Originally published in The American Prospect on July 7, 2017.
For the past 30 years, Maia Szalavitz has researched and reported on science, drug policy, and health. Before that, in her early 20s, she herself became addicted to cocaine and heroin—sometimes injecting the drugs several times a day. Even after overdosing, after being suspended from Columbia University, and after getting arrested for dealing—facing a 15-year-to-life sentence under New York’s now-repealed Rockefeller drug laws—Szalavitz struggled to quit. In her latest book, Unbroken Brain: A Revolutionary New Way of Understanding Addiction, Szalavitz explores why getting off drugs is so difficult. She challenges the public to see addiction as a neurological learning disorder—much more like autism and ADHD—than a moral failing, or a chronic illness. This conversation has been edited and condensed.
Rachel Cohen: Your book takes aim at some of the nation’s central narratives around drug addiction. Can you start by describing some of these, and why you think they’re off the mark?
Maia Szalavitz: We have this whole public narrative around the idea that addiction is a chronic brain disease, which is wrong, and that narrative is overlaid onto a treatment system which is primarily focused on getting people in 12-step self-help groups that basically involve confession, restitution, and prayer. If such a treatment were suggested for autism, or any other illness, people would say, “Wait a minute, that’s faith healing, and that’s not what we do in modern medicine.” But in addiction nobody seems to notice this contradiction, and that’s because we as a culture don’t really believe addiction is a disease—we see it as a sin.
One of your major arguments is that we should start to think of addiction as a learning disorder. What does this mean?
You cannot be addicted without learning that the drug fixes something for you. On a very basic and silly level, if you don’t know, then you can’t crave it, and then you can’t go out and seek it. People can recover from addiction when they learn to do different things.
Addiction, like other learning disorders, tends to start at a particular period in brain development. Like schizophrenia, addiction is overwhelmingly a disorder of late adolescence and early adulthood.
You talk about the problem of “overlearning”—and say addiction is defined by compulsively using a drug or activity despite negative consequences.
One of the most interesting things about addiction is that it’s a special kind of learning, in that it gets learned more deeply. Basically if you think about it, if you love some subject, like math, you will learn about it with an intensity someone who hates math could never achieve. Or if you fall in love with somebody, you start to learn every little thing about that person.
Our brains are evolved to do this so we can successfully reproduce and raise children, but when that system gets misdirected towards a substance, you get this intense learning of cues associated with the drug, intense longing, this sense that if you don’t have it you just can’t survive. It resets the priorities in your brain. If you don’t have love to compare it to, you’d just think this person is completely crazy and they’re making really stupid choices. But when you understand that it’s basically the same thing as when people have affairs—complete with the lying—you realize this is just a misdirection of a very natural system that we all have and are all vulnerable to having misdirected in varying ways.
So “overlearning” occurs when you just focus so intently on one thing. That is a terrible disadvantage when the thing is a drug. But it can be an incredible advantage if that thing is a subject of inquiry you’re using in your work, for example.
What are some implications of recognizing that addiction is a learning disorder?
So there are several things. One is that there’s this interminable debate about whether addiction is a disease or not. My feeling is basically that if you want to call it a disease, if that’s important to you, you can say it’s a disease that takes a form of a learning disorder, like ADHD and depression. If by “disease” you mean that it’s not the person’s fault—I’m totally with you. If by “disease” you mean it’s chronic and progressive, like cancer or Alzheimer’s, well the data just don’t show that.
And like other learning disorders, it only affects narrow parts of learning. For example, you can have dyslexia, but still have a very high IQ.
The other and even more obvious implication is that if addiction is marked by a failure to respond to punishment, then we should realize that punishment is a really stupid way of dealing with addiction. Yet this is what we as a country have decided we’ll do. It’s just insane that we think we can use the criminal justice system for this. It does not solve anything to put someone in a cage for a couple days for possession of a substance.
You find that most of our drug policy was crafted not based on public health, but on racism.
There is no reason other than racism that marijuana is illegal, and it’s very clear from the history that that’s the case. Many tend to have this misguided idea that the Drug Enforcement Agency sat down one day and rationally weighed the costs and benefits of each substance. But all of our drug laws, including alcohol prohibition, resulted from racist or anti-immigration panic, or a combination of the two.
In your book you talk about the importance of “harm reduction” for drug policy. Can you briefly talk about what that is and why it matters?
The idea is well let’s stop moralizing around the idea that people shouldn’t have these types of pleasures, and instead we should care about a person’s drug use when that person’s drug use does harm. If you’re using and things are good, we shouldn’t care. If you’re using and harming yourself and others, that’s when policymakers should get involved.
Harm reduction says let’s accept the fact that people in every culture around the world for all of human history have used psychoactive substances, and instead of trying to stamp out versions of them that we don’t like, let’s focus on the harm. That allows you to figure out why people are using, help them to get better, or to do it more safely. The beauty of harm reduction is it allows you to say to someone, “Hey I want to save your life, it doesn’t matter if you’re still using drugs, I’m not here to judge you, but I don’t want you getting HIV or dying of an overdose.” When you approach someone like that, especially people who are really marginalized and face all kinds of horrible situations, it’s really powerful. They’re so used to people coming at them with an agenda of I’m going to fix you. Simply treating people with kindness and respect creates an opening for change that you can never get through threats and humiliation.
Most people accept that alcohol prohibition didn’t work, yet for some reason still back broad bans on other types of drugs. And you note in your book that even though the U.S. has fought harm reduction policies for drugs, we all can see that harm reduction policies associated with alcohol, such as teaching people to select designated drivers, have been really effective.
This again comes back to racism. Alcohol has long been accepted by white people. Drugs that white people like are legal and drugs that white people have tried to use to oppress other people are not. In America, and around the world because of America, we have decided that certain substances are OK even though they’re more harmful than some illegal ones.
It’s actually kind of surprising that tobacco was legalized because it was an indigenous American drug, but the reason why is because it was one of the first products that America could sell to support its capitalism. Rum, sugar, and tobacco were big drivers of our economy for a very long time—and a lot of that runs on addiction.
We banned other indigenous drugs like marijuana and cocaine because we basically associated these with threats to white culture, particularly threats to white masculinity. If you review the history of how things became illegal, it’s always about how this particular substance makes it easier for this hated minority to get white women through rape and seduction.
Nixon also had his “Southern Strategy” and the idea was to associate black people with crime and drugs, which created a rationale to lock them up. When black people were seen as a signal of criminality, then harsh measures were needed. But when symbols of drugs are associated with white people, we tend to think they need treatment, not punishment. As someone who has advocated for treatment and not punishment for decades, it is really sad to me that the way we have made progress towards humane policy is because we want to be humane towards white people. If we can get towards compassionate policy, though, then hopefully we can make it humane for everyone.
Your book was published before Attorney General Jeff Sessions came to power, and he’s been spewing a lot of regressive rhetoric on drug policy recently. What do you think the Trump administration means for drug reform?
I don’t think anyone knows, but I do think it will be very, very difficult to put the marijuana genie back in the bottle, and that’s a good thing for drug reform generally. Once people realize that you can legalize marijuana and the world does not end, once you see what nonsense our drug laws are based on, it opens the door for creating sensible policy. Our current policies are not rational. They are not scientific. They are not based on anything other than prejudice. And to be clear, this doesn’t mean I think we should create Philip Morris heroin—that would be a bad idea, too—but what we should be thinking about is what is the best way to regulate the human tendency to use psychoactive substances and how do we make sure that the substances people use are the least likely to yield harm. That’s the basis on which we should craft drug policy, not that drugs are immoral.
You talked a bit about disability rights advocates pushing for ‘neurodiversity.’ Do you see addiction as something that should, or will, be part of this movement?
I absolutely do. I think addiction should be considered a form of neurodiversity and we should understand addiction through the lens of disability. If you think about it in terms of autism, people with autism often take comfort in repetitive behaviors, which is very similar to people with addiction who take comfort in repetitive behaviors. When you accommodate people and allow them to be their weird selves, you make things better for everyone.
How was your book received by other experts in the field?
It’s been received amazingly well, which really surprised me because I’ve been saying pretty much the same kinds of things for a long time and it used to be seen as really out there. I’m not the first person to make these arguments, but there really has been a sea-change.
I certainly have gotten criticism from some 12-step people, mainly those who felt like they wouldn’t have been able to recover if they weren’t forced into the 12-step program. My answer to that is that 12-step programs can be fabulous self-help, and should be available, but if we want to argue for more compassionate medical treatment of addiction, then we need to let doctors actually treat it.
Progress often feels slow. As someone who has followed this for many years, is it hard to stay hopeful?
Actually it’s funny because some of the younger activists will say to me, “How can you be so optimistic?” But when I first tried to get people to pay attention to humane drug policies in the ‘80s and ‘90s, I was cast as fringe and radical. And now we have eight states where recreational marijuana is legal. In the 1980s, you’d be told you’re a traitor in the drug war if you even think about stuff like that. We also today have white empowered parents fighting for harm reduction, whereas in the past the white empowered parents were saying to lock up drug users, use tough love. Nobody today even has a good case for why locking up a heroin user for possession is helpful, and that’s a really radical change compared to all the stuff I used to hear during my own addiction and early recovery.