Reducing Harm to People and Communities
Air Date: November 8, 2021
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HEFFNER: I’m Alexander Heffner, your host on The Open Mind. I’m delighted to welcome our guess today, Maia Szalavitz, she’s a reporter and author who focuses on science, public policy, and education and addiction treatment. She is author of the book “Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction.” Maia, thank you so much for joining me today.
SZALAVITZ: Thank you so much for having me.
HEFFNER: Maia, for those of our viewers who are not aware of this term, that’s become quite popularized and pretty well established now, I just want to give you a chance before talking about your book and its implications, to tell us what harm reduction means.
SZALAVITZ: Sure. So harm reduction is the idea in drug policy that we should focus first on stopping people from getting hurt, not stopping them from getting high. And in other areas like, for example, COVID-19, it means accepting that people are going to do risky things and working our best to reduce the harm associated with those risky things that they are going to do, whether we like it or not.
HEFFNER: And in the context of your book “Undoing Drugs”, what inspired you to write this book?
SZALAVITZ: Well, basically harm reduction saved my life. And in around 1986, I was shooting drugs and I was seriously addicted to cocaine and heroin. And I found myself at a friend’s house. There was this woman there who was waiting with him. all I knew about her was that she was from San Francisco, and she was a friend of his. We were waiting for him to come back with the drugs, and I was about to inject. And she said, wait a minute, you know, you are actually at risk for aids. And I had no idea, even though I literally read two newspapers a day and was a very, watched a lot of TV news as well. So I was just like, you know, I thought this was like a gay men thing or something. So, anyway she told me I was at risk, and she taught me to use bleach to clean my needles because she couldn’t provide any clean ones. And she knew that even though she was just telling me about a horrible, fatal risk, I was addicted. I wasn’t going to stop that second. And so, ever since she taught me to do that during my active addiction, I was as compulsive about using bleach as I was about using needles, which since I was like shooting up 40 times a day when I was doing coke, was pretty compulsive. So she, yeah, I, you know, and in New York at the time, about half of all iv drug users were already HIV positive so I was seriously at risk.
HEFFNER: Now that you, you know, reflecting on your time when you were addicted and how harm reduction enabled you to stay safe, even as you were still addicted, how has harm reduction as a practice become more utilized? Because I think at the time that you were adopting that practice and it was, in effect, educating you on how to be safe in attempting to recover and rehabilitate, it was not as predominant as it is today?
SZALAVITZ: Oh my God, no.
HEFFNER: Right? I mean, it was even, even stigmatized.
SZALAVITZ: I mean, you know, literally I was just today copying some old newspapers, which were about you know, Mayor David Dinkins wanted to stop funding to a program that would teach people to use bleach because it would encourage drug use. Now these were people that they knew could not get treatment slots, even if they wanted it. And they were just like, so into, we need to send the right message to the children that they didn’t care if hundreds of thousands of people died and infected their partners or their children or both. And so, this is why once I was taught to protect myself, I was simply outraged, and I just thought how could it be okay to use one group of people to send a message to children by dying? And that is basically what the drug war was doing. It was making and still continues to do. It’s making it less safe to take certain substances for moralistic reasons and saying that well, if we actually made it any safer then, you know, kids would do it. So bye-bye, and you know, we don’t have the death penalty for other non-violent crimes. And we have drugs that are legal, that are way more harmful than some of the illegal ones. And the reason the illegal ones are illegal is because of racism and anti-immigrant panics. It’s not like some scientific agency sat down and said, okay, marijuana is much more harmful than cigarettes because you couldn’t do that in a scientific context. So it is really, you know, so I was just, yeah. And so harm reduction started back then in the eighties with a small group of people in Liverpool who took some ideas from Amsterdam Needle Exchange, most notably and basically said that, you know, aids is a more serious threat to public health than drug use and if we are going to protect public health, we need to reduce harm to people who use drugs. And then that way A) dead people don’t recover and B) we can stop the spread of this, you know, at the time it was almost a hundred percent fatal disease.
HEFFNER: Now tracing the evolution of harm reduction and how it’s utilized today, you know, there have been major investments, you document in the book in harm reduction in theory and in practice. And to what extent have those practices helped, in any way, you know, mitigate all the damaging realities we know of the War on Drugs for so many years? And I mean, how would you characterize the role of harm reduction in transitioning folks today from, you know, being addicted to potential rehabilitation, is, you know, beyond the health benefits of harm reduction, even as you’re using, where are you able to correlate the deployment of harm reduction and the, not disappearance, but diminishment of, diminishing of use of drugs?
SZALAVITZ: That’s not the point of harm reduction for one reduction history to harm. And so it, doesn’t, it’s agnostic about whether people get high. And so since its point is not to reduce drug use, that is not a fair measure of it. However, if you look at the data, it is for example you are five times more likely to enter treatment. If you participate in a needle exchange for the prevention of HIV, then if you don’t participate and are still an active drug user. And there is lots of evidence from all of the harm reduction tactics, whether it’s handing out Naloxone to reduce overdose or even prescribing heroin itself, that this does not deter people from getting abstinent or from other forms of treatment. In fact, it lengthens people’s lives, it improves their health, and it makes them more likely to get into treatment.
Now that sounds weird because everybody thinks, oh, they have all the heroin, they could want. Why would they get help? Because when you have all the heroin that you want, just like, if you think about any ordinary situation, you get everything that you want, and it doesn’t fix everything. And suddenly you have a lot of time that you didn’t have when you were chasing that thing. And so it sort of opens the world in a way so that you can consider other things such as abstinence. Now, this is not to say that that that is the only thing that happens, but a lot of people just stabilize on the heroin itself and they get a job and they get their family back and they don’t have to spend a lot of time chasing illegal, dangerous things. And since the nature of opioids is that I could be on it right now and you wouldn’t know if I was taking a steady stable dose, which is why methadone and buprenorphine can work. You know, so that is that is basically what happens.
HEFFNER: I understand what you’re saying that it’s, it may be a by-product, but it’s not the intention of reducing harm. For people who are trapped in the system who are incarcerated or on parole or on probation as a result of using drugs that have been criminalized, we know that there is a vicious cycle though, that the undoing harm, the extension of that harm undone may be, you know, freeing them of potential legal ramifications of their use, right? Not just the use being harmful, but potentially being caught up in a criminal justice system that has failed a lot of people. So from that perspective, you know, harm reduction, what is sort of the kind of steps of undoing the harm in your mind, if we’re looking at this from the perspective of policymaking and how what is still a relatively new presidential administration, federal agencies can take the stories that you document, your own and others, and, and try to counteract them with a vision of harm reduction that’s going to correlate with those outcomes: not criminalizing, not incarcerating and not killing people.
SZALAVITZ: Right. Well, so, addiction is defined by compulsive behavior that continues in the face of negative consequences. So basically if punishment and jail and all of the things we try to do to make life horrible for people with addiction, if that were going to work, by definition addiction, wouldn’t exist. This whole idea that we push people to hit bottom and that’s what helps them is completely falsified when you just think about the fact, who’s more likely to recover. Somebody who has a job and a wife and kid, and the cat or somebody who’s homeless? And you see right there, the bottom is not the answer. And that people who have resources with any kind of disease tend to do better. So the way forward in terms of drug policy, is first to start by decriminalizing possession. There is no good argument for locking people in a cage in order to do anything to fight addiction. It doesn’t prevent kids from taking drugs and it doesn’t prevent the person who is using from it. There’s no treatment in jail. And if you force people into treatment that creates another whole set of problems. For example, a lot of people with addiction are severely traumatized. And if I were to be in a group and I’m talking about the horrors of my trauma, and everybody else is sitting there like, oh my God, when’s this going to be over because I have to be here, but I don’t want to be here. You know, this is. But this is what we do. We think that arrest is a diagnostic tool, and then we can pick and put people into treatment that way. That isn’t the way we treat anything that we actually believe is a disease. When we, you know, when somebody has cancer or depression or whatever, we don’t say, okay, well the best thing we’ll do, we’ll just lock them up. And that will arrest the progress of the disease. That just isn’t how it works for anything. And so we need to first move away from criminalizing possession, and that will free up an awful lot of money, hundreds of millions of dollars at least, to spend on treatment that we know actually works. We have two medications that cut the death rate from opioid addiction by 50 percent or more. These are methadone and buprenorphine, if used long-term. So we need to spend money on treatment that actually works. One third of our current residential treatment programs allow these medications, the rest of them don’t there is enormous sentiment that if you are on medication to treat addiction, you are not clean. And again, so we just have this whole system that’s criminalizing and punitive, and that sort of the whole goal is this like sort of moral purity of like not having an evil substance in your system, rather than what I think most people care about, which is, are you working? Are you loving? Are you being there in your life? Are you able to be productive? Are you able to, you know, give the gift that you have to the world? And to me, that’s the beauty of harm reduction, because the idea is that’s what we focus on. I don’t care if you have euphorias. The government shouldn’t care if you have euphoria. We should care if you’re hurting yourself or someone else. And …
HEFFNER: No, that’s well said. I mean that, and that was really my question. And I know you dismissed fairly the linkage, but what I’m really talking about is correlation with harm in your community or undoing harm in your community. And the perception still is, even in what is a transformed electorate and public consciousness, in the wake of the Floyd murder, during this pandemic, there still is I think the governing perception that by freeing up possession, you know, making possession of really any substance, not a crime, that you are at risk of causing harm to communities. You’re arguing that, you know, basically that’s the drug policy that is going to undue harm at the individual and the community level. And I just want you to get at that tension because there continues to be at least the perception, maybe it’s a prejudiced one, that by having a zip code or a state, a town where you have in effect, free and open drug possession, that the result of that is going to be actually harm for the individual and the community. But, you might dispute that.
SZALAVITZ: Well, first of all, you have to look at what’s going on now. We have the worst overdose crisis we’ve ever had in American history. And we have all this prohibition and all this locking people up, and all of this stuff going on, and we still have this problem. If you look at Portugal, for example, where they have decriminalized possession, it’s not like people running down the street naked having drug orgies, it’s basically people getting on with their lives and feeling more comfortable to seek treatment, because it’s available, it’s funded. And because they don’t have to like admit to a crime or, you know, threaten their you know, job or all of these other things that you have to do when you are facing a criminal accusation. I mean the communities that are most harmed by addiction are also most harmed by mass incarceration. And just locking people up for something that doesn’t … it doesn’t help them. It doesn’t help their families. It doesn’t help anybody else. It spends money harming people, like people who go to jail for example, for heroin possession, are like three to four times more likely to die of overdose. They’re more likely to get HIV. Therefore they’re more likely to spread HIV. This is just not a positive public health policy. And the thing that people think that, you know, people with addiction are just these like animals, and they only respond to force. Like that is influenced by like just years and years and years of propaganda and prejudice. When alcohol was illegal, we saw alcohol-related crime in terms of shootings around the trade and all of this kind of violence that was associated with gangsterism. Now decriminalizing possession would leave dealing for another day, but the idea that if you know, if you criminalize something, you stamp it out, that’s not what’s happening.
What’s happening is we have created a poisonous supply that is only going to get worse, and we haven’t solved the problem because people take drugs for reasons. And the people who become addicted are vulnerable in many ways. They may be poor. They may be, they may have mental illness. They may have child trauma or all three, because child trauma is often what turns a predisposition to a mental illness, into an actual mental illness. And so if we actually want to prevent addiction, like I don’t see why most people, most people would like there not to be addiction. I don’t think they really care if somebody is stoned somewhere sometimes, and they don’t see it and it’s not bothering them. What they care about is, you know, somebody going to rob them or somebody’s going to, you know, their kid’s going to overdose or something like that.
We have a lot of ways of reducing that risk and reducing that harm, but we are not using almost any of them.
HEFFNER: And how could we?
SZALAVITZ: Well, for one, decriminalize possession. But also spend more on more effective prevention, because our prevention right now is focused on drugs. We need to focus much earlier on what makes people vulnerable. Like about 10 to 20 percent of the population is at risk for substance addictions. And so, you know, if you look at, you know, people who try alcohol, people try cocaine or marijuana, about 10 to 20 percent of them will have trouble quitting. And so what’s different about that group? Despair, trauma, mental illness, how do we work with preventing those things? So despair and poverty are difficult, but we can certainly do a lot about child trauma and about mental illness, because what happens is these are all developmental disorders. And if you can get to people early, before ruminating on depressive things becomes actual depression and before people turn to drugs to self-medicate the horrors of being depressed, you will have a lot better chance of preventing addiction or nipping it very early. But that’s not about, let’s stop these people taking drugs. It’s about let’s figure out why these people are so unhappy that they need to escape. And that more compassionate open perspective, realizing that people who use drugs are just humans and they happen to use the drugs that white male colonialists didn’t prefer, you know is, you know, is it’s just like we have to recognize how arbitrary our laws are and how harmful we’ve been to people who are for the most part, just trying to feel okay, you know? Yeah, there’s some sociopaths out there. There are jerks in every group of people and they’re probably overrepresented among people with addiction, but the situation that we’ve created for people with addiction to illegal drugs is one where they are more likely to be criminal, where they are basically required to lie. You know, this idea that people with addiction are just these compulsive liars, regardless. If you actually look at the research, people lie when they have a reason to lie. If they don’t have a reason to lie, unless they are sociopaths, which there are some of but when they don’t generally they don’t. And so it’s really, you know, we’ve created this class of people and criminalized them, and then punished them for being criminals. And this enforces racism, it creates horrible conditions and it just does not treat or prevent addiction.
HEFFNER: Well, Maia, I think that if you tie this idea to public safety. Harm reduction, you know, has hugely beneficial implications for communities. I mean, and I think that that’s the political argument, right? Because ultimately it is about those decades of misperception in your mind or prejudice or propaganda. But that’s not going to be eroded so easily, but, but what you do need to counteract is a new narrative. That’s what you’re articulating. And I think that that narrative is about how reducing harm at the individual level is also going to reduce harm at the local level for your community. And that’s why you know, if you have tested data that can show, you know, if not a correlation with, you know, lessening addiction, but a correlation with increased safety.
SZALAVITZ: Well, and I mean, like the harm reduction data is all overwhelming. It does not encourage drug use. It does encourage treatment. It does not extend addiction in terms of like, you put somebody in a harm reduction program, and they would have otherwise got abstinent. It basically allows people to be alive long enough to recover or to stabilize or to, you know, get the best that they can be…and…
HEFFNER: And not be a threat to public health, but actually
SZALAVITZ: Right. Exactly. Not a threat to anybody. And I mean, the reality is of course that most people with addiction are a threat to themselves, mostly. You know, they’re not making their families happy. But for the, you know, the vast majority of people with addiction are not violent, are not going to start going out, you know, mugging people or that kind of thing. I mean, one of the things that you have to recognize is that all the progress that we started to see towards harm reduction and towards better drug policy has been, as soon as we started to see people with addiction as white. Once we see people with addiction as one of us, not one of them, all of a sudden harm reduction is what you want for your kid, right? If your kid gets arrested or your kid gets in trouble, do you want them to be in jail with all that threat and COVID and all of that stuff? Or do you want them to get diverted to something that would actually help them?
SZALAVITZ: If you think about what we do for people we care about with addiction, it is much, much, much nicer …
HEFFNER: Restorative justice, harm reduction, right.
HEFFNER: So in the minutes we have remaining you see,
SZALAVITZ: But I just want to say one more thing. I do not believe that it is right for that to have happened because of white people.
HEFFNER: Right. No, we hear you. I’m glad you clarified that. You’re, you’re suggesting the ones you love you care about, and it should not be about zip code or skin color. Restorative justice and harm reduction should be the philosophies espoused in practice in all communities. Let me just ask you in the minutes we have left, you seem to suggest Maia, that it is not only at peak crisis, but it may be the worst that it’s ever been when it comes to overdoses right now, and drug addiction in many communities. And I don’t know how much that’s related to increases in homelessness, or, you know, can be correlated with what is a homelessness crisis in a lot of American communities right now too, or, you know, just more broadly speaking, an economic crisis and economic inequality?
SZALAVITZ: Yeah. I mean, when you, when you look at places that have really bad overdose and opioid addiction problems, you tend to see really high levels of economic inequality. About 10 or 15 years after the factories go, you start to see these rises in all types of unhealthy behavior, from drinking to opioids, to whatever. And part of the thing that just breaks my heart that we’ve done is that, you know, we cut the medical supply of opioids by 60 percent, since 2011. And we didn’t provide any help for anybody. We just cut them off. And so now we have pain patients who are committing suicide because they don’t have any alternative relief. We have people who are addicted on the streets, getting fentanyl, which is just far, far, far more dangerous, street fentanyl compared to you know, medical fentanyl, because you know, the dose, if you get it from a doctor. So we just continue to make the wrong assumptions over and over the drugs are the problem.
And we, we don’t look at why did suddenly so many people actually want these pills that were lying around because Phrama pushed them on patients who didn’t need them. In certain instances, you know, I mean something like 60 percent of people who get prescribed an opioid have leftovers. Now this should not be surprising. But if you think about that, there’s an irony in there because you know, this is the most addictive drug ever. Why are most people having leftovers? They’re having leftovers because the vast majority of people don’t get addicted. But now you have people who are in economic despair. Each one of these pills is worth 30 bucks. And they’re sitting around and they’re not using them. You create kind of a, a mirror image of what we saw with crack in black communities in the eighties and nineties.
HEFFNER: Last question, we only have seconds left Maia, you’re President Biden, or, you know, Majority Leader Schumer, Minority Leader McConnell. I mean, let’s, let’s assume for a moment they genuinely care about the plight that you’ve identified over this episode. We’ve talked about decriminalization of possession. But what else, if anything, would you impart as the most important thing to extract us from extricate us from, from the crisis?
SZALAVITZ: Treat people with addiction like human beings. Recognize that this is a medical problem. Get the legal system out of it. And don’t believe that cutting the supply will fix what, the only way you can really fix it is by actually helping people with the kind of despair and the kind of mental illness and the kind of symptoms of, you know, post-traumatic stress. If we don’t deal with that, you’re just going to get people going from one substance to another.
HEFFNER: Maia, thank you so much. I encourage our viewers and listeners to check out your book “Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction.” Really appreciate your time and insight today.
SZALAVITZ: Thanks so much.
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