than helping that person.

Harm reduction focuses on trying to practice that. Maybe we can, for this one person, help them avoid an overdose, or provide them with medication when they’re incarcerated. The long-term goal is to move beyond that. But we can do something to save these lives now. Every time I talk to people who are actively addicted I realize, these are human beings who have something to give. Every single one of them. And we just throw them away.

Ars Technica:  I want to talk a little bit about the distinction between helping and enabling, because this is something that many people struggle with when dealing with addicted loved ones.  

Maia Szalavitz: My feeling is that we should get rid of the word enabling. The concept of enabling comes from the idea that addiction is cured by hitting bottom. So if you enable a person with addiction, you’re preventing them from hitting bottom and therefore preventing them from recovering. However, for many people the concept of hitting bottom is ridiculous, because every time you relapse, you hit a new bottom. It’s a narrative device, it’s not scientific. Instead, what you want to do is help the person to stay alive until they can hopefully find their way as best they’re able.

For friends or family members, you have to figure out what you’re comfortable with doing. But don’t just think, “Everybody says I should just throw them in the street and then they’ll get better.” They might get better or they might die. If you want to throw somebody out of your house because they are stealing from you or harming your children, or you can’t deal with their active addiction, that’s fine. It’s totally okay not to let somebody abuse you. But do that for you. Don’t do it for them.

Ars Technica: The US is currently in the midst of an “opioid epidemic” in which increased prescription of opioid medications led to their widespread misuse. I know you have strong opinions on how US public health policymakers have handled the crisis. 

Maia Szalavitz: Eighty percent of people who develop problems with prescription opioids did not have a prescription for the first opioid they misused. They got into someone’s leftovers. This is a sign of how non-addictive opioids generally are: between 40 percent to 60 percent of people who are prescribed opioids end up with leftovers. We had an overprescribing issue where the people who were getting addicted were not the patients. They were the friends and relatives of the patients. There were also people who would fake pain to get prescriptions, and there were pill mills. So what did we do? We decided to monitor all prescriptions and start cutting doses, and cutting people off.

It’s happening to hundreds of thousands of people. Doctors are being told, “You can’t prescribe over X amount and if you do, law enforcement’s going to be on you.” There’s even a reduction in opioid prescriptions for patients with terminal cancer. How does that make any sense? Denying people who have gotten benefit from opioids access to the medication that is often the only thing that works for them does not help anybody. It is more likely to make that person commit suicide or turn to a street drug than it is to help them. We’ve forgotten everything we know about how to use these medications effectively.

Ars Technica:  So what is the solution?

Maia Szalavitz: The solution is complicated. One, stop cutting people off of pain medications even if you think they’re addicted. It should be legal for doctors to maintain people’s prescriptions if only to avoid forcing them to resort to street drugs. Just cutting them off doesn’t “cure” the addiction. Two, stop locking them up, which is also killing them. And three, figure out ways to provide a safe supply without marketing it.

Ideally, we would fund treatment that is user-friendly and welcoming and evidence-based and that recognizes that addiction is a highly individualized, complex thing. If I come in, and my problem is depression and loneliness, and I’m using drugs to self-medicate that, we need to find a way out of that that will give me a new sense of meaning and purpose and comfort in life. That’s going to be different for different people; what helps you, I might hate.

We need to re-humanize the whole system. I’m actually hopeful about this, because two-thirds of the public now supports decriminalization of possession. You couldn’t have imagined that in the 1990s. I have seen harm reduction go from being championed by two people in Liverpool, to being an international movement that is making inroads against prohibition. There is still a fight over needle exchange programs, but now the CDC is saying that states should have them, rather than the federal government saying, “We’re going to ban funding on that because it sends the wrong message.” And I am very hopeful about medical students and young doctors who’ve really grasped the idea of harm reduction and are trying to change systems to adopt it.

Editor’s note: The terminology in this article has been updated in accordance with current AP style guidelines, replacing “addict” with “person with addiction.”