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Drugs: What America gets wrong about addiction and policy

Addiction is not a moral failure. It is a learning disorder, and viewing it otherwise stops communities and policy makers from the ultimate goal: harm reduction.

MAIA SZALAVITZ: Addiction is compulsive behavior despite negative consequences, and it's really important to start by defining addiction because, for a long time, we really defined it very poorly. We used to think that addiction was needing a substance to function and what that resulted in was that cocaine was not addictive because cocaine does not produce physical withdrawal that is noticeable. You may be cranky and irritable and crave cocaine, but you won't be puking and shaking and have the classic symptoms that you would see with alcohol or heroin withdrawal. So, cocaine wasn't addictive. Then crack came. And we realized that defining addiction in that way not only harms people by telling them that cocaine is not addictive. It also harms pain patients because people who take opioids daily for pain will develop physical dependence, but they are not addicted unless they have compulsive behavior despite negative consequences.

CARL HART: Addiction. Typically we think of it as people may exhibit tolerance to a substance. They may go through withdrawal when they don't have the substance. They may spend an increasing amount of time engaged in the behavior to obtain or use the substance. They may have had unsuccessful, a number of unsuccessful attempts to cut down their use of the substance. They may use despite the fact that they are having psychological or physical problems. These are the hallmarks of addiction.

MAIA SZALAVITZ: Addiction is a learning disorder because it can't occur without learning. You have to learn to associate the drug with some kind of relief or pleasure, and you need to do that repeatedly over time before you can become addicted.

CARL HART: Crack in the mid-1980s, one of the worst myths is that one hit, and you are addicted for life. We saw that in the 1980s and we are seeing it again with methamphetamine today: 'One hit and you are addicted.' And it's simply not true. Addiction requires work. Not that people should go out and experiment or do this themselves, but the fact is that's a myth. And the concern is that it's dangerous because when people perpetuate such myths and then when young people or people actually try methamphetamine or crack cocaine and find that that doesn't happen to them, now they disregard everything that comes from these official sources.

MAIA SZALAVITZ: So the learning is involved where you learn that this works to fix a problem and you basically then fall in love with the substance. And once you've fallen in love with somebody or something, you will persist despite negative consequences in order to sustain that relationship because the biology is going to tell you that your life depends on this. It basically acts in a brain region that is involved in survival and reproduction and those are the two fundamental purposes of biology. So that creates really, really strong cravings and it changes your priorities tremendously. This is a condition that can affect not just anybody but people who are in some sort of emotional pain. Addiction kicks people who are already down.

In order to overcome addiction you need to figure out what purpose the addiction was serving. In my case I had a lot of depression and I was very, I had a lot of difficulties connecting with people. I was also sort of overwhelmed by my senses and emotions a lot of the time and opioids turned that down very nicely. So I needed to sort of figure out what was up and deal with those issues in order to be healthy and comfortable in recovery. And that's going to be different for different people because they are going to have different issues that they are medicating with the drugs.

So, I think that the way to get beyond that and the way to help people with addiction is to understand that people with addiction are not seeking extra pleasure. They are not hedonists who are just out there having so much fun using that you can't stop them unless you put them in jail. People who get addicted, which are only 10 to 20 percent of the people who use drugs like cocaine and heroin and prescription opioids, those people have problems. The drugs seem like a solution to them. Until we recognize that those people are seeking, reasonably rationally, to deal with emotional and psychological problems and sometimes economic problems we are not going to solve this problem. And one of the things that I think we're actually in denial about with regard to the opioid epidemic is that while big pharma certainly didn't do anything good here, what they—to say that this is caused by Purdue Pharma selling Oxycontin is to miss the fact that the people who are overwhelmingly becoming addicted are people who are either falling out of the middle class or never managed to get into it. If you actually look at the economics of this problem it's not that middle class people certainly don't get addicted and it's not that rich people don't get addicted, it's just that if your life is despair and you feel like it will never get any better, which is often the case when you lose the American Dream or you lose the hope for your future, opioids are going to become very attractive and the idea that we can solve this by taking away the supply is just ridiculous. I mean as soon as we started cracking down on the pill mills we started seeing a rise in heroin use. This is not an unpredictable outcome.

ETHAN NADELMANN: Why are some drugs legal and others illegal? Why are cigarettes and alcohol legal and pharmaceuticals in the middle and these other drugs, marijuana, illegal? Some people sort of inherently assume 'Well, this must be because there was a thoughtful consideration of the relative risks of drugs.' But then you think well, that can't be because we know alcohol is more associated with violence than almost any illegal drugs and cigarettes are more addictive than any of the illegal drugs. Heroin addicts routinely say it's harder to quit cigarettes than it is to quit heroin. So, it's not as if there was ever any kind of national academy of science that a hundred years ago decided that these drugs, these ones had to be illegal and those ones legal. And it's not as if this is in the bible or in the Code of Hammurabi. I mean, nobody was making legal distinctions among many of these drugs back until the twentieth century, essentially. So, if you ask how and why this distinction got made, what you realize when you look at the history is it has almost nothing to do with the relative risks of these drugs and almost everything to do with who used and who was perceived to use these drugs.

So, back in the 1870s when the majority of opiate consumers were middle-aged white women throughout the country using them for their aches and pains and the time of the month and menopause and there was no aspirin, there was no penicillin, lots of diarrhea because of bad sanitation and nothing stops you up like opiates. I mean millions, many more, a much higher percentage of the population back then used opiates than now, but nobody thought about criminalizing it because nobody wanted to put Auntie or Grandma behind bars. But then when the Chinese started coming to the country in large numbers in the 1870s and 1880s and working on the railroads and working in the mines and working in factories and then going back home at the end of the night to smoke up a little opium the way they did in the old country—the same way white people were having a couple of whiskeys in the evening—and that's when you got the first opium prohibition laws in Nevada, in California, in the 1870s and 1880s directed at the Chinese minorities. It was all about the fear 'What were those Chinamen with their opium do to our precious women addicting them and seducing them and turning them into sex slaves' and all this sort of stuff.

The first anti-cocaine laws were in the South in the early part of the twentieth century, directed at black men working on the docks and the fear of 'What would happen to those black men when they took that white powder up their black noses and forgot their proper place in society?' The first time anybody ever said that cops needed a .38 would not bring down a negro crazed on cocaine, you needed a .45. I mean, The New York Times, the paper of record, was reporting this stuff as fact back in those days. That's when you got the first cocaine prohibition laws.

The first marijuana prohibition laws were in the Midwest and the Southwest directed at Mexican migrants, Mexican Americans, taking the good jobs from the good white people. Going back home to their communities, smoking a little of that funny, smoking marijuana, reefer cigarette. And once again the fear: What would this minority do to our precious women and children? I mean it's always been about that. And it wasn't as if the white Americans weren't also consuming. It's just many of them knew that when you criminalize a vice that is engaged in by a huge minority of the population and you leave it inevitably to the discretion of law enforcement as to how to enforce those laws, those laws are not typically going to be enforced against the whiter and wealthier and more affluent or middle class members of society. Inevitably those laws will be disproportionally enforced against the poorer and younger and darker-skinned members of society. So, to some very good extent that's really what the war on drugs has been about.

MAIA SZALAVITZ: So, this is where our laws come from and we have to be honest about that and we have to stop pretending that there is some kind of rational basis for the laws that we currently have. The reason that we continue to have these stereotypes about who drug users are is because of the ongoing racism of our society. And until we acknowledge that, like, I am the typical drug user if there is such a thing. I don't look like your stereotype, but that doesn't mean that the stereotype is accurate. So, I think that's a really important thing that people really have to learn because for too long the media has enabled the racist view of addiction and has enabled people to say, oh, I'm not the typical addict. And I used to say that and then I realized wow, that's kind of racist. And it comes from images that we shouldn't have ever had.

What I do think is interesting about the future of drugs is that we can make better drugs. Part of the reason that prohibition is collapsing at the moment is because of what are called new psychoactive substances or legal highs. And basically you can make a new recreational drug by tweaking molecules of the other ones and it will be technically legal because it hasn't been made illegal. And what this reveals is that our system for making drugs illegal is completely irrational and based on nineteenth-century prejudices. It has nothing to do with science.

This idea that we could use a drug that will block the effects of the drug of choice is generally misguided because the problem isn't the drug of choice. The problem is why you need that drug and why those drugs appeal to you and why you are trying to get out. Why you are trying to escape and what you need in your life in order to feel comfortable and safe and productive.

MAIA SZALAVITZ: I think the most important place to start is that addiction is a learning disorder. It's not a sign that you are a bad person. And if you want to have a safe and addiction-free or at least lower level addiction workplace or school, you want people to feel included and comfortable and safe and you don't want this to be an adversarial thing. The research shows that the best way to get people help is through compassion and empathy and support. And absolutely not tough love. Help them realize that this is not a sin. I am not trying to control you. What I want to do is for you to be at your best—at work, at home. And you're not being at your best right now, so what can we do to help?

And I have to say, it's almost never going to be easy because people whether they have addiction or mental illness or anything else going on with them, often don't want to admit to themselves that there's a problem. In the addictions field, there's been this whole thing, 'We've got to break through denial' and everything like that. Well, people have denial for good reasons. If we didn't have denial everybody would be sitting around obsessing about death—or at least I would be. It's a defense mechanism because we need defending. So, recognizing that can allow you to approach somebody not from an attacking stance; approach somebody from a befriending sort of stance. And that is hard to do and some people are going to get very defensive no matter what you do. And it's not going to be a pleasant conversation most of the time, but you can minimize harm. This whole thing always comes down to reducing harm, making things less unpleasant if you can't make them non-unpleasant.

And I think really important in getting people into any kind of treatment is that—and I always say this to parents or anybody who has an addictive loved one—the first step should always be a complete, thorough psychiatric evaluation by somebody who is not affiliated with any treatment organization. So that you can know going in what the problems may be and what kind of services you should be seeking.

I should say methadone and buprenorphine, the opioid agonists, are the best treatments that we have for opioid addiction and what they do is two things. The first thing is they cut the death rate by 50 percent which this happens whether you continue using on top or not. So that's sheer harm reduction and that's wonderful. If we can keep you alive long enough that you stabilize your life that is a lot better than having you die. The other thing that they do is they allow people who are ready to stabilize their lives—so, you couldn't tell right now if I was on a maintenance treatment or not because basically once you get a tolerance to these drugs you are not high or impaired and you can drive and you can work and you can love and you can do all of these things. What we don't understand is we think oh, you've just substituted one addiction for another. No, what you've done is you've substituted compulsive behavior despite negative consequences and now you just have physical dependence and that's not a real problem as long as you have a safe and legal supply.

We also have this idea that you can't provide these medications without also providing counseling, and we don't do that for any other medical service. We don't say, 'Oh, you can only get your insulin if you do X counseling on diet' or whatever. We realize that people need the tools to stay alive regardless of if they're improving as quickly as we would like them to do and forced counseling doesn't actually help anyway. So, what we should do is we should have different thresholds for treatment. So with buprenorphine some people may just want to show up and get a dose and that's it. And that will work as sheer harm reduction. That should be available in emergency rooms. Then what we need to do is realize that you can't make policy based on, 'I think it's bad for you to have unearned pleasure.'

MAIA SZALAVITZ: You have to make policy based on: Does this hurt you, does this hurt other people? And that's where harm reduction comes from. The basic idea of harm reduction is: What policy will most reduce the harm related to drugs? And once you start to focus on harm you have to look not only at harm associated with drugs, but harm associated with drug policy. And this is why so many harm reduction people rapidly become legalizers, because the harm associated with drug prohibition has not produced the results that people would like. It does not stop addiction. It does not prevent kids from using drugs. It makes the kids who use drugs be at higher risk of dying from them. It doesn't save society's productivity by keeping people from taking substances that will make them not work. It just doesn't work and when you think about it, if addiction is defined as compulsive behavior despite negative consequences and you're trying to use negative consequences in order to stop it, something is seriously wrong there.

So our drug policy has to acknowledge the reality that punishment doesn't fix addiction and that putting drug users in cages does nothing but worsen the problem, and it doesn't deter kids. Kids are going to do stupid risky things. You want to reduce the chances that those things will kill them. The idea that we can prevent adolescents from having sex or prevent adolescents from doing some kind of risky behavior is just absurd. This comes out before humans even evolved.

CARL HART: People who are young today won't be the same folks tomorrow. And so as new generations come about they have to find their own way, not only with drugs—they find their own way with fashion, they find their own way with the way they wear their hair. A wide range of domains in which they find their way, and drugs is just one of them. It's not special, it's not unique. You see some generations really being into LSD or into psychedelics in general whereas other generations are really into the stimulants. By that same token you found that some generations were into bell bottoms, other generations were into straight-leg pants. And so I think that as each generation finds their way they will also select their psychoactive intoxicants similarly.

JEFFREY MIRON: By trying to discourage people using drugs and trying to discourage the genuine unfortunate circumstances which happen sometimes because of drug use, we incur far worse negative outcomes, far worse cost than would result simply from the use of drugs in a legal framework. So, what are all these adverse consequences of attempting to prohibit drugs? Well, to begin with we don't actually eliminate drugs. We drive the market underground. And the underground market for drugs is violent, it's corrupt, it has poor quality control and in the attempt to enforce it we have to infringe civil liberties by basically shredding the Fourth Amendment to the Constitution. We reduce the ability of people who are sick to use drugs like marijuana or opiates freely to reduce pain, to relieve nausea from chemotherapy and a whole range of other symptoms. We interfere in other countries. The violence that we observe in Mexico, the profitability underlying the Taliban in Afghanistan. All those result from the fact that we've driven drug markets underground and so terrorist groups make a profit by selling their protection services to the drug traffickers. The drug traffickers get protection and the terrorists get profits, so that's another ancillary cost of trying to wage the war on drugs.

So my view is that if we had a fully legal market for all of these substances we would observe roughly the same set of things we observe now for alcohol, for caffeine, for tobacco, for other products which can be dangerous. We would see a large fraction of people use them in moderation, use them reasonably responsible with at most mild negatives for themselves or for others. We would see a small fraction who would misuse them in bad ways but mainly they would adversely affect themselves, not the rest of society. And that's a far better balance, and in no way, shape or form a solution in the sense of eliminating all negatives, but a far better balance than the current policy of trying to prohibit drugs.

  • "Why are some drugs legal and others illegal? ... if you ask how and why this distinction got made, what you realize when you look at the history is it has almost nothing to do with the relative risks of these drugs and almost everything to do with who used and who was perceived to use these drugs," says Ethan Nadelmann.
  • In this video, Maia Szalavitz, public policy and addiction journalist; Carl Hart, professor of neuroscience and psychology at Columbia University; Ethan Nadelmann, founder of the Drug Policy Alliance; and Harvard University economist Jeffrey Miron dissect why American society's perceptions of drug addiction and its drug policies are so illogical.
  • Drug addiction is not a moral failure and the stereotypes about who gets addicted are not true. Policy that is built to punish drug users for their immorality only increases harm and death rates.

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