Joshua B. Hoe interviews Maia Szalavitz about her book “Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction”
Full Episode
My Guest: Maia Szalavitz
Maia Szalavitz is the author or coauthor of eight books including the bestseller “Unbroken Brain.” She has written for the New York Times, The Washington Post, Scientific American, the Atlantic, Time, the Guardian, and Vice.
Notes From Episode 112 Maia Szalavitz
The book Maia suggested was “The New Jim Crow: Mass Incarceration in the Age of Colorblindness” by Michelle Alexander
Full Transcript
Joshua B. Hoe
Hello and welcome to Episode 112 of the DecarcerationNation podcast, a podcast about radically reimagining America’s criminal justice system.
I’m Josh Hoe, and among other things, I’m formerly incarcerated; a freelance writer; a criminal justice reform advocate; a policy analyst; and the author of the book Writing Your Own Best Story: Addiction and Living Hope.
Today’s episode is my interview with Maya Szalavitz, about her book Undoing Drugs: The Untold Story of Harm Reduction, and The Future of Addiction. Maya Szalavitz is the author or co-author of eight books, including the bestseller Unbroken Brain. She has written for the New York Times, The Washington Post, Scientific American, The Atlantic, Time, The Guardian, and Vice. I also consider her one of the smartest people writing about addiction policy. I’m very excited to welcome Maya to the DecarcerationNation podcast to discuss her new book undoing drugs, Undoing Drugs: The Untold Story of Harm Reduction, and The Future of Addiction.
Welcome, Maya Szalavitz.
Maya Szalavitz
Thank you so much for having me.
Josh Hoe
I always ask the same first question, the comic book origin story question. How did you get from wherever you started in life to where you are now, writing books about addiction – and feel free to include as much or as little as you want. I know that sometimes that can be a traumatic story, too.
Maia Szalavitz
I was a very strange child. And part of that was seeming incredibly smart. And part of that was seeming incredibly weird. And so I struggled socially from the very beginning. And eventually, I discovered that drugs were an interest that people actually did want to hear me talk about. And I became obsessed with them. And then I got addicted to cocaine and heroin, and then eventually got into recovery. And so then, I was very curious about what had happened, because all of the stereotypes about addiction didn’t fit. So I wanted to learn what was going on with this. And so I basically became a journalist who covers neuroscience and addiction in particular.
Josh Hoe
Your new book is about harm reduction. I know this is a big question. And there’s probably not necessarily a complete answer. But given that some of the people who are listening to this might not totally be familiar with the concept, how would you take a stab at defining harm reduction, so we have a common place to start?
Maia Szalavitz
Sure. So harm reduction is the idea within drug policy, that the goal should be to reduce harm, not to stop people from getting high or taking drugs. And beyond drug policy, it means focusing on reducing harm first, recognizing that people are not going to abstain completely from whatever activity you are trying to change their behavior related to.
Josh Hoe
And you also talked about there being a continuum from getting better to feeling better, or feeling good, to actually improving in regards to addiction; is that correct? Is there kind of a continuum?
Maia Szalavitz
It started, the whole idea of harm reduction in drugs, starts out with fighting HIV. And so, in the 80s, there was this new virus that was killing people, it was recognized rather early that it could be spread by sharing needles. And the obvious thing to most people was, well, let’s not have people share needles anymore. The easiest way to get that to happen is to actually provide clean needles to people because addiction is difficult to change. And assuming that people will change immediately when you tell them: “don’t do that anymore”. It’s bad, it is a really dumb assumption. So harm reduction meets people where they are. And it helps people first, to get rid of the biggest risks that they are facing, and helps them make the changes that they want to make in order to make their life better. And sometimes that may be using less, sometimes that might be using more, sometimes that may be becoming completely abstinent. But the whole idea is that people generally have a pretty good idea about what their needs are. And imposing stuff from above is not an effective way to change behavior. Because what you’ll generally do, if you try to terrify people, is just make them hide the behavior instead of actually stopping or changing.
Josh Hoe
And that’s, I think, a lot of the problem with a lot of the reason for the resistance that we see to the concept, is this notion that maybe the people who are most impacted directly, should have a say in what the point of the programs are, the way that they deal with their problems, or if they’re even problems to start with. You tell a story in the introduction of the book, about tracking someone down that you met after many years who first taught you about bleach and needles. You say “ours was a story of how change happens and how even the smallest things we can do sometimes make a tremendous difference”. Can you contextualize this for everyone?
Maia Szalavitz
What happened was – and this was my introduction to harm reduction before it actually had a name – I was injecting drugs, it was 1986, it was New York City, about half of the people who injected drugs in New York City at that time were already HIV-positive, including the person that I was probably about to share needles with. And so this woman was visiting. I didn’t even know her name, but she was like, you know, you’re at risk for AIDS, you should always clean your needles with bleach. And I was like, AIDS, that’s a gay male thing I thought, and you know, I just didn’t know. And so she was like, no, it can also be spread by sharing needles. And ever since that moment, I cleaned my needles as compulsively as I used them until I got into recovery, and thankfully, avoided HIV. So I was always really grateful to this person. But I didn’t know her name, I knew she was a friend of the guy that I was injecting with. But that was about all I knew. In fact, she was his girlfriend. And it turned out – I knew she was from San Francisco also. And through the research in the book, I was eventually able to track her down. And oddly enough, she just emailed me. I’m hoping to go out to San Francisco and meet her in person again, which I wasn’t able to do, thanks to the pandemic. And, anyway, she just told me a few things. And she was visiting this friend of mine in order to get him into rehab. And most people in that circumstance would be like, stop, shooting up is bad. You know, most people need to really focus on abstinence, but she was, we were getting together, she was seeing me and the guy anyway, she was seeing what was going on and that telling me to stop at that moment wasn’t going to be especially effective. But she knew that people don’t like to share needles. And that, in fact, if you know that you’re at risk for a deadly disease, and you can take 30 seconds to clean your needle, why wouldn’t you? So I did. And I was just so infuriated by the whole thing, because I was like, why are people letting us die of ignorance? This is outrageous. Here’s the simple thing, bleach is cheap. Why don’t we know about this? You know, in San Francisco, I learned at the time they had a superhero named Bleach Man who was going into the neighborhoods, dressed up with a giant bleach bottle and teaching people how to inject more safely. But in New York, they’re just like, I let them die.
Josh Hoe
You mentioned a “Bleach Man.” I think one of the main things that we struggle with in this whole field is the notion of how to deal with the media, and media narratives about a lot of this stuff. And Bleach Man was an interesting example of that. Have you taken anything away from this research and everything you’ve done on this – things like bleach man and other people? I think there were activists that you talked to whose strategy was actually to go directly to the media and start cultivating relationships with them; what have you taken away from this idea of how we change media narratives?
Maia Szalavitz
Well, I actually recently co-founded a group called Changing the Narrative, which is about doing exactly that. It is a very hard thing to do, because the media has been steeped in propaganda about drugs for many, many, many decades. And, you know, in fact, in the 80s and 90s, newspapers were happy to take money from the government to include anti-drug messages in their coverage. Now, if you were implanting government propaganda in news, it would be a scandal in any other area, but drugs are bad. So of course, this was fine. Anyway, this eventually came out and eventually was a scandal. But the point is that the media loves a good drug scare. And it has always been a part of the panics that politicians and other moral entrepreneurs like to stir up around various substances that end up targeting particular groups of people. So I feel if you can get journalists to understand how they’re being used in this scenario, and that this sensational drug story that you’re telling, is actually the same story that’s been told a zillion times. And it’s no different now; you could actually tell a more interesting story about what’s really going on. But it’s hard to get people to see that because for a long time, people had a really difficult time distinguishing between the effects of drugs and the effects of our policies around those drugs.
Josh Hoe
The backdrop of much of your book is an over 50-year failure of the war on drugs. I’m often shocked by how people remain so committed and ruthlessly dedicated to a system that has been proven over such a long period of time to be a total and categorical failure. What is your take? We talked about the media a little bit; what is your take on why people and politicians remain so committed to something that by any rational measure has failed? Why do you think we remain so committed to stopping substance use as opposed to helping people?
Maia Szalavitz
Well, I think it’s because we’re committed to stopping certain types of substance use by certain types of people. And Michelle Alexander very brilliantly revealed this in her book, The New Jim Crow. What the drug war has served as is cover for racist enforcement. And as a tool against black people, it is actually very successful; as a way of fighting addiction, it’s awful. But if you look at it as a way of locking up black people, it works really well. So once people of color began to see this, and once activists across race united to say, this is racism, it’s not drug policy, it became very difficult for the people who had sort of innocently supported the drug war because drugs are bad, and we need to crackdown. And that’s the only thing that will work. And if we don’t do that, we’re pro-drug. Once they deconstructed that whole thing and the racism became very clear, especially – so we have this overdose crisis right now, and it’s been portrayed in the media as overwhelmingly white, although that is not actually true. But in that case, it was useful, because what happened is, suddenly people were like, Oh, well, we should be nice to people. These are our kids. These are people who were hooked by doctors, they didn’t choose to smoke crack, they were innocently hooked, which actually isn’t true, either. But the main thing is that we perceived it very differently when we saw the drug problem as being a problem of white people. And at that point, harm reduction became much, much, much more acceptable because parents didn’t want their kids to get HIV. Parents didn’t want their kids to die from overdose. When it was somebody else’s kids dying, as an example to prevent your kids from doing it, that was fine. But in this instance, people began to see very quickly that that stuff actually doesn’t work to fight drugs. But it does work to promote racism.
Josh Hoe
Although I think in that case, I think you’d have to concede that to some point that there was still an urge to punish. The shift just went from people of color to doctors, right? 2
Maia Szalavitz
I think it’s more that the rhetoric changed much more than the policy. So everybody’s going around, including Republicans and Democrats, going around saying we can’t arrest our way out of this. Meanwhile, drug use is still criminalized. And meanwhile, as you noted, we are prosecuting doctors for creating people with addiction, which actually is not possible because, in order to get addicted, you have to continue to take drugs despite negative consequences. And you cannot get addicted if you are taking drugs as prescribed. If you’re taking an opioid as prescribed, you can become physically dependent, which means that you will have withdrawal if you stop. But taking it as prescribed cannot produce compulsive behavior that continues despite negative consequences, because you can’t do that and continue to take it as prescribed, because you have to take more and more over time in order to actually enact the compulsive behavior. So this is not to say that we should blame people with addiction because there’s many reasons why around – [it] varies in the circumstance, but up to between 1 and 20% of people become addicted, depending on setting and drug and situations like that. So the people who fall into that minority, have things that are different about them. It’s not just exposure to drugs that causes the problem. And so anyway, once we realize what addiction actually is, we can be a lot better at actually creating policy that does work to manage it better.
Josh Hoe
I think some of the book could be seen as a critique of traditional ideas of recovery. I personally frequently have been a critic of absolutist ideas about abstinence-only focused recovery. And I’ve seen this kind of thinking cause a lot of pain and suffering. What are your thoughts about first, the idea of recovery being more about ensuring sobriety than happiness? And also ideas like rock bottom, shame-based recovery, and stigma?
Maia Szalavitz
Right? Well, I think that it is abundantly clear that there are multiple pathways to addiction and multiple pathways to recovery, and the idea of the only way to recover is going to 12-Step groups and being completely abstinent from everything except for caffeine and tobacco; that is not for everybody. That helps some people. But it’s not a majority of people. And we have no area in medicine where we’re this is the one true way and any other approaches are bad. You know, we recognize that different things work for different people. So there’s only one cancer treatment. 2We don’t have people who were on chemo going around saying those people using radiation aren’t really in recovery. So what we don’t understand about addiction is that it is driven by shame and self-hatred and that increasing shame and self-hatred increases the addictive behavior. And the only way to actually get past the addictive behavior is to give people some hope, and give people a sense that they are worth saving, and a sense that they can feel comfortable and okay in their own skin without this compulsive behavior. And punishment does not create that sense of safety and welcome that is most conducive to recovery.
Josh Hoe
Yeah, Katherine Otter said in your book: “I’ve watched people die for years in Narcotics Anonymous”. And that statement really brought back my own struggle in 12-Step programs. A lot of the stuff in 12-Step worked for me. And I know a lot of people who had similar success, but every time I went to a meeting, I also saw a lot of people in those meetings who were clearly miserable, and guilt-filled, and looked like they were almost physically in pain, even after years. Is there anything else you would like to say about your own journey or anyone else that you’ve encountered with 12-step methods?
Maia Szalavitz
Sure. So I actually did get into recovery through 12 Steps myself; that was the only option that was offered to me, and I just clung on to it like a life jacket, or a life raft, or something like that. And so I was told this is the one true way, the science supports this, blah, blah, blah, blah. But then I started to see all around me that actually, the science doesn’t support this and that a lot of people like you said, are not doing so well. A lot of people are dropping out. when I looked at the data regarding methadone and well, buprenorphine didn’t exist at the time, but methadone, – or it existed, but it wasn’t approved. When I looked at that, I found wow, this actually works. And it isn’t a case of people being high all the time and not being in recovery. It’s the way the drug pharmacologically does its thing. And so I actually wrote a piece saying that methadone was like replacing vodka with gin. And actually, that’s not true, because the thing about opioids is that you can get complete tolerance to the intoxication, without being in withdrawal and without being high. So if you find the right dose of a drug like methadone or buprenorphine, you are unimpaired, whereas even on a low dose of vodka or gin maintenance, you will still be impaired. So I was wrong. And I began to learn more and more about addiction and what it really was, and you know, what myths were coming from 12-Step programs, and what myths were coming from the street, and what myths were coming from the government. And, you know, I began to find my way gradually to what was actually true about addiction. And, I think it’s really important to say that, for some people, the whole 12-Step thing can be super helpful. The problem is imposing that on people as a paid form of treatment; you can get that for free in church basements everywhere. And it’s not the case that people who start recovery have never heard about the 12 steps. So what needs to happen, I believe, in the American addiction treatment system is to replace all 12-step content with content that is based on evidence and that is not moralistic and is not making you take moral inventory or make amends and this kind of stuff that we would never stand for in any other form of medical care. That said, it can also be really helpful for people to make amends and look at themselves and not hate themselves because now they have made up for what has happened. It just can’t be forced, and it just needs to be a matter of separating self-help and mutual aid from professional healthcare. And when we do that, I think 12 Steps will work a lot better because the people who will be there will want to be there, and healthcare will work a lot better because it’s not trying to fit this weird moralistic thing into a mold that it doesn’t fit. It’s just terrible that we’ve developed the system where 90% of our addiction treatment that’s behavioral is based on the 12 Steps; that just has to change. That is not a sensible way of having a treatment system.
Josh Hoe
Yeah. I think you’re hitting the nail right on the head when you talk about legal, quasi-legal for-profit areas where you’re forced into 12 Steps, really even within the 12-step methodology seems very bizarre. And I really worry about people who are struggling and frequently get kicked out of, for instance, rehabs for relapsing or even having the wrong attitudes. We have this bizarre triage, where people who most desperately need help often get immediately disposed of when they don’t act perfectly while in crisis. It just seems very strange and twisted to me. Am I wrong in that?
Maia Szalavitz
I think the thing that is really important to note here is that we don’t throw people with diabetes off of insulin for failing to avoid eating sugar; you recognize that this is a difficult behavioral change that will take time. Addiction treatment that throws people out for basically having addiction – what it’s doing is making its success rate look good because the graduates will do well because they’re really motivated to put up with all the crap that the program puts you through in that treatment program. And the people who really need help, right, they get expelled, and they don’t count towards their success or failure statistics.
Josh Hoe
So the thing is, it’s this weird thing where they only count from the segment of people who stay in the model. It’s very weird.
Maia Szalavitz
Right. And the technical name for that is “failing to do an intention to treat analysis”. And the research world has recognized that you cannot test drugs or any other form of medical care if you don’t do this intention to treat analysis, because let’s say you have an antidepressant, that is a really great antidepressant, but it causes unbearable itching in 99% of people. If you only look at the people who don’t drop out, you will look like you have a massive hit drug, whereas most people are going to drop out.
Josh Hoe
You know, I think a lot of people listening might hear us talking like this and say, Well, you know, these people still need help, what’s the alternative? But one of the things I think is really wonderful about your book is that it catalogs all the things that have started because of individuals doing incredible work, from their place, wherever they were in society, to create solutions that worked, everything from needle exchanges to Naloxone, just all kinds of things. Do you want to talk a little bit about the victories or the things that have worked because of the harm reduction movement?
Maia Szalavitz
Sure. Needle exchange is the first and really good example. Because what happened is, we were facing HIV, it was a disease at the time that had no treatment, it was almost universally fatal, it was a horrible way to go; we needed to do something. And it was clear that okay if you don’t share needles, you’re not going to get it that way. And if you do share needles, that’s a really effective way of transmitting this virus. So go out and teach people to use bleach before we have – and what was amazing, in New York State, we went from having 50%, or 50% of those people were already HIV positive by the time the virus was discovered, to we now have, it’s less than 3% of our IV drug users are HIV positive. And we don’t have children being born at that time, were initially linked to people who use drugs. So if you actually protect the people who use drugs to protect the rest of the community as well, this is why public health is called public health. So anyway, discovering that needle exchange worked was a sort of enormous paradigm shift for a lot of people because it kind of debunked a lot of the myths about what active addiction is like. Because the idea was if you’re actively addicted, you don’t care about anything, you won’t protect yourself, you won’t try to protect any other people, you just have to shoot up that instance, not do anything to take care of your health. And what needle exchange showed is no, people who are actively using actually do respond to information and they respond even more to respect and support and kindness. And so once people start to feel like they’re valued, they start to value themselves more. And then actually, people who participate in needle exchange are five times more likely to start other kinds of treatment than people who don’t. So this whole idea that if you give clean needles you’re enabling and you’re going to prevent them from hitting bottom and prevent them from getting into recovery, the opposite is actually true. If you treat people with dignity and respect, they will be more likely to feel worthy of recovering, and more likely to feel capable of making the changes that they need to do for them.
Josh Hoe
In your book, what Dan Bigg called reclaiming the term recovery as part of harm reduction, kind of reminded me of what happened during the riot grrrl movement in music. So taking back terms that have been used against people in recovery, or who are addicted, or whatever you want to call it – do you think that that is an important part of both talking to people in the media and all like we talked about before?
Maia Szalavitz
Yeah, I think the word recovery can be confusing because so many people just associate it with abstinence-only and 12 Step. But I do feel that like reclaiming recovery, like the Chicago Recovery Alliance, and Dan Bigg, they framed recovery as making any positive change. Now, I can see how that would annoy people in abstinent recovery because now you have people who are clearly chaotically using, but they are using clean needles, and now they’re in recovery, what? But what you have to realize about that is, that before you get to abstinence, for a lot of people, there’s a struggle, and there’s work that’s going on, and that is the beginning of the process of recovery. And, you know, counting days and all the stuff that you know – I have x number of years completely abstinent – like that can end up doing harm, because let’s say you have 10 years, and then you slip for one day. In traditional recovery, you have one day when you come back, and your 10 years go away, and they don’t count. I think that a compromised position, in order to make recovery more welcoming, would be okay, you have 10 years, you come back, you get 90 days again, you get your 10 years back because they didn’t go away; you’re still sober for those 10 years. And I think making pathways so that it isn’t this black and white, binary thing, in recovery or not in recovery, is a much more sensible way of dealing with what is often a chronic condition for many people. And it’s just so demoralizing for people who do have long periods of time to just have that taken away.
Josh Hoe
We’ve seen, time after time, this mainstream notion that what we’re trying to do is restrict supply, and deter people from becoming drug users and stuff like that. And we’ve never seen that actually work. But Dr. John Marks talks in your book at one point about how providing access to free, medically supervised drugs kind of breaks the economy of drug-selling, and reduces use. Can you talk a little bit about that as kind of a counterpoint to the dominant narrative on this?
Maia Szalavitz
Sure. Well, it’s really visible in these trials of heroin-prescribing, even more so in Switzerland than in England, because they just had a much more concerted study of it. And basically, they started providing heroin prescriptions after a disastrous experiment of sort of quasi-legalization in one park, which turned into sort of a horrible drug and crime orgy. So they say, okay, that’s not the way to do it. Let’s see if we can prescribe it and how that will work. And as it turns out, when you get prescribed heroin – when you’re actively addicted, 90% of your time is spent thinking about and trying to obtain and ensuring that you continue to obtain the substance – if you take all that cops and robbers and all of this stuff you have to do in order to make sure you’re affording your drug use, you take all that away, people are left with an awful lot of time. And that time, often people feel they have the space, they have this freedom to think and to act in a way that they didn’t have when all of their energy was about chasing the substance. And so people get bored, and they’re like, well, maybe I should go back to school, maybe I should go to work, maybe I can reach out to my family who is estranged. And you see this kind of healing. And in terms of the market, when you are actively using – a lot of people will do low-level dealing in order to be able to afford their drugs without actually having to steal or do something that is directly victimizing people – so you know, when you take away or when you take those people out of the scene, you are shrinking the market a lot and you were shrinking the marketing a lot, so it is very interesting that in Switzerland after the heroin prescribing began at scale, the drug scene became almost invisible.
Josh Hoe
That’s interesting because it seems to me – I’m not an expert in this, I do dabble in it, but I’m not an expert in it – but it seems to me that, most of the reason why drug-dealing is so lucrative is because there’s laws against it. And most of the reason why there’s so much violence is because there’s enforcement of laws against it. And the rewards are so high, that people are willing to risk that. And it seems like, in a lot of ways, getting rid of those perverse incentives has to work better than what we’re doing now. 2
Maia Szalavitz
Yeah, the thing is that when you look at who sells drugs and how it happens, you’re either addicted people or poor people with very few opportunities. And they’re sometimes both a poor, addicted person with very few opportunities. In the drug world, you don’t have to submit a resume to become a drug dealer, you don’t have to have a college degree, you can just do it. So, in areas that have been historically neglected, of course, people are going to go into that underground economy, [then] because they have a criminal record, they can’t get into the above-ground economy. So it creates this horrible self-replicating mess. And it also creates incentives for people to actively sell, because that’s how they’re going to make their money. So if you take all that away – and don’t give it to say, a Purdue, so they can go and advertise it and tell everybody they should always take opioids every day, every second – because commercialization can be a problem, too. You don’t want to go from complete prohibition to free-for-all capitalism in terms of drug sales, because that is bad, too. You want somewhere in the middle, where you really control access, not so much that you create a black market, but just enough to get rid of these awful side effects that you see in communities affected by drugs because of poverty.
Josh Hoe
A lot of times I get asked in my own work – I’ll be talking about how people deserve second chances, third chances, fourth chances – and people say, well, I can understand the first time. But you know, what about people who’ve been arrested many times? And I think you give a really great story that answers that in your book, the story of John Parker, who you say was arrested at least 30 times, and then turned around and did some pretty amazing things that probably saved a lot of lives. Tell us about the value of looking at people as more than their worst moments, even when the moments are plural?
Maia Szalavitz
Right? Well no, he’d been arrested 30 times I think, by the time he was in his mid-20s, or early 20s. He grew up really poor, and he became addicted to heroin, I believe, if I’m remembering correctly, it was in prison, or just immediately after he got out, the system that they put him into, in order to try to deal with this little juvenile delinquent was not helping. And so he was addicted. And he just kept going out and doing it again. Eventually, he was offered treatment and he was able to go back to school. He ended up at the Yale School of Public Health. And it was there that he realized that something needed to be done about HIV in drug users, because somebody was lecturing and saying, Oh, you know, we have to forget about the drug users. They won’t help themselves; we’ve got to let them die. You know, the gay man we can work with. And he was like, No, that’s ridiculous. I’m a former drug user; we change and we get better. And so he began – you called him the Johnny Appleseed of needles – he was going up and down the East Coast getting himself arrested in order to make a legal case for why needles should actually be legal during this public health emergency.
Josh Hoe
This is a quote from your book: “Research has shown that one of the most dangerous periods of time for people with opioid addictions is their first week or two after being released from jail or prison. During these weeks, the risk of death is three to eight times greater than their already existing elevated odds of dying”. I have been through the system myself, both in jails and in prison. And I’m not aware of any reentry support the jails, parole, probation, or prisons provide to confront this particular problem, or any education or access to Naloxone that’s provided when people leave incarceration. This all seems, when reading it, incredibly dangerous and poorly conceived.
Maia Szalavitz
Actually, to be fair, there are now states, and there are prisons and jails that do hand out Naloxone, and even better, get people on buprenorphine or methadone or even Vivitrol, although very few people seem to want that. But Rhode Island, for example, I think they decreased their overall overdose death rate by 12%, simply by providing medication treatment, starting when people were within, and immediately continuing on as they re-entered. So there was no interruption in care. And this reduced this insanely high risk for people. New York State has methadone within Rikers, and we’ve had it for a very long time. The thing is the discontinuity when people get out, and you know, people are working on that, but it is, there’s all kinds of crazy, stupid barriers. But you’re right, it makes no sense. Like, we have people that are often in a period of enforced abstinence, which means that they have no tolerance. And that means that their overdose risk is extraordinary when they leave. So rather than just plunking them down with $20, and a bus card, or whatever people get, you should actually have health care for them immediately. So that if they are trying not to use, they have a really good chance of not doing it.
Josh Hoe
And there’s also the problem, the corollary problem of trying to do withdrawal in a holding cell, which I understand is also very dangerous. Is that correct?
Maia Szalavitz
Well, it doesn’t have to be dangerous if people would actually provide appropriate health care, but since they don’t, it’s very dangerous, because people get dehydrated, and they get disbelieved when they have medical complaints, and then they die on opioid withdrawal, while extremely unpleasant, shouldn’t be deadly. But it often is in jails and prisons, because people don’t get access to water. And because they don’t get access to IV fluids if they become so dehydrated that they need that. It’s again, it’s just “harm production”, we’re just making things worse, by the way we deal with these things. And I think, again, there’s this whole history of, well, if we just let them go through the worst of it, then that’ll teach them not to do it again. Now, if that were true, people would go through withdrawal once, and that would be the end of addiction. That is not how addiction works. Many people, most people with opioid addiction, will relapse and withdraw and be abstinent for a while and return to use again, over and over and over. If withdrawal was the barrier for people to get into recovery, or really bad withdrawal made recovery more likely, we wouldn’t see this relapse after it, because the physical dependence is not the thing that drives addiction. It makes it harder to quit. But the main thing that drives addiction is the psychological need for comfort from the substance.
Josh Hoe
I know when I’ve talked about, for instance, extending legal access to drugs like Suboxone to people struggling with addiction inside, everyone looks at least a little bit like I’m crazy. But there are a lot of reasons for this medically, as I understand it, and people in jails and prisons right now can’t even get cards from their kids in much of the country because of the threat of Suboxone smuggling. Surely there has to be a better way. Am I wrong here?
Maia Szalavitz
No, I mean, what’s really stupid is there would be no smuggling if everybody had access to it. And given that we have two medications that are proven to cut the death rate from opioid addiction – which is really high, by 50% – that’s methadone and Suboxone. So it’s a human rights violation not to provide this standard of care, the best treatment that we have, to people with addiction while in prison. The only reason we don’t provide it is because we don’t believe addiction is a disease or medical condition. And we see it as a sin. And we want people to suffer when they’re in prison, so they shouldn’t get medication. What people don’t realize, again, is that if you are on a steady dose of methadone or Suboxone, you are not high. So you are just as available to feel lousy in prison as anybody else. You’re just not going to be in withdrawal. And you’re gonna have less craving for your drugs, which is good for everybody. You know, it’ll reduce other forms of contraband within the prison. And it will make everybody more manageable. Oh, it’s just really stupid and it should be illegal.
Josh Hoe
And this is when, usually whenever I say stuff like this, I get someone who says, well, but what about fentanyl? People are dying all over the place from fentanyl. I know you’ve written about this recently in Scientific American and a little bit about it in the book. You know, part of the reason we have fentanyl in the analogs is because of the way we enforce all this stuff, that it’s actually the enforcement that drives the analogs and the different kinds of drugs that are becoming more and more dangerous. I think I’ve heard of it referred to as the “iron law of prohibition”.
Maia Szalavitz
Exactly. I mean, when you think about it, like if you actually think about alcohol prohibition, what did people drink? Cocktails, people drank spirits, they were not drinking beer or wine, because those are much more difficult to smuggle, because the product is physically much bigger. And that’s the same thing that happens, moving towards insanely strong drugs like fentanyl, because, you know, a tiny bit of fentanyl would be enough to get you know, all of New York City high compared to the amount of heroin you would need for that task – which I’m not suggesting, by the way. But of course, prohibition is going to drive people to use stronger, more intense forms of substances, because physically they’re easier to smuggle. And that is why it is called the iron law of prohibition. Now, some people say, well, people still drink vodka and stuff like this. Yeah, but if you look at the sales of alcohol, the less extreme stuff, beer, and wine, actually sells more. So, you know, it’s not driven by the market. It’s driven by the need to smuggle the illegal drugs. And the other thing that is kind of interesting is that if you can’t even keep substances out of jails and prisons, how can you keep them out of an entire country?
Josh Hoe
Yeah, I mean to my knowledge they’ve never substantially decreased supply, maybe a supply of a particular drug, but that gets replaced by something either more dangerous or different.
Maia Szalavitz
The only drugs that they ever managed to eliminate, which actually may be coming back at this point. But it’s quaaludes, like that used to be a medically used drug that was massively diverted to recreational use. And when they banned the medical use of it, people didn’t start making it. And I think, you know, there was no internet, there wasn’t the kind of thing that allows us to just make anything, or you know, just send it away to a chemist and get it made, the way it is now. But anyway, that drug was completely eliminated from the market, although I have heard some rumors that it is back to some degree.
Josh Hoe
One of the other things that formerly incarcerated people tend to struggle with is housing policies. And, you know, there’s a new war brewing, unfortunately, in many ways in major cities targeting homeless people. This is also of huge importance to people struggling with substances, to formerly incarcerated people, to people in certain communities. Harm reduction has a role to play here too. When you talk about Housing First politics, what has happened in New York City and other places that have addressed this?
Maia Szalavitz
Well, I mean, Housing First works, but it only works if you fund it appropriately. Because it’s not like we’re stopping creating new homeless people, people are still being driven out by rising rents, and eviction policies that are around active drug use, and this sort of thing. What Housing First does quite sensibly is it says, gee, I don’t think most people while being homeless, are able to kick drugs, because like, they’re just busy surviving being homeless. And in fact, if you give them a home and provide support, people are likely to dramatically reduce their drug use, they dramatically reduce their use of emergency rooms, the amount of arrests, and, you know, people tend to stabilize over time if they have housing. And so that’s what Housing First is about. It’s not about you must get sober to deserve a home, it is about everybody deserves a home. And we’re going to help you do what you want to do in order to maintain and stay in your home. And, you know, most people don’t want to ruin their lives and feel horrible and be chasing drugs all the time. The reason that that happens is because their lives are miserable, and the drug is the best thing in their life. So if you give people alternatives, they start to have other good things in their lives and reasons not to use excessively.
Josh Hoe
Now, one more legal issue that I think has come up recently [and] that’s addressed in the book – and I think we should at least talk about – is this notion of drug-induced homicide charges, and that they are counterproductive relationship to Good Samaritan laws. Where do you think we are on this right now and what should be happening?
Maia Szalavitz
Well, it seems insane to me that people think that oh if we just prosecute people for somebody else’s overdose, this will solve the problem of fentanyl. Now, in New York State we had the harshest drug laws in the country for a while starting in the 70s, they were called the Rockefeller Laws; very small amounts of sales or possession with intent to sell, you got 15 to life, no second chances. I was very lucky to avoid that. But, anyway, we had this; we didn’t call them murderers, we just called them drug dealers and gave them 15 years. Calling somebody who’s – you have two people getting high, one dies of an overdose, the other person provided the drugs, and they didn’t happen to overdose on them themselves for some physiological reason – I’m making that one person a murderer, and putting them away for 15 years doesn’t work any better than it would if you just call it being a drug dealer. It’s dumb, it doesn’t work. We know it doesn’t work. I understand that people want vengeance if their child dies. But the best way to prevent your child from dying from an overdose is to have people as willing as possible to call for help. 1
Josh Hoe
And also to have medically-assisted places where they could test their drugs, right?
Maia Szalavitz
Yes. But what I want to say is that if you can be spared the charge of drug possession by a Good Samaritan law if you call for help, but you’re going to get prosecuted for murder, people are not going to call for help; the whole point of the Good Samaritan laws was to allow people to call for help, without the fear that they would be arrested and prosecuted and incarcerated for a long time. If you make the incentive such that you are afraid to call for help, because you’re going to go to prison forever, then more people are going to die.
Josh Hoe
Am I wrong that most of the fentanyl probably gets – I don’t know if this is true or not – but it just seems likely to be that in a lot of cases, the fentanyl gets mixed in upstream. Is that correct or not? Or is it a street dealer problem?
Maia Szalavitz
No, I mean, I think the economics of fentanyl are relentless. So let’s say I’m a Mexican cartel or a cartel in any country that grows drugs. I can either have this complex supply chain where I’ve got farmers and processors and smugglers for this big product that smells. Or I can have two guys in a lab, making a much smaller, less detectable substance, without any of the risks that come from – maybe the farmers get caught, maybe the smugglers get caught, maybe the processors get caught. Like, economically, why would I still sell heroin? Why wouldn’t I sell fentanyl as long as I could feel confident that I could mix it properly to minimize overdose risk? And I mean, I think you know, what will probably happen over time is they’ll get better at mixing it so that people don’t die, because it’s not in the drug dealer’s interest to have dead customers because they’re not going to buy anymore. People tend to think of drug dealers as evil people cackling aha a high can kill people. No, those are serial killers. Drug dealers just want to make money. And you know, one can certainly say that this is an unethical way of making money. But if you understand the motivations of the people you’re trying to change, there are ways to make them change. But if you assume that they’re just cackling up there, putting fentanyl in for the heck of it – no, that just isn’t how it works.
Josh Hoe
I’ve been talking about subjects that were raised in your book. But a lot of the point of your book is to catalog a huge number of people who’ve made a very significant difference from fairly, what I think all of us would consider normal, lives you know, [that] turned them from pain or personal experience to really successful activism. What can we all learn about activism and being active from these amazing people that you’ve cataloged in your book?
Maia Szalavitz
Well, one person or a small group of people truly can make a huge difference, but it will take a lot longer than you think. You know, when I first saw the rise of harm reduction in the late 80s and early 90s, it was extremely on the fringe, there were maybe 300 people in the world who’d heard of it. And now you know, if you search for jobs in harm reduction, you’ll find hundreds of them. So it can change. We’ve gone from a climate where every single politician was racing to lock people up for longer and longer, to a situation where people at least say we can’t arrest our way out of this. But that took like 30-40 years. And so the thing about activism is people are a pain in the butt. It’s difficult, it can seem very unrewarding for a long period of time. But if you keep at it, and you work together, you can actually have a huge, huge impact. And that is just so inspiring. I mean, I remember early on just seeing ACT UP who were in New York, the first people to do needle exchange. And just seeing [that] they won a lot of things, watching how HIV went from a death sentence to being chronic and manageable. A lot of that was down to the activists fighting for it. And so there’s lots of things that can be learned. For example, needle exchange was an interesting case, because it had to be okay, we have to be providing the service, like handing out needles and that can require dealing with bureaucracies and working with people in the system. But then in order to get there in the first place, you need people shouting in the streets. So you kind of need both a service provision kind of group that may be more conservative among your activists and a radical group saying, that’s not enough, we need more. When you have both the inside and the outside, that’s when you really make a difference.
Josh Hoe
And you end the book in a pretty, I think, in a really hopeful place. I feel like you’re saying that you think harm reduction isn’t just winning, but ultimately is going to overturn the drug war mentality. Am I wrong?
Maia Szalavitz
Well, that is an optimistic view. But I do think so because I feel the thing about harm reduction, the thing that makes it such a powerful idea is that if our current policy was effective, you wouldn’t need an alternative called harm reduction. Why do you have a policy that is increasing harm? That does not make sense. And so the whole logic of the drug war was, drugs are the worst evil in the world. Well, no, actually, what’s more evil is losing your kid. So if we can actually help people, and reduce the harm, reduce the risk of dying, reduce all of this collateral damage from this policy, why would you maintain this policy? It makes no sense. I think that the common sense logic and compassion of harm reduction really offers a more powerful alternative to a drug war. I think a drug war is only sustainable when it’s waged against people that are “other-ized”, that are seen as not useful to society. When you see that people who use drugs, regardless of race, or class or whatever, are actually people who can have an enormous amount to give, if you can just keep them alive through this part, then you will see better policy.
Josh Hoe
This year I’m asking people if there are any criminal justice-related books they might recommend to others. I know we’re discussing yours. And we’ll definitely put links to that in the show notes. But do you have any other personal favorites?
Maia Szalavitz
Well, I have to say The New Jim Crow, which is pretty obvious, which probably has been mentioned a few times before. I’m afraid that’s sort of a lame answer, excuse the term. But it was not something I thought about. I read a lot of interesting books in terms of doing this book, but I’m not going to come up with it.
Josh Hoe
It’s okay to say [The New Jim Crow], even though other people have said it before, it’s still a good book for people to read. I always ask the same last question: what did I mess up? What question should I have asked but did not?
Maia Szalavitz
I think you did a really good job. It’s a large subject and there’s many different paths you can go down. So I think in terms of your listeners, you got it.
Josh Hoe
Where do you want people to find you or your work; or is there a place you prefer they purchase the book? And any information about you before we go?
Maia Szalavitz
Oh, sure. So bookshop.org is a network of independent booksellers. So that’s always a great place to support. My website is maiasz.com, and since I’m a freelancer, and usually try to update it, that’s where you can find my work; my book stuff is definitely on there. And I’m spending way too much time on Twitter @maiasz, talking about these kinds of issues, usually . . .
Joshua Hoe
I have no idea what you mean by spending too much time on Twitter.
Maia Szalavitz
It’s funny because I would actually say – lots of people think Twitter is evil and a waste of time and all this stuff – but I have actually met extraordinary activists who organized on Twitter and fellow colleagues in the area that could never come together without it. So while yes, there’s a lot of horrible evil flame wars and trashings and all this kind of stuff, I have to say I have found drug policy on Twitter to be remarkably free of that. Yes, people definitely fight a lot. But you know, and I’m knocking on wood here, but we haven’t seen the kind of horrible racist, sexist horrors that seem to infest more general Twitter.
Josh Hoe
I would say that, and I think this is fair, that probably 98% of the people who’ve been on the podcast are people I’ve met through Twitter, so I definitely agree with you. And I’m pretty sure I met you on Twitter, too. 2
Maia Szalavitz
The thing about it is that if you use it in the right way, and just find a group of people to follow who are doing good stuff, I think it can really connect people in a useful way. And yeah, people will flame you. And you might say something dumb. But as I like to say, it selects ruthlessly for impulse control. So if you want to improve your impulse control, just do that first.
Josh Hoe
Well, thanks so much for doing this. I’ve actually been waiting to talk to you for a long time. It was a real pleasure to have you on DecarcerationNation.
Maia Szalavitz
Oh, thanks so much. Thanks for having me.
Josh Hoe
And now, my take.
Right now, at this exact second, there are still over 4000 people who were sent to home confinement as part of the Cares Act, compassionate release during COVID. These people were all pre-qualified, could not have had less significant crimes (not that I approve of those kinds of procedures and restrictions), and they have been home for 16 months. And still, apparently, President Biden is still too scared to push back against the legal interpretation of the Cares Act that suggests that they will have to go back to prison after 16 months with no problems, when the state of emergency for COVID is lifted. And President Biden is also too scared of the politics of commuting them so that they can stay home. The New York Times said, quoting sources inside the administration, that they were scared that someone might recidivate and make the administration look weak on crime. Are you kidding me? We are at a critical tipping point in this country, the President could take hold of the microphone and use the full power of the bully pulpit to tell America a different story, a story about the importance of celebrating success, a story about how important it is to change how we look at mercy. For God’s sake, if being tough on crime and arresting more people reduces crime, why do we have a spike in homicide? We spend more on police than all but three countries in the world spend on their national defense. As a country, we spend over $80 billion on incarceration every single year. It might sound great on television to act like the crisis in homicides is about policing and incarceration. But that story makes zero sense when you look at the actual data. Regardless, President Joe Biden should keep these approximately 4400 people home. Last weekend, we ran a Twitter event and sent 10s of 1000s of tweets, tagging the President’s and Vice President’s accounts, asking them to #keepthemhome. I hope you will join in and send them a message too.
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