Maia Szalavitz, a prominent neuroscience journalist and progressive drug reform champion who has written for the New York Times, Washington Post, Huffington Post, Salon and other publications, is the author, among other books, of Undoing Drugs (2021), a stirring history of the harm reduction movement.
A former cocaine and heroin addict, Szalavitz is one of the country’s foremost journalistic critics of the war on Drugs era, and she remains a fierce proponent of non-punitive approaches to addressing addiction. We invited her on to this latest BCB episode to make her case that harm reduction remains the right way to handle the spread of fentanyl addiction, homelessness and open air drug markets in cities like Seattle, San Francisco and Philadelphia.
Szalavitz forcefully argues the War on Drugs never really ended, and that efforts to criminalize drug use have always been shaped more by politics, race, and social control than by science. She argues that American drug laws have historically targeted marginalized groups such as Black Americans, immigrants, and the poor, while legal substances like alcohol and tobacco remained socially accepted despite causing greater harm. She further contends that criminalization has failed by virtually every measurable standard, citing America's simultaneously high incarceration rates and overdose rates.
The earlier part of our discussion focuses on the emergence of the harm reduction movement during the HIV/AIDS crisis in the 1980s. Szalavitz recounts how activists in the Netherlands, Britain, and eventually New York pioneered needle exchange programs to prevent HIV transmission among injection drug users. She argues that these efforts demonstrated that treating drug users with dignity and providing clean syringes dramatically reduced disease transmission without increasing drug use.
Later in our conversation, we press Szalavitz on what we see as the limits of the harm reduction ethos in its present, expansive form, questioning policies common in blue cities like handing out foil and pipes to drug users, and suggesting that the current fentanyl crisis may require stronger interventions than previous waves of heroin use. We point to the enormous suffering created by today's open-air drug scenes and the social harm addiction creates in impacted communities, asking whether there is a place for greater "friction" or limited coercion in public policy.
Szalavitz rejects that premise, maintaining that evidence consistently shows voluntary treatment, housing-first policies, medication-assisted treatment (methadone and buprenorphine), supervised consumption sites, syringe exchanges, and social services outperform coercive approaches. She repeatedly emphasizes that there is little evidence that harm reduction increases drug use, while she contends that substantial evidence shows it keeps people alive long enough to eventually seek treatment.
OUTSIDE SOURCES:
Maia Szalavitz, Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction, Balance (2021).
Maia Szalavitz, Unbroken Brain: A Revolutionary New Way of Understanding Addiction, St. Martin's Press (2016).
Bruce D. Perry and Maia Szalavitz, The Boy Who Was Raised as a Dog: And Other Stories form a Child Psychiatrist's Notebook, Basic Books (2007).
Please send your feedback, guest and show ideas to bluecitypodcast@gmail.com
[00:00:10] Hello and welcome to the latest edition of Blue City Blues, the only podcast featuring smart guests talking about the problems facing blue cities and how to fix them. I'm David Hyde with Sandeep Kaushik. And Sandeep, I wonder if you could remember with me the sort of height of the war on drugs in the 1980s. And there was that ad that comes out where the guy's holding up this egg and he says, this is your brain. And then he cracks the egg on this frying pan.
[00:00:39] And this is your brain on drugs. Any questions? Which, as I remember, was sort of we were both in Portland, Reed College students at the time, and it was kind of a running joke that ad with the counterculture. Another reason why we hated the Reagan administration. Oh, yeah. You remember that, right?
[00:00:58] Oh, vividly. How could I forget? I mean, obviously, I was, you know, in some sense, we were like, you know, in some sense, part of my adolescence and early 20s was a fuck you to Nancy Reagan, right?
[00:01:15] And that whole world. And like, I mean, part of the reason I really got into drugs when I was younger was as a kind of Indian immigrant kid, there was this kind of, I mentioned this, I think, in our conversation with Sherman Alexie that we haven't posted yet, but that kind of 70s head culture was an entry point. It was a very kind of welcoming world in some ways, like, and it was a sort of entry point for me to become an American.
[00:01:43] We were all kind of the same, and we all shared this, like, you know, this culture of getting high and whatever. And then, obviously, yeah, but again, a lot of it was just my adolescent politics, too, about like these conformist bourgeois.
[00:02:02] Well, I wanted to be a bohemian, and I wanted to live outside the bounds of bourgeois propriety, and I read too many William S. Burroughs novels, and I listened to too many Velvet Underground records, and I took it all too literally, and, you know, here you go. So, yes, I remember that world vividly, vividly.
[00:02:19] Yeah, well, and just with that ad in particular, it just sort of epitomized how inept and out of touch and just stupid the Reagan administration was, it trying to reach people, you know, on the question of drugs and drug use. And I bring it up because our guest today is Maia Szalavitz, a writer and neuroscience journalist who focuses on questions about addiction, drug policy, and public health.
[00:02:45] She's a frequent contributor to The New York Times, and her books include The Boy Who Was Raised as a Dog and a number of books about drugs and addiction, including Unbroken Brain and Undoing Drugs. Maya Solovitz, thanks so much for joining us. Thank you for having me. Hey, Maya. Thanks for coming on.
[00:03:05] And, you know, I mean, we'll get into this, but yes, I mean, that whole era of the kind of just say no, war on drugs kind of world was totally different worldview that sort of animated that. But before we get into all that, Maya, you yourself have an addiction history, right? You were a heroin addict, heroin user. Tell us a little bit about what your personal experience was with addiction and sort of how you sort of entered and exit.
[00:03:35] How you started that world. Sure. Sure. So, I mean, it was sort of the same for me about the drug culture actually being welcoming of strange people. And I was a really weird, geeky kid who sort of really didn't know how to connect with other people. And I, you know, relatively recently discovered I'm on the autism spectrum.
[00:04:02] And that sort of explained a lot about why I had so much difficulty. And I always had, you know, some obsession that I was really into that, like, my peers were not. So, when, so as a kid, it was like opera and science fiction, as you can imagine, that was very popular. And then when it became drugs, I actually did have friends and I actually did connect with people. And I read, you know, the electric Kool-Aid acid test and all of these kinds of things.
[00:04:32] And was very sorry that I had missed the 60s, but was trying to replicate it on my own in the 80s, being a deadhead and all of this thing. And that obviously included the drug culture. And, you know, I think it's a sad commentary on American society that the most welcoming clique of teenagers is almost always the kids who use drugs.
[00:04:58] And that should be a thing we celebrate, you know. It should not be the case that, like, that's the only place you can feel safe, right?
[00:05:11] I, what I'm trying to say is that a lot of people use drugs for social reasons and that a lot of sort of bullying and hierarchical teen culture is set up to exclude people. And, you know, we obviously know all the issues that go around when people develop addictions and have problems with drugs.
[00:05:38] But the fact that that culture is welcoming of people is a good thing in the sense that at least you can find some social connection. And we know that when people are ready to recover, the main thing you need is social connection. Welcoming as long as you're willing to do drugs. Yeah, but like. Only if you're willing to do drugs. No, I don't even think that's true, actually. I do.
[00:06:06] But we can disagree about that. Let me ask you about Blue Cities and the ways in which we think about the war on drugs. Because it's something we often talk about, like, not wanting to return to is the war on drugs when we come up with public policy. We don't have to worry about returning to it. We're still in it. We never end it. Oh, okay, okay. Well, but when we're talking about designing public policy, we talk about not wanting to return to the war on drugs as it existed in the, say, 70s through the 90s.
[00:06:34] But even though a lot of us live through it, we may or may not have been aware or really remember a lot of what really went on is one of the things that you've looked at in your writing and your research is what that war on drugs was really all about. One of the issues you point out is kind of the inconsistencies when it comes to the drugs that end up being made illegal and the ones that don't.
[00:07:00] So I wonder if you could talk a little bit about that and how it informs your understanding of the ways in which the war on drugs has been such a disaster or continues to be such a disaster, I should say. Yeah, it is the war on some drugs. And it is really how we determine what a drug is, is a lot about how we determine who an insider and outsider is in our society, which is kind of interesting given what we were just talking about.
[00:07:27] But what we have historically done is targeted outsiders, associated them with a particular drug, and then said that drug is bad because those people do it, essentially. And so alcohol is good because, you know, white middle class people do it. Cigarettes are good because at least when they were introduced, same deal there.
[00:07:54] And, you know, but these other things, oh, like, you know, they might be associated with black people or jazz musicians or Mexicans or Chinese people. And, you know, even alcohol prohibition was driven in part by anti-immigrant sentiment.
[00:08:15] So our drug laws are zero based on science, like the scheduling system that we have, which includes LSD, heroin, and marijuana as the most possibly dangerous drugs. And fentanyl in a lower category and no category for cigarettes or alcohol. You can't get there by science.
[00:08:41] You have to get there by racism and, you know, just weird cultural dynamics. I was thinking about that argument that you made in the context of the 19th century temperance reform movement, where in part, you know, when I was in grad school, part of the story was about social control.
[00:09:01] That this was a middle class moral reform movement and we wanted to take folks and make them, as middle class factory owners, we wanted to make folks better prepared for the factory system. We had to sober them up. So part of it was that. But the other piece of it, as a medical history professor pointed out to me in grad school, he was an older guy, sort of more old school liberal, was just how much booze people drink in the first part of the 19th century. Seven gallons of alcohol per person per year.
[00:09:30] And presumably, that's every man, woman, and child. And every child is not drinking two bottles of booze every week. So people drank way too much, which had, you know, huge negative consequences, not just for them, but for the rest of society. So in thinking through the temperance reform movement, because that was the beginning, there was a kind of a war on a drug, which was alcohol. How do you kind of balance the two pieces of that? One was about social control.
[00:09:58] And a part of it was people are drinking too much booze and it's having horrible consequences for their health and for the health of society. The moral panics that we get into around specific substances are not completely without substance.
[00:10:12] You know, the concerns that we had about alcohol at that time and about, you know, men drinking up their salary and then beating their wives and not, you know, this is in part why women led the temperance movement. So it's not, it's not ever just the anti-immigrant thing or just the racist thing.
[00:10:38] It's the racist thing on top of the genuine problems that can occur associated with the substances. So I'm, you know, prohibition obviously didn't work and it also took women to get us out of prohibition. But the, you know, it's not, that's, none of this is to say that like alcohol is a safe drug. Maya, I've been reading Undoing Drugs, right? Your 2021 book, which is like history of the kind of rise of the harm reduction movement.
[00:11:08] Fascinating read, by the way, and we'll put a link to it in the show notes. But, and you really, one of the things that jumps out, particularly reading in the early pages of the book is how, and David, you referenced this in the kind of, you know, the kind of just say no ads from that era. How different the worldview was back then about drug use. Now we're talking about the 1980s here, right? In the United States of America.
[00:11:35] And how addiction back then was real and addicts were perceived. So speak a little bit about that because it's sort of, it's very, very different. And you kind of reading your book really reminded me of, you know, that kind of, that world that in some ways is not the same anymore. Our attitudes have evolved quite a bit. Yeah.
[00:12:01] I mean, the thing, you know, if you look at the most racist stereotypes, they are basically the stereotype of the person with addiction. And it's about lying, manipulative, like criminal. And it's all about, you know, the many different ways you could be a bad person is all concentrated in our stereotypes of both addiction and stigmatized minorities.
[00:12:31] And it's not coincidental that that is the case. So that's one thing to note. The thing about the 80s in particular was that, you know, the politicians were using the Southern strategy, Republicans in particular, to target people like African Americans and poor people.
[00:12:58] And, you know, they were poor because they were drug addicts, not because they just randomly cut all the services and inequality starts rising dramatically in 1980, 79, 80. So in that same time, that's when the overdose rate starts taking off.
[00:13:19] We attribute it to Purdue and OxyContin and all this like, but if you look at overdose more broadly, the exponential increase in overdose tracks the exponential increase in inequality, which is, again, not a coincidence.
[00:13:35] But I think, you know, in the 80s, you know, targeting people who use drugs and welfare queens and crack babies and, you know, crime, this was all a way to get people to not see that they had just gutted social services.
[00:14:01] And that cities were struggling with deindustrialization and that hit, you know, black people and brown people first. And then we saw, you know, crack comes in, right? And it's like, oh, crack is causing all of this. No, crack was a symptom of this because and it's exactly the same thing that happened with like poor white people with opioids in the OxyContin era.
[00:14:28] Because what you have is you have an introduction to a community where there's no jobs and a lot of pain and a loss of hope. Now you have a substance that's available cheaply that you could either use to escape and get high or you could sell and actually have some economic prospects for yourself.
[00:14:49] And that's when you see all of these problems escalate around drugs and cities first and then in the rural areas with the 90s and the prescription drugs. If you're enjoying this podcast, can you please do us a favor? Spread the word.
[00:15:15] Tell your friends, your family, your coworkers, anyone who's interested in the future of Blue Cities and better governance. Basically, anyone who thinks that the conversation in Blue Cities is kind of stagnated and thinks we need to be hearing from more smart people, even people that we might disagree with about many things. And one more favor to ask, if you want this podcast to continue, can you take a minute right now to give us a five-star review on Apple, Spotify, or wherever you get your podcasts?
[00:15:42] Because the way the algorithm works, it's the five-star reviews that give other folks a chance to discover the podcast. And finally, we want your feedback, positive, critical, whatever. Please send that to us directly. You can email us, bluecitypodcast at gmail.com. That's bluecitypodcast at gmail.com. And send along show ideas, guest ideas. Sandeep and I would really appreciate that as well. Okay, back to the show.
[00:16:16] And so, yeah, just to follow up on that. So, obviously, this was the era in some sense where the belief system was that stigmatizing drug use, which is what they were very, very, very explicitly doing. Right. They really saw it in that era as a – it's rooted in all of these kind of social and racial sort of coded things that you're talking about.
[00:16:42] But they also, in some sense, saw that, did they not, as like – as an effective intervention mechanism to keep kids from, you know, becoming, you know –
[00:16:56] Yeah, no, I mean, I think the thing there is that because they stigmatized and stereotyped drugs as being a source of hedonism and a source of, you know, people who don't work and a, you know, a thing that is just bad. They thought that you could stigmatize it to children and then they'd be like, oh, I don't want to do that.
[00:17:24] It works about as well as stigmatizing sex to children. It works until they're about 12 and then suddenly all the just say no pledges go right out the window. Because you can, like – if you have a, like, fourth or fifth grader, it's really easy. They're like, drugs are bad. I don't want to do that, you know. And all of a sudden it changes with puberty, right?
[00:17:46] So the – I think, you know, the reality of what happens with problematic drug use is that it's about trying to feel better and escape economic despair, mental health-related despair, trauma-related despair.
[00:18:05] And so just telling people just say no when they've found something that actually makes them feel okay for the first time in their lives is really not going to be very effective. Like, just say no will work great if you are – your life is great and you don't need any extra thing to make you feel okay. And, you know, like, the vast majority of people who use drugs do not become addicted.
[00:18:34] The people who do overwhelmingly have trauma, economic despair, and or mental illness, often all three. Yeah, I mean, and what all of us grew up with was the celebration of drug culture from pop culture, right? It was the Velvet Underground. It was Cheech and Chong. It was – I went to a number of Grateful Dead shows myself and then ended up at Reed College. And so that was the context. You know, the Reagan administration comes along and they say, this is your brand on drugs.
[00:19:04] And we're all like, well, that's not – an egg frying in a pan is not very accurate or evidence-based. It's not really telling us very much about – it's not doing much to try to discourage people from using drugs because it's just such flat bullshit.
[00:19:21] Well, I mean, and I think, like, right, the whole business of they had to create marijuana as a gateway drug because the damage associated with marijuana use is minimal compared to the damage associated with tobacco or alcohol. And so the – you know, they had to do something to make it bad so that they could criminalize that. And so this was – you know, it's a gateway to the other things.
[00:19:50] And all of that stuff, like, you know, when you educate people with propaganda and they see their friends and their older siblings doing these things and none of these terrible things happening that they claimed would – you know, the moment you smoke pot, you just turn into this monster and, like, start shooting heroin and start robbing people. When they see that those things don't happen, your prevention message just fails dramatically.
[00:20:14] Because in order for effective public health prevention to work, you need trust. And the people – you need to be honest about what the risks are and what the issues are.
[00:20:27] And so, I mean, part of the thing that happened in the opioid crisis is that we'd been telling people for so many years, you're going to die of marijuana and nobody seeing this, that the – you know, they didn't have the appropriate caution with opioids. You know, once you tell kids a lie as public health, then why are they going to believe you about anything?
[00:20:52] Like, if what they're saying about marijuana is such crap and it's clearly demonstrated to be so, then why would they be right about heroin? It does seem to me that there's clearly a – you know, there are sort of – there's a class dimension to sort of how we have responded to drug use over time in the United States, right?
[00:21:16] I mean, obviously, there have been these waves of – where, I don't know if we're black or a better term, middle-class white kids got more into doing drugs, right? Like, the late 60s, early 70s, we go through the kind of – like that classic, like boomer, you know, counterculture drug use sort of period. Although, to be fair, Gen X is the drug use generation. Well, that's what I'm about to get to, right?
[00:21:41] Like, there's a – people don't recognize it, but kind of in the late 80s and 90s, early 90s, there's this other very big wave, right, of kind of spike in, you know, kind of, let's say heroin use coming out of like – yeah, yeah, cocaine and heroin use.
[00:22:05] 50% of the adult population who – in their 20s, in the 80s and 90s, 50% tried cocaine. That's a crazy number. Yeah, yeah. There was – I mean, in the early 80s, you couldn't work in a restaurant and not like – you know, it was glamorous to like do a line of – you know, everybody's kind of hanging out and doing coke.
[00:22:23] And when David and I were in Reed College in the 1980s, you know, there was definitely a culture around all of that stuff that was very much entrenched among, you know, outside of inner cities, outside of poor and minority communities. There was like a drug culture, right? Well, and I mean, I think the – this is the thing about the way, you know, when we see drug users as people like us – Yes. Don't want to lock them up.
[00:22:53] And we want to have treatment and we want to decriminalize and we want to do all these like more compassionate things. Like harm reduction becomes okay if it's your kid that's going to die of an overdose. If it's crack and those people doing it, then, oh, we better lock them up. Right. And so it is very much like all of this stuff fits together to create a very, very bad policy.
[00:23:18] Like because you could not – like if you look at our drug policy, it is so ineffective in every single way that you can look at it. You know, America has the number one incarceration rate in the world and the number one overdose rate in the world. So if criminalization is so great, like why are we so bad?
[00:23:38] You know, everything we – you know, when you look at like supply side interventions, when you look at the way our treatment system is just terrible, all of the stuff we do is very effective at locking up poor and black and brown people and virtually not effective at all at changing actual drug-related harm. As I was reading undoing drugs, it struck me as not completely coincidental.
[00:24:04] As you're saying, right, it's when sort of people like us are doing drugs or our kids are doing drugs that there's this kind of rethink about how punitive we want to be about drug use or how we want to – do we want to put it in the frame of sort of, you know, morality and criminality or put it into a frame that this is a, you know, a kind of issue of public health or of – or a social issue, right?
[00:24:30] Middle-class deadheads serving 30-year sentences for dealing LSD or what have you. Well, right. In the 70s, they pass all these draconian drug laws and they start catching up, you know, like, yeah, white middle-class kids and stuff. There's a reaction to that. Interesting thing in New York, right? We had the Rockefeller laws, which were some of the absolute toughest laws, and they were the model for – these went into effect in the 70s, and they were modeled for the national crackdown in the 80s.
[00:24:58] Now, in – so 1973, you get 15 to life on a first offense. Marijuana – and these are quantities that are – they assume are associated with dealing. So for marijuana, cocaine, heroin, 15 to life first offense, right? This is the Rockefeller laws. And so the – by 1977, guess what drug is no longer included in that?
[00:25:29] Cocaine? No, marijuana. Weed, weed, yeah, of course, because all the kids are smoking weed. Yeah, yeah. They're going to jail for this. Yeah, yeah. They're smoking weed, and yes. Yeah, no, no, totally. So I think we've kind of painted a portrait here of kind of what the worldview, what the establishment kind of consensus was around drug use back in the 1980s, right?
[00:25:48] And so the story you tell, Maya, in Undoing Drugs is in this period where there is this very, very dominant view about the evils of drug use, the evils of drug users, the fact that they were, you know,
[00:26:10] very much like outside the acceptable circle of people that kind of dehumanization of drug users in some sense that was going on in this period. You say that it's really – this is the seedbed out of which the harm reduction movement begins to emerge in the 1980s.
[00:26:33] And it's really a bunch of rebels and very outside-the-box thinkers who are fighting in direct opposition to this entrenched conventional wisdom, and they're spurred to action by the AIDS crisis and the terrible toll they're seeing take around them in terms of human suffering and lost lives. And you talk in the book about all of these kind of really pioneers of harm reduction in cities like New York, San Francisco, London, other places. So tell us a bit about that.
[00:27:03] Where does this movement – where and why does this movement originate and who are its initial experts? So, I mean, so it is an international movement. And I sort of start – because I had to start somewhere – with the Dutch who – a guy named Nico Adrians, who was an injection drug user himself.
[00:27:29] And there was a very deadly, unusually deadly hepatitis B outbreak in the city of Rotterdam in the early 80s. And he, having injected drugs himself, knew that people prefer to use clean needles. You know, there was a myth I had to fight constantly in the 80s that like, oh, addicts are these horrible, scummy people, but suddenly it's peace and love when it comes to needles. And we're not selfish at all about that. We're going to share them with everyone.
[00:28:00] You know, of course, people prefer clean needles just like people prefer clean anything. And so the – you know, he knew this. He started distributing clean needles and taking dirty ones off the street. And that is the first needle exchange, right? He also founds the first drug user union.
[00:28:25] And, you know, the Dutch have an important role in like setting up the grounds for harm reduction because they had quasi-legal marijuana going back to the 70s because they realized that their laws were doing more harm than the substance itself. And so what happens is in Edinburgh, Scotland, there's a outbreak of HIV.
[00:28:50] And before – when they first start testing people, suddenly it's like 50% of their injection drug users are infected. And these were like young white people in their 20s in Edinburgh with a disease that was deadly. Almost universally deadly, right? And so UK starts freaking out.
[00:29:12] In Liverpool, a bunch of people are like, hey, you know, because Edinburgh and Liverpool were very similar in terms of the socioeconomic stuff going on. There was mass deindustrialization, huge youth unemployment, and hence lots of young people injecting drugs, right? So you – but Liverpool, unlike Edinburgh, HIV had not been introduced into the population there. So they're like, we have a chance to stop this.
[00:29:41] And so they knew what the Dutch were doing. They knew what people in San Francisco were doing in terms of gay men as prevention. And so, you know, they spoke to people and the – one of the San Francisco people told the Liverpool folks like, hey, if I had my way, I'd be giving out clean needles. This is America. We're not doing that. But the Thatcher administration sees what's happening in Liverpool.
[00:30:11] Liverpool starts like handing out needles, prescribing heroin, which is legal there, prescribing cocaine, just meeting people where they are. And they explicitly say HIV is a more serious threat to public health than drug use, and we're going to act that way. Because basically in the UK, it was us who was getting HIV from drugs.
[00:30:35] And yeah, they were working class people, but there wasn't that racial element that we had here. And in terms of at least the stereotype of the injecting drug user that they were working from when they did this. So Thatcher says, okay, 1986, we're doing syringe exchange. We're doing harm reduction. It's national policy. In the United States, we had to have a lot longer fight.
[00:31:02] And so, you know, San Francisco starts handing out bleach because they can't get needles. Like that's a bridge too far in the war on drugs. And so they're teaching people to use bleach. This spreads to New York. People realize that, like, we really need to do the needle thing.
[00:31:22] And so, you know, ACT UP starts getting involved with we're going to do illegal syringe exchange because New York actually very briefly had a syringe exchange pilot program. But Mayor Dinkins, his election promise was I'm going to shut this thing down because this is a whole thing. He shuts it down. ACT UP starts doing their thing, deliberately trying to get arrested.
[00:31:53] And they do get arrested. I was there for this arrest. And they, you know, they bring it. It goes to trial. And they had this incredible piece of evidence, which was in the United States, the states with the worst, the highest numbers of IV drug users were the states with the toughest drug laws.
[00:32:20] Those states were also the same states with the worst rates of HIV. And so the argument for keeping needles illegal was that it will prevent it. And clearly this was proven false by the actual numbers. And so the judge was like, OK, these activists are right. This is a medical necessity.
[00:32:45] And that paved the way for needle exchange to be legalized in New York state and paved the way for, you know, we had 50 percent of our injection drug users who were HIV positive when in the day when I was using there. And, you know, it's now less than 3 percent.
[00:33:08] And there are now I was just reading about there's an outbreak of HIV in IV drug users in Maine at the moment. And there are now like these little tiny towns in places like rural Maine where there are literally higher numbers of injection drug users getting AIDS than in all of New York City. And I'll tell you, we have a heck of a lot more injection drug users than Bangor Maine does.
[00:33:38] We just have better syringe access. I wonder if I could just follow up on the thread where it was Dinkins of all people in retrospect to end that needle plan for drug users. And then he's defeated in 93 or whatever by Rudy Giuliani. So politically, things go from bad from bad to worse almost, I guess. Is that how did Giuliani approach the war on drugs? Is that part of the story?
[00:34:07] He was absolutely worse than Dinkins. But the thing is that like in the 80s. America's mayor. In the 80s and 90s, like the Republicans and the Democrats were and including the centrist liberal folks were like, we got to crack down on this so that like the Republicans can't target us as being soft on crime. And so they were opposed to things like needle exchange.
[00:34:31] And there was a lot of opposition in the black community in New York City to syringe exchange because they felt like many of the leaders there felt like, oh, you're giving us needles to kill us rather than giving us treatment access. Yes. And there was a sort of whole respectability politics that that went around that, which was why Dinkins and the Black Leadership Commission on AIDS were like opposed to syringe exchange.
[00:34:59] But it was also part of the Democratic thing of that. Yay, war on drugs. And so, yes, we went to Giuliani. It was very interesting, actually. He was, you know, he tried, obviously was opposed to syringe exchange, tried to shut that down, did not succeed, also tried to shut down methadone.
[00:35:23] And it was quite interesting because I helped organize a thing where we got an ad placed in the New York Times when he was campaigning against methadone. And we had a young man, GMHC styled him so he looked great and he was a person on methadone and talking about his job and like very, very respectable.
[00:35:46] And we had all these statistics and the most one, the main thing we wanted to do with this ad was reach Giuliani because what do we, what is one of the things that is like very clear in the data on methadone? You add methadone to a place, you get less crime. You take methadone away, you get more crime. And this has been replicated a lot. And since we knew that's what he cared about, we did this and he did not try to pull methadone.
[00:36:15] I will just say, because for me, it was methadone. Methadone, you know, I spoke a couple of years ago here in Seattle, the big methadone clinic is Evergreen Treatment Services. I spoke at their lunch because I was a, when I first moved to Seattle 27 years ago, I was a client of theirs. And now I'm obviously way past that. And, and, and yeah, methadone saved my life. Right. I mean, it, it, it became the, the, the only thing, you know, I tried 12 steps.
[00:36:44] I tried after none of that stuff worked. Right. Well, I mean, what's really important for people to know these days is that we have two medications that cut the death rate from overdose by 50% or more. If we had this for cancer, we'd be dancing in the streets. But because these two medications are themselves opioids, and I mean methadone and buprenorphine, we are like, oh, you're not really in recovery if you're on these medications.
[00:37:10] And we stigmatize the single most effective treatment we have for reducing overdose deaths. Sanji asked earlier about stigmatization and sort of de-stigmatization.
[00:37:26] And one of the many thought provoking things that you are asking us to think about is to see addiction as a developmental learning disorder, which I found super interesting in part because I know a lot of people with developmental learning disorders. And I know a lot of people struggling with addiction as well. And I know that people who had dyslexia back in the bad old days, they were treated like they were stupid.
[00:37:54] They were, if they were put in special schools, it was special schools for, you know, people who had a hard time learning anything at all. And they were told, you know, you just need to focus and try harder, et cetera, et cetera, et cetera. So I'm wondering, in what ways do you think it's helpful to think about addiction as a developmental learning disorder? Like why that shift and why didn't you make that analogy? Well, I mean, I think like I spent years obsessing over what is the definition of addiction.
[00:38:24] And I eventually came down where pretty much the field has come down, like including, you know, the National Institute on Drug Abuse and the DSM. And the essence is compulsive drug use despite negative consequences. It isn't dependence. It isn't physically needing something to function. And that error, like Scientific American in 1982 said that cocaine is not as addictive as potato chips. Of course, we now know that potato chips are addictive.
[00:38:51] But the point was that, like, everybody thought physical dependence was where it's at in terms of the nature of addiction. In fact, compulsion is where it's at in terms of the nature of addiction. And if you think about compulsive drug use despite negative consequences, there's one key implication, which is, A, punishment isn't going to fix it because by definition it does not respond to punishment.
[00:39:15] But B, what is punishment but a form of learning or attempted form of learning? So this obviously means that it is fundamentally a problem with learning, right? And so there's that bit. But it's also the case that 90% of all addiction starts in the teens and early 20s.
[00:39:36] And if you know anything about brain development, there's like three key periods of brain development, prenatal, zero to five, and teen to young 20s, right? So this is suggesting a developmental thing going on here. And so that was sort of one part of why I felt that framing was important.
[00:39:59] The other reason is that if you look at what happens and the way people behave during addiction, it's as though they're in love with a substance or an activity rather than, you know, the sort of obsession that a parent has with their new baby or that a person has with their partner, right? So it's basically you fell in love with the wrong thing.
[00:40:21] And when you fall in love or have a child, the, you know, evolution is trying to get you to make sure that your reproductive strategy succeeds, right? And so that means in order to tolerate a child or a partner, you need to persist despite negative consequences, right? Like all, nobody would survive if they couldn't persist despite negative consequences, right?
[00:40:49] And crying and like all of the stuff that comes with, you know, having a baby. I can talk about the stuff that comes with having a partner that's a pain in the butt. We've all experienced that. So when you look at addiction as love gone awry, what that fundamentally means is A, it is a kind of specific learning path in your brain that you have for these evolutionary purposes. And B, that your brain isn't broken.
[00:41:17] It isn't damaged. I mean, you could damage it with substances, but that isn't the essence of addiction. The essence of addiction is that compulsivity, and that is sort of a misguided learning rather than your brain cells are broken.
[00:41:37] And that is A, destigmatizing, and B, true when you look at what the neuroscience suggests about how addiction acts in the brain. I did have a follow-up on the dyslexia question just because I'm really familiar with it in my own life. And, you know, as we mentioned before, like the punitive approach doesn't work, right?
[00:42:01] The sort of harsh approach, accommodations, better learning environments, et cetera, that's what we want for kids that are struggling. But the other piece of it, I was thinking about this earlier, is kids are in school. It's not voluntary. They're required to go. Learning to read is not voluntary. You know, if you took your average second grader who's struggling with dyslexia or ADHD or whatever and said, hey, it's voluntary. You can learn to read or not. You know, if you want to play video games, that's cool.
[00:42:30] You know, how many kids are going to learn how to read in that situation? So I'm kind of wondering about, is this the limits of the analogy in some ways? Is there any role for coercion when it comes to dealing with both things like school as well as growth? So we have to remember that when we're talking about people with addiction and coercion, we are talking about adults. We're not talking about children.
[00:42:57] And if you actually want effective treatment for people, the best way to do it is not coercion. If you look at, you know, people who participate in syringe exchange programs, five times more likely to enter treatment compared to people who don't participate regularly. There is zero evidence that being nice to people who are actively using prevents them from recovering.
[00:43:24] And there is also zero evidence that coercion is the most effective way to get people into treatment for addiction. Like you can get about 85 percent of people who are unhoused and mentally ill and have drug problems into treatment voluntarily if you just offer them proper services.
[00:43:49] The problem is that we are so hung up on coercion that we think that, oh, people with addiction are just having so much fun out there on the street being homeless that, you know, that they won't get help unless we kick them in the butt. And that is just the most ridiculous thing, because, first of all, if you've ever seen somebody who's unhoused, they are usually not having much fun.
[00:44:14] But also, if you look at the whole history of the housing first concept, why did we develop housing first? Because treatment first failed. Because trying to get people into recovery when they don't have a house is pretty much a fool's errand. And if you want people to get better, you have to give them a sense of hope and purpose and connection.
[00:44:40] And, you know, there may be instances where coercion is necessary, where somebody is an explicit danger to themselves or others. But because coercion also does serious harm, like there was a recent study that I was I'm going to be writing about, but is so they looked at judges who were deciding whether or not to commit people to psychiatric hospitals.
[00:45:10] And they looked at the edge cases where like, maybe they should commit, maybe they shouldn't. And a lot of these people had both addiction and mental illness. So what did they find? For the edge cases that got committed, they were twice as likely to die of overdose afterwards. They were also twice as likely to commit a violent crime afterwards. And they were not more likely to get better.
[00:45:39] So we can clearly do harm with coercion. And I my feeling is coercion lives. You start by doing the thing that will not do harm, because we know that being kind and welcoming does not do harm.
[00:45:57] We know that coercion can do harm, especially coercion also does harm in a more oblique way, which is that if you have a treatment system that gets all its patients involuntarily, they don't have to be nice to people. They don't have to do anything to be consumer friendly. And the most effective kinds of treatments are kind and welcoming.
[00:46:22] So if you make treatment coercive and you have people, for example, if you were let's say you have a history of being sexually abused, you're sitting in a group with people who are coerced and you're going to share this very, you know, private information. And everybody's sitting there like watching the clock like this, like it's not conducive to a therapeutic environment.
[00:46:49] It may be necessary in extreme cases. But why don't we start by providing services that people actually want? Because you can get 85 percent of people into them and also spend a hell of a lot less on policing and force and stuff that we know has the capacity to do harm. Let me get at this question another way, because I agree with I agree with I think most of what you said.
[00:47:18] And I do think the vast majority of people that are suffering from addiction, the better approach is not a coercive approach. But the term I would use rather than coercion, I think, is is is friction in the system. But but but before I get to that, let me let me get it another way.
[00:47:38] Um, so harm reduction rises up right in the in the 80s and 90s out of the HIV AIDS epidemic needle exchange we were talking about. And the public health nexus is absolutely clear.
[00:47:52] There's just no question that needle exchange was a incredibly valuable, beneficial public health intervention in reducing the spread of this horrible, incurable disease at the time, along with other stuff, hepatitis, everything else that that was associated with needle use. Um, but harm reduction has evolved as a concept quite significant or expand, maybe maybe has become more elastic as a concept.
[00:48:22] And to me, I think the devil's in the details sometimes and where it gets more controversial nowadays. Right. Is when we're talking about not needle exchange, which I think is pretty much widely accepted in any kind of blue jurisdiction blue, you know, not not everywhere. But but at least the Seattle's of the world. Right. I don't think there's a whole lot of questioning of needle exchange anymore. But um, but there's still a lot of controversy around handing out like tinfoil or handing out glass.
[00:48:51] Like that is silly. Like where is the data showing that that does harm? Like there is no such data. In fact, if you look at OK, what is the most enabling harm reduction thing you could imagine doing? Giving out free heroin. Right. People in Switzerland who get free heroin, the longer they stay in free heroin are the more likely they are to get into more traditional forms of treatment.
[00:49:18] It does not deter traditional help. Um, and it reaches people who have been failed by traditional help over and over and over. So, again, if you can show me some data which does not exist, I and I have looked for it, um, that pipes are a bridge too far or naloxone causes moral hazard. And so people use more because they know that they could be rescued. Like this is simply not true.
[00:49:46] First of all, getting an overdose reversed with naloxone is very aversive. Um, and second of all, giving people naloxone doesn't give them extra money. And if you don't have extra money, most people who are using use all that they can get at that particular moment. So naloxone can't cause this supposed moral hazard.
[00:50:08] Like the, the methodology on the one study that found it, um, was really problematic because they didn't look at when, when the laws were actually introduced. And when you look, um, more precisely at when naloxone gets handed out, you see that it reduces, um, overdose deaths. Um, it is no fun to have an overdose reversed by naloxone. Um, and, you know. I've seen it. I've seen it happen. Yeah.
[00:50:38] Yeah. I mean, I've seen, yeah. Yeah. It's not, it's, you know, um, and like, again, you know, what people fail to understand, they think that like, oh, I'm going to walk into, New York's overdose prevention site where you can use under supervision and people are sitting there, shoot, shoot, shoot, shoot, shoot. Like a keg party or something. Right? Like that is not what goes on there. People are just treated kindly.
[00:51:05] And suddenly they also, you know, most of people, many of the people who work there are people in recovery. And they, when they start to be treated kindly, they are much more likely to say, well, how did you stop? This really isn't being so fun for me. You know, I really would like to not be in this lifestyle anymore.
[00:51:25] Um, you know, it's just like the whole idea that, um, harm reduction somehow encourages, um, uh, you know, public drug use or any of these things. Like where is the data? Okay. The state that has the highest overdose rate in the United States is West Virginia. Tell me that's the capital of harm reduction. Also tell me that it has a lot of homelessness. It doesn't. And a lot of public drug use. Again, it doesn't. Why?
[00:51:53] Because it is a rural state and people are very spread out. Like where you see problems with public drug use and lots of homelessness is in cities that have very high rents. And you do not see this in places where that is not the case. Um, and so, you know, again, I would really like these people who are making these arguments to show me a single shred of data that supports them.
[00:52:22] I'm interested in your point that giving out free heroin can help people get it, help people get into treatment that they, that they tried that in Switzerland. Um, and I would totally support anything that would help people and help society, including that. But in that instance, only if it was nationwide, I don't have the data to support it. But man, if you make heroin legal in Seattle, I'm telling you, people are going to be moving to Seattle. That's pretty good. If you have that kind of harm reduction program just in one city, I'm not sure it's going to work.
[00:52:51] I agree with you on that. And I mean, what's interesting, though, is like, let's talk about Oregon for a second, because people are claiming that like, um, decrim failed there because, um, a million people moved to Oregon to like get high. And if you actually look at the data, they surveyed people, um, unhoused people in Oregon, um, at the time of decrim. And something like 80% didn't even know that fentanyl had been decriminalized.
[00:53:21] Um, so how could they have changed their behavior? And also something like 80%, like a very large majority of the people that, um, uh, are unhoused, that are in Oregon, have lived there for 10 years or more. Um, and so it's, you know, again, and you can't even be attracting dealers because decrim doesn't legalize dealing.
[00:53:44] Um, so also if you look at like, I have this, um, uh, graph somewhere, um, where if you just look at when does overdose rise in a particular place? And it is when fentanyl hits a certain saturation point, um, in the drug market. And when did that happen in Oregon?
[00:54:06] Right around the same time when decrim happened, it was a terrible coincidence, but the states around Oregon that didn't decriminalize, didn't see, um, any difference in their increase. Um, so, you know, Washington also briefly decriminalized during their brief decriminalization overdose went down because fentanyl, not because decriminalized something.
[00:54:31] But the, um, you know, you have to actually look at like what the data shows and the attacks on harm reduction are purely political. They don't have any data. Yeah.
[00:54:47] So, um, I do, I do think, cause obviously Maya, you and I were both, we were using heroin right back in the eighties and I, and me through, throughout the nineties into the, into, into the two thousands. Um, um, fentanyl and meth have largely displaced heroin and cocaine as the kind of street drugs of common uses.
[00:55:15] In cities like Seattle or, you know, uh, Portland, Los Angeles, San Francisco, LA. Um, and fentanyl in some ways, I, when I look at the sort of havoc that fentanyl, fentanyl has brought, right. And it's a, it is in some ways, the addiction to fentanyl is more akin in my mind to being addicted to crack than it is to heroin. Right. It's more, it's not as just, it's just heroin addiction was sustainable. Right.
[00:55:45] In, in a kind of, well, I was a heroin addict for, like I said, a dozen years. Right. You can't function on fentanyl. It's an anesthetic. Yeah. Yeah. Right. And the, and the, the risk of overdose is so much higher, right. You know, the, the lethality of the drug is so much higher. And to my mind, that says that difference between heroin and fentanyl says to me, we have to be way more proactive in our interventions. Well, why don't we, if that's the case, why don't we have treatment on demand?
[00:56:15] Yeah. Like, yeah. Well, and look, voluntary stuff, more treatment on demand. It's not like, it's not rocket science here. Yeah. Let's have more safe consumption stuff. Yeah. All of that. Like, it's not, you know, because the, the, of course we should be. Um, it's not that people who do harm reduction are like, we shouldn't have treatment and like, everybody should be high all the time.
[00:56:40] And like, you know, that is not what, you know, harm reduction is to reduce harm and keep people alive so that they can get better. Um, and for some of them that may never happen, but at least they're alive. Um, for some of them, it will take a while.
[00:56:56] Um, but the, um, you know, the thing is that there, we make up this idea that there is this, um, you know, problem between, um, you know, abstinence and, um, harm reduction. Like, first of all, let's say we did have treatment on demand. 90% of people who attend treatment relapse at least once. Um, so we need harm reduction for these folks, no matter what, even if we did have that, right?
[00:57:26] So it's like, you know, the way people, you know, 12 step programs are a great example of, you know, they talk about in AA and NA, like it's a program of attraction, not promotion. Um, and certainly not coercion. It's a voluntary program. It's for people who want it, not people who need it. Um, and they talk about that because the people don't get better if they don't feel like they have something to live for.
[00:57:54] And when 12 step works for people, a lot of what it does is give you meaning and purpose and community so that you can connect with others and help people like yourself. Um, so this like notion that like, um, you know, we are not, I like, I'll just put it this way.
[00:58:17] Nobody who's walked into a syringe exchange or any harm reduction program has never thought, gee, I should not, maybe I should go to, you know, they've all thought maybe I should go to treatment, right? It's not like you walk in and you should go to treatment and that's going to be a new thought to them. Um, like, you know, the, the way to get people to get better is to bring them in and to provide services that will work for them.
[00:58:43] Um, and you know, it's like, it's not glamorous and it's not, um, you know, perfect. Um, but given the tools that we have in this country to deal with addiction, um, we could be deploying the money that we're spending in just a way better way.
[00:59:07] Sure. But, uh, just to, yeah, kind of follow up on, on my, on my train of thought. I mean, when I look at sort of the effects that fentanyl was wrought on the streets of, of Seattle, if you go to Little Saigon, I've gone out with outreach workers a few times to, you know, kind of, kind of observe the work they're, they're, they're doing there. Um, or, you know, I mean, not just a little Saigon in Seattle, go to Kensington in Philadelphia, go to, you know, MacArthur Park in LA or the Tenderloin in San Francisco.
[00:59:38] Right. Yeah. It's not like they need a kick in the butt to get help. It's that they're miserable and they don't have hope. True. I agree with all of that. But I also, it, it, it, when I look at the kind of scale of the human suffering, right.
[00:59:58] And, and, and devastation that is being wrought in these kind of open air drug markets, it does say to me that it says to me that nobody, no, I don't think anybody, whether you're the leftiest housing first harm reductionist, whether you're the rightiest, like they're all bad, morally bankrupt people thrown. Nobody's got a good answer. Right.
[01:00:25] You know, I, I, I'm not seeing, um, I'm just seeing the scale of the suffering. Right. And I'm not, I mean, if we're going to talk about that, we have to talk about inequality and we have to talk about the fact that the American dream is being destroyed.
[01:00:41] And that if you know, you look at, um, like people do drugs and are severely mentally ill in a horrifying way, like you see in these places with massive histories of trauma, massive histories of poverty. Um, just like about every dysfunction that a human being can experience. A lot of the people there have been through. Right.
[01:01:09] And so, um, you know, uh, let's cure schizophrenia too. Like I'm all in favor of this. I'm really in favor of like, you know, making this better. Um, but the, um, the thing that we have to deal with is we don't have national healthcare. We are trying to marginalize people.
[01:01:31] Um, we are doing everything we can to make things uncertain and stressful, um, for everybody. Um, and I don't understand why the billionaires don't find it stressful for themselves because if the market crashes, they're going to be in trouble too, as it's going to be, they're going to be in trouble. From the climate also, um, because they have to live on this planet and Mars is not acceptable yet. Accessible rather. But I would wish they would go.
[01:02:00] Um, but the, you know, again, it's, it's just like, yes, the scale of that suffering is horrible and you want to help. Um, but we have ways of helping that we are just not doing. I guess I'll follow up with that. Yeah. Yeah. Just, just with, um, those places in cities like Seattle, because I've covered a lot of that as a politics reporter and, and seen it from multiple sides. And, you know, getting at root causes, absolutely.
[01:02:28] But short term, you know, the piece of this, uh, sort of public health piece of this is the downstream negative consequences for people. And not just bougie people living in fancy apartments in Manhattan or Seattle or whatever. All for low income marginalized people who are living in Little Saigon or some of these neighborhoods. That's, that's a part of it too.
[01:02:50] And so while we're waiting for our society to wake up and figure out how to be more progressive and solve problems before they start. What about just the short term consequences of those kinds of open air drug markets for the folks that are living there? Not just the people who are struggling with addiction. How should we as a society kind of take that into account when we're talking about designing good public policy around drug use and addiction and that sort of thing?
[01:03:18] Those people who are out on the streets using drugs in those public drug market areas are citizens, are people, are part of the population whose views need to be respected. Not, well, they're the only ones we've been talking about so far. So I wanted to talk about the people who weren't those people who live amongst that and are in some cases victims of crime and theft or intimidation, et cetera. Or, you know, by those, by those folks, because addiction is not pretty. We all know.
[01:03:47] Again, we don't see Elon Musk robbing people to get his ketamine. And, you know, the reason that you see the crime that you see associated with drugs is the economic piece of it, not the, you know, the drug piece of it for the most part. Now, again, there are people who have had been severely abused and became violent before they started using and then the drugs made it worse.
[01:04:16] But again, for the people who are citizens of those neighborhoods who are not using and are not mentally ill and are just trying to get by, like they need housing too. They need, you know, like I'm not saying we should have like, let's just have street encampments around everywhere and let's just like, you know, do that.
[01:04:41] What I'm saying is that to help people in this, for example, in New York, we have On Point, our supervised consumption site. And it's in Harlem and it's across the street from an elementary school.
[01:04:56] And one of the principal or the head of the elementary school spoke to me recently about the, you know, and she's like, you know, when a little kid falls down, we pick them up and we nurture them. And if they fall down again, we do the same thing. And that's what those people across the street are doing. And what they're doing across the street is also they're using inside the place, not outside in front of the kids.
[01:05:24] And if you actually want, you know, I mean, we have evidence that if you work to clean up, you know, encampments that have gotten really unhealthy and you just offer people services that that are good, they will happily leave. You know, it's like, it's like, it's not, it just isn't, it isn't rocket science.
[01:05:47] And we can, we certainly should try to make sure that, you know, you don't have a horrible unsanitary situation where, you know, little kids are trying to go to school and people are shooting up and there's all kinds of garbage around. Like nobody wants that.
[01:06:07] The way, the most, the cheapest, most effective way to fix that, however, is housing first and is providing services to support people with mental illness and addiction through their recovery processes. And most of the time that can be done voluntarily, which makes it a lot cheaper because you don't have to involve the police who are very expensive and you don't have to involve the prisons, which are very expensive.
[01:06:36] And by the way, like there was a, just a study that came out looking at San Francisco and they asked people on the street, you know, if they had recently been incarcerated, recently participated in needle exchange, recently been in treatment. The people who had recently participated in needle exchange were twice as likely as the people who had recently been incarcerated to have recently been in treatment.
[01:07:01] Like, it's just, I know that it doesn't seem intuitive when we're in a punitive and coercive society, but when you just look at the actual data, it's not the hippies that are being unrealistic. It's the cost. Maya, thank you so much for coming on and jibber jabbering with us about all of this stuff. Thank you guys. Yeah, thank you.
[01:07:25] And the boy who was raised as a dog, I was excited to see that that was also one of your topics that came out a while ago. I'm David Hyde. He's Sandeep Kaushik. Thanks again for listening to this edition of Blue City Blues. Our editor is Quinn Waller. And yeah, that's it. Thanks.