Maia Szalavitz: What’s a Town to Do About Addiction?

Handshake Media, Incorporated was honored to present “What’s a Town to Do About Addiction? A Conversation with Maia Szalavitz, Author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction” on Wednesday, August 3, 2016, at New River Valley Community Services in Blacksburg, Virginia.

Anne Giles made the introduction, Mike Wade of New River Valley Community Services filmed the presentation, and Shawn You and Daeshaun McClintock of Mor11 Media photographed the event. Laurel Sindewald transcribed the presentation, with almost 9000 total words spoken in about one hour.

  • In her presentation, Maia Szalavitz mentions initiatives in Ithaca, NY. We’ve compiled a report here.
  • Photos from the event are on Facebook here.
  • The invitation describing the August 3 event is here.
  • Luanne Rife covered the event in The Roanoke Times here.
  • A list of Maia Szalavitz’s recent publications is maintained here.

Added 8/3/17: Read Anne Giles’s one-year update, The Conversation About Addiction Has Changed Since Maia Szalavitz Came to Town.

For more information about local efforts to organize an effective response to local addictions challenges, please contact Anne Giles, [email protected], 540-808-6334.

Transcript: What’s a Town to Do About Addiction
A Conversation with Maia Szalavitz

Anne: Welcome! Welcome to all! We’re so glad you’re here!

[Fillers and logistics explanations edited out for brevity.]

We are so grateful to New River Valley Community Services, NRVCS, for donating this meeting space and for livestreaming this event on its Facebook page.

I am Anne Giles and I am a…person.

I share openly and publicly that I’m a person in recovery from alcoholism. I developed alcoholism just before I turned 50 right here in Blacksburg. I am a former teacher, a current business owner, an addictions recovery counselor, and a Virginia Tech alumna. I spent the first half century of my life trying my very best to be good and to do good. When I developed alcoholism in spite of my knowledge, training, education and formidable will, I thought I was a good person gone bad. How could this have happened to a Hokie?!

Until, however, I read Maia Szalavitz’s book released in April of this year, Unbroken Brain: A Revolutionary New Way of Understanding Addiction. In Unbroken Brain, Maia Szalavitz reports on the science of addiction. The science says I am simply one of the one in ten Americans – and one of the over 16,000 people in our locale – who has developed the health condition of addiction for which health care is needed.

Just a little over 40 miles from here, at the Virginia Tech Carilion Research Institute, I participated in a research study that included scans of my brain. That study is one of the thousands of accumulating studies showing that the occurrence of addiction is so little about me – my morality, my will, my choices, my goodness or badness – and so very much about an organ in my body – my brain.

My hope rises like fireworks! We have a brand new School of Neuroscience right here in this town at Virginia Tech. Through VT KnowledgeWorks and the Virginia Tech Corporate Research Center, we have an entrepreneurial culture founded in innovative problem-solving. Through the service of our local government officials and Chamber of Commerce, we have government, business and professional leaders ready to take action. Through NRVCS, we have a staff of experienced, devoted addictions treatment professionals already at the forefront of providing care for the people of our community. In 1996, Blacksburg was named the “Most Wired Town in America.” In 2016, we are poised to lead the world with what I believe can be our new accolade: “Most Recovered Town in America”!

Here to have a conversation with us about what the science says – what the research shows – can help us, as a town – as a community – take care of our people with addiction is award-winning neuroscience journalist Maia Szalavitz. She is the author and co-author of multiple books, the most recent of which is Unbroken Brain: A Revolutionary New Way of Understanding Addiction, published by St. Martin’s Press. Her reporting has appeared in The New York Times, The Washington Post, TIME, Scientific American Mind and many others. Described by reviewers as “frank,” “brave,” “smart,” and “brilliant,” we are so honored to have Maia Szalavitz here with us tonight.

Maia: Thank you so much for that lovely introduction. Now I hope to live up to that. I am just grateful and honored and really, really psyched to be here. It’s so nice to see a community coming together, caring about this problem, seeing this problem as a health problem, and wanting to do something for our kids and our adults who are affected by addiction.

Maia: I think in order for us to have a comprehensive response to addiction we need to start by understanding what addiction is. I think a lot of times in a lot of places we haven’t done that and then we’ve tried to solve the wrong problem and ended up creating new problems. Addiction is defined by the National Institute on Drug Abuse, by the Diagnostic and Statistical Manual of the American Psychiatric Association, better known as the DSM, as compulsive behavior that continues despite negative consequences and in the case of drugs it’s compulsive drug use that continues despite negative consequences.

Maia: So a lot of people think that, well that’s kind of a weird description, isn’t addiction when you get sick when you don’t have your drug, when you need something to function, and you’re desperate for it? Actually, no. When we defined addiction like that in the 70s and 80s, we thought cocaine wasn’t addictive, because when you quit cocaine, you do not shake and puke and feel all those physical horrible things that people do when they’re kicking alcohol or opioids. You might be mighty cranky and sleepless and very annoyed and quite desperate for the drug, but you’re not sick. And we have for a long time thought addiction is needing something to function, and what that means is we’re all water addicts, and we’re all air addicts, and we’re all food addicts, and the term becomes meaningless if you use it that way because it doesn’t describe what’s problematic about addiction. And what’s problematic about addiction is the compulsion and the negative consequences.

Maia: When you understand addiction this way, you understand the treatments for it a lot better. So, with opioids we only know of one method of treatment that reduces the death rate by 50% or more. That method of treatment is ongoing, indefinite, possibly lifelong maintenance with either methadone or buprenorphine which is also known as Suboxone. And a lot of people don’t think that, it’s like, “oh, you’re just substituting one drug for another,” or, “oh, you know, people who are on maintenance are always high.” In fact, that is actually not the case, and when we understand the nature of addiction we can see what’s going on.

Maia: So, when maintenance is working for somebody, and this is true for about 30% of patients at any given time, which, I might add, is about the same percent that are going to be in recovery from, in an abstinence place, or probably slightly less, at any given time. But about 30% will be getting their lives back, getting their jobs, taking care of their family, doing what they need to do. In that instance, those people are in recovery, and what they’ve done is they’ve replaced the addiction, the compulsive heroin or opioid use despite negative consequences, with physical dependence, they happen to need the substance to function, but since the substance is pure and safe and they have a reliable supply, it doesn’t do harm.

Maia: When we understand that, maintenance makes a lot more sense. Now, you might say, “well, there are also those people who sell their drugs or what about those people you see like this.” Well, what happens is, with maintenance, people sometimes relapse and people sometimes use other substances on top. And so those people are not stable, and are not necessarily going about their lives in ways that are productive or getting their lives back together, however, they are still at reduced risk of dying and the longer we keep them alive the more likely they are to be able to move over to stabilized version of maintenance and to be able to benefit from counseling and to benefit from all the other aspects of recovery that is what we really want.

Maia: Because really, as a person who cares about addiction, I don’t care if somebody gets high, what I care about is harm. I care about people harming me, people harming other people, people harming themselves. If no one is being harmed, I don’t want to know about it. If someone’s being harmed, that’s when we as a society have to step in and help people. And so, as of right now, the best stuff we have for opioids is maintenance, and we really need to think about it the way we think about insulin for diabetes. We would never say, “oh, you ate a big mac” or “oh, you had a giant chocolate doughnut, therefore you can’t have your insulin for today,” but unfortunately we’ve sort of done that with access to maintenance, and that has meant that a lot of people do not access a lifesaving medication that they should be able to have access to.

Maia: So, the other thing that I want to say about the nature of addiction is, as I argue in the book, addiction is a problem of learning. What happens in addiction is, rather than learning that you love this particular person, you instead fall in love with a drug. Now, we don’t tend to think of falling in love or parenting as a kind of learning, but it is a form of emotional learning. If only we could fall in love with math, we would be as good at math as we are at relationships with people and we would be much more interested and much more driven, but that isn’t the way most people learn math.

Maia: But when you put that brain circuitry, the devotion that brain circuitry has toward its goal, like, it’s good for us to have brain circuitry that devotes us to putting our kids first, putting our partners first, taking care of these precious relationships and doing everything despite negative consequences to make those things continue, but when that is misdirected towards a drug, all of that becomes very problematic and people behave in ways that look completely irrational. If I am sneaking around to meet my lover, we can kind of understand that, we may not approve of that, but we sort of get what’s going on there. But when somebody is sneaking around to get drugs and they keep getting arrested and they keep getting arrested, and they still do this, and they lose their job, they lose their kids, they lose their wife, and their homeless, and they’re still doing this drug, we just, you know, we don’t understand what’s going on there. And since they’re doing all of this obsessive planning, you know, you’ve got to like, find the dealer and get enough money and do all this stuff in order to get the drug, we think “oh they must be choosing to do this because look at all of that work they’re putting in there.”

Maia: But no. What is happening is, when your brain falls in love with either a person or a substance, the way your priorities are set gets changed, and that thing comes to seem absolutely essential to your emotional survival. Life would be meaningless, there would be no reason to live, you would not be able to be safe and comfortable ever again. And this is why people don’t want to stop using. They just think, you know, they’re going to lose the love of their life. What we need to understand is that when people are in that state, it is not fun. They are not having such a good time that they need to be kicked in the butt in order to stop. What is going on is they have found something that they think that allows them to cope with their life that is no longer working. So, I hark back again to the definition of addiction as compulsive behavior despite negative consequences. We have tried for the past hundred years to use negative consequences, aka punishment, to stop a condition that is defined by its resistance to negative consequences and I would argue, this makes no sense.

Maia: In order to help people with addiction we need to attract them into recovery. We need to understand the reasons why they have so much pain that they feel they need anesthesia. And that brings us back to, you know, how does somebody get addicted in the first place. 99 times out of 100, what doesn’t happen is a perfectly happy person is walking along the street, a syringe falls from the sky, and they get shot up and they think, “this is the best thing ever I have to go find a dealer.” In fact, I can guarantee that 100 percent of the time that doesn’t happen.

Maia: What tends to happen when people get addicted is, first of all they tend to be teenagers and people in their 20s. At that time in life your brain is developing and you are trying to figure out: how do I find a mate? How do I find friends? How do I create a life for myself? How do I cope with all the emotions and the upheaval of all of that stuff and the feeling that I’ll never have any of this stuff, the feeling that I might not get a job, or I might not be able to do what I want to do, or I might be just left out and worthless. How do you deal with that stuff? And that stuff really hits you when you are a teenager. And at that same time, your brain is developing, the sort of biological purpose of the brain at that point is, “get out of the house, get away from the family, find your friends, find your mate.”

Maia: In order for that to work, in order for us to do that and grow up, the region of the brain that’s involved in love and desire and risk taking and passion gets really strong. That’s the area that’s especially developing during the teen years. It is not until the mid to late 20s that the area that controls and puts the brakes and chills out that stuff develops. And so, if you’ve ever met a teenager you probably understand this and if you’ve ever been a teenager you probably understand this. But what is happening at that time of life makes teenagers and people in their early 20s really vulnerable to addiction because it seems to solve the problem of “how do I get friends? How do I get partners,” because it makes you feel better socially, often times.

Maia: The important thing there is that if we recognize that this is a point of vulnerability, if we recognize that certain people are more vulnerable than other people, and we know what makes people vulnerable to some extent: first of all, about two thirds of people with addiction have some kind of childhood trauma issue and this is a much larger percentage than the rest of the population. So they may have PTSD, they may have all kinds of issues related to this trauma, for women, unfortunately, it’s often sexual abuse or being raped, and what they’re doing with the substances is simply trying to feel better and feel safe and get away from that.

Maia: About half of people with addictions, both male and female, tend to have a preexisting mental illness, whether it’s depression, or anxiety disorders, or things like schizophrenia, biopolar, there could be personality disorders, but there’s all kinds of things that, long before the person ever encounters the drug, set them up to be vulnerable if they do. What’s astonishing to most people is that, even with drugs like heroin, cocaine, methamphetamine, alcohol, only 10-20% of people who try these drugs become addicted. We have just sort of focused on, “if we can just stop 100% of people from trying it we will solve the problem.” We have never been able to do that because even before humans existed, getting high existed. I give you cats and catnip.

Maia: It’s something that’s really old and runs throughout nature, and different cultures have dealt with it in different ways. But the way our culture has dealt with it is to basically say, “these substances are ok and these substances are bad,” without regard to actually whether this one’s more dangerous than that one, which makes it even more confusing for young people. So, in order to do better we need to create ways for people who have outlying temperaments that will eventually, I’m talking 2-3-year-olds, outlying temperaments that will eventually predispose them to both mental illnesses and addiction. So, you know, everybody can see the totally ADD 7-year-old, or the 7-year-old who is sitting in a corner, is totally anxious, and has no friends – we know that both of those kids are at high risk but for very different reasons and if you try to use the same approach for both of those kids you’re probably not going to help either of them. We have ways to try to reach people that we should be using.

Maia: And since addiction is something that is learned, we need to find ways to teach recovery. Now I think that in terms of what a specific community can do – and it’s just great to see so many people here, coming together, and thinking about these issues and talking about them – there have been other communities that have faced these issues and that have tried to come together and work on them, and there are processes that you can engage in and there are people that have done this, particularly in Syracuse, where the mayor and a whole bunch of other people decided “our community has a really bad problem.” They’re also a college town so I think there’s a really nice parallel here. And they went ahead, and – I’m getting this wrong, it’s Ithaca, not Syracuse. But anyway, sorry about that, I will get the information correct. – But anyway, they decided that they needed to deal with this and they had meetings, they had law enforcement talk with treatment, they had prosecutors talk with defense people; it was really a lot of cross communication. There was also a lot of assessment of, like, “what do we have in our community that is working, and what do we have that is not working, and what do we need in order for this to get better?” How can we move away from using punishment to solve a problem that’s defined by its resistance to punishment? How can we get prevention into the schools that actually works to help the kids that are most at risk and also helps the other kids not fall into those categories. So you need to do all the assessment of what’s needed. After that, when you know what you need, you need to find the best evidence for what works to provide that need.

Maia: So, it can’t be just, “well, you know, we need treatment so let’s just, like, throw in some treatment and we’re all good.” Unfortunately in this country our treatment system has been, for a very long time, very much not based on evidence, very much based on the idea that, “if we can just force people to hit bottom, if we can just be cruel enough, if we can just humiliate and attack them enough they will finally start responding to punishment and then we can break them and then we can rebuild them.” And that does not work. That often backfires; there are a few people who manage to survive that and do well, but if you look at the studies that compare an approach that’s empathetic and treats people with dignity and respect to an approach that’s humiliating and dehumanizing, guess what love wins. So, it’s really important not to just, you know, throw treatment at it and not look at what that actual treatment contains.

Maia: Finally, and this is quite related, there is a huge stigma associated with addiction and it really impedes peoples’ way of seeking help. When I was addicted to coke and heroin in my 20s, I was afraid to seek help because I knew so much of it was this idea of, “we’re going to put you in a group, we’re going to put you in a hot seat, we’re going to scream at you, you’re not going to have any privacy, we’re going to make you dress up as a hooker or something, and – I’m not making this up, this is a part of some treatments, sadly – I knew that it would be really harsh and I knew that it would involve me interacting with tons of people and I’m actually really scared of people and I used a lot of drugs in order to be able to deal with people. So the idea of taking all of my drugs away and being totally among people who were attacking me was basically the reason I used drugs in the first place – or I felt as though that was what was happening when I interacted with people, whether or not that was the case is another story.

Maia: A lot of people fear treatment for reasons that have nothing to do with “I don’t want to get into recovery.” They fear it because they fear that it will mean giving up their only source of meaning and purpose and love. And when you understand that, you understand that we need to find ways, that are individualized for people, that will allow them to get those things in their lives. If you have a doctor in treatment, probably what this person will need is “let’s address the psych issues and make sure you get stable, and you’re back, you’re good – all is well.” If you have somebody who is homeless and who has never graduated high school and has never held a job, you might want to give that person some job training and education and stuff like that but if you give that to the physician it’s going to be completely useless.

Maia: So you need to tailor and individualize, and unfortunately in the addictions field we’ve had this one-size-fits-all thing for a very long time. We’ve had this idea that all treatment should be 12-step or all treatment should be one particular thing or another and currently 85% of our treatment in this country is based on the 12 steps. And I am certainly not here to say that the 12 steps are bad or that we should ban them or that they don’t work for people. They actually helped me a lot, particularly early in recovery, but I am here to say that if I went to a doctor for cancer and I was told that I should get on my knees and pray, and meet with people, and confess my defects of character, and make restitution to people I have harmed, I would not go back to that doctor for my cancer. I would not see that as a medical treatment for cancer. I would be perfectly happy to have that kind of thing happen in a support group. But that isn’t what should be the content of our treatment that you pay for. For one, you can get it for free elsewhere so why should you pay for it. But secondly, if we want treatment to be as accessible to the largest number of people possible and the 12-steps stuff works consistently for a minority of people, to have the best of both worlds, what we should have is a treatment system that provides evidence based tactics like cognitive behavioral therapy, dialectical behavioral therapy, motivational enhancement therapy, and a bunch of others; those things you can’t get for free. We know that social support is really important to lasting recovery so we should refer people to support groups whether it’s 12-step, or SMART Recovery, or a number of different things; we need to have many options for different people.

Maia: Finally, if you embark on this process as a community, it’s really important to get the different agencies to buy in and to collaborate rather than be working at cross-purposes because if the police are locking up everybody you give a clean needle to, that needle exchange isn’t going to work very well. So it certainly needs a level of coordination that needs to be thought of consciously. Just like I was talking about a minute ago in terms of social support, for people in recovery social support is often the critical thing that makes the biggest difference. If we know that people care and that they want us to get better and that they are not thinking we are awful, evil creatures that they just want to exile, we’ll try a lot harder, you know? People with addiction are, as Anne said, people, and we want to connect and we want to do ok, but often times we just don’t know how and certainly there are so many people from so many dysfunctional families where they just never were taught the skills that they needed in order to live safely and comfortably in their own skin.

Maia: The more we can build a recovery community that accepts all different varieties of recovery and that welcomes people, and that realizes that – you know, I don’t know anybody who has ever dieted and has not cheated – we have to realize that people with addiction will probably slip at least once or twice, but that’s ok. As long as they don’t die we can deal with that. We should provide naloxone to reverse overdose if that occurs and we should be able to have people come back and say, “you know what? Ok. This happened. Not happy that it happened, but it happened.” What led up to that? What was the thought process immediately before it happened? What were the emotional events immediately before this person relapsed? Like anything else in learning, if you can figure out where you made the mistake, you won’t make the mistake again usually. Or you might have to make it a couple times before you learn it but you will eventually get it. So I also think, using the analogy of learning, when we teach kids, the best teachers all of us have had tend to be people that were demanding but they were also kind, and we wanted to get their approval. We wanted them to like us, and we were willing to learn and to do the homework so that we could get that praise. If we bring that idea, which is what helps learning across all different disciplines, into addiction treatment, again I think we will dramatically improve it.

Maia: So I’m going to stop here and I’d love to take questions.

Anne: I am very open to helping my community with its addictions problems, but in my own personal home I have someone who is struggling with addiction. My loved one. My loved one is suffering. I don’t know what to do What am I supposed to do if I have a loved one who is suffering from an addiction – alcohol, opioid, whatever?

Maia: As you would start with a community so you should start with an individual, which is you need to assess what’s going on. You need to find out why this person is using the way they are using and what they are doing and how long they’ve been doing it for and what issues are going on in their life. If it’s a young person, often times the most effective treatment will be family therapy that will figure out, because often times the issues in a young person’s life are intimately connected with the issues in their parents’ or caregivers’ life. So you want to start by very thoroughly evaluating, and for most people or families this can start with getting a complete psychiatric evaluation because if there are things like ADHD or depression or any of these other things that are being self-medicated, you’re going to need to know what they are and you’re going to want to try to deal with them as soon as possible because otherwise it will be difficult to sustain recovery.

Maia: And if there are trauma issues you want to know about them, although you don’t want to sort of rip off the band-aid and say, “yeah, we’re going to deal with your trauma now!” – that’s not good either. But you sort of want to know what you’re dealing with right from the start because unfortunately in the addictions world there are a lot of treatment centers that say they offer certain things but don’t actually offer those things and if you at least know what you want the specialty to be you can look for that and if it doesn’t prove to be provided, go elsewhere.

Maia: One of the most important ways to motivate a family member into treatment is to just tell them, “look, I know there’s a lot of lousy treatment out there. I don’t want you to get it. If we end up with you being in a lousy treatment place, we’ll take you out!” Because, when they know that they feel safe, and they feel not like, “you forced me into this,” or “you want to take away my fun” or “you want to enforce your control on me.” They feel like, “oh, they actually want me to get better.” I think a lot of times with young people who are using, they know it’s messed up, they do want to stop, at least in some part of them, but they just don’t know how to get what they’re getting or think they’re getting, from the drug, elsewhere. So start with the psychiatric evaluation.

Maia: I understand unfortunately around here there’s a real shortage and there’s a long waiting list. I think as a community that sounds like a problem that could be addressed, potentially early on. So after that you would find the treatment that is suited best to what the particular problem is. With teenagers or young people, it’s really important – family therapy or individual counseling are both interventions that generally do no harm. And this is really, really important because sometimes with young people is, you catch a kid smoking pot and the kid has a family history, you know, you were both alcoholics and you panic and you want to send them away somewhere. But what you’re doing by doing that actually is taking a kid who’s smoking pot and putting them in a peer group where they’re doing opioids, they’re doing heroin, they’re doing cocaine, and unfortunately the treatment center will tell them, “you all have this chronic disease and you have to work on this for the rest of your life,” so the pot smoker’s going to think “I haven’t even tried the good stuff yet.” And they know where to get it now.

Maia: So you can do real harm by, basically what you’re doing is taking a kid that’s in a reasonably ok crowd and putting them into a much more deviant crowd. Which is exactly what parents don’t want to do, generally. So, if you’re kid’s already shooting heroin then that issue is not an issue, but if someone is early in this and you want to prevent, you want to do something like family therapy or individual counseling where you’re not going to expose them to more dangerous peers and where you do have a chance for the kid to work out what’s going on with them in a safe place. And, again, none of this is going to be perfect and, young people especially, it’s going to take time for them to develop the self-control that they need to be able to completely stop, so we need to work to make sure that we keep them alive to get through that. And then, you know, the talents and abilities and capacities that people with addictions have can really flourish.

Maia: One of the things that we forget about addiction is it is not only a disability or a disorder. It gives you the ability to persist, which is incredibly useful in most careers. I can tell you as a writer, I have to persist despite negative consequences all the time because I get rejected all the time and if I stopped when I got rejected I would never have gotten any of the publications that I have. So if we can just keep people alive, keep them safe as much as possible, reduce the harm as much as possible, then they will be able to be the fully functioning, important members of the community that they are capable of being.

Maia: And I guess I want to add one note to that. There are definitely are some people with addiction who also have antisocial personality disorder, and these are unfortunately the folks who give everyone else with addiction a terrible name. And this is where the sort of lying and manipulative and callous stuff comes in. If a person with addiction has this personality disorder, most people don’t really know what to do. And when a family has to deal with a family member who simply doesn’t act humanely toward other people, that is a way bigger challenge than simply dealing with somebody with addiction. And I don’t think anybody has worked on how to deal with that. The good news, however, is that that is at most 20% of people with addiction, 80% of people with addiction do not have that. We need more research in this area, but it’s important to realize that while we absolutely need to be compassionate to everyone with addiction, there are some circumstances in which families do have to cut off family members or have them not be in their lives for the protection of themselves or their kids. And that’s another problem that needs to be addressed, but fortunately we can deal with the other 80% first.

Anne: How can the moral, legal perspective of the war on drugs be transformed to change emphasis on community based responses and to a focus on public health, harm reduction, and psychosocial perspectives?

Maia: Haha, well if I had the answer to that I’d probably be rich… or maybe not because people may not want this question answered. I think that we’re on our way, I’m really hopeful – I’ve been writing about and talking to people with addiction and people with family members with addiction since 1988-1990, and at that time if I spoke to an audience like this and said what I just said I’d probably get tomatoes thrown at me if not something worse. And people would be like, “we’ve just gotta crack down harder. If we just close the borders and if we just lock the dealers up for 50 years or if we lock them up for life.”

Maia: Right now in the Philippines people are being executed without trials simply for using drugs, not even selling them. They’re executing sellers randomly as well, or supposed ones, but to get humanity for people who use drugs and to get compassionate and empathetic and less criminal justice response I think there’s two forces that are pushing us in the right direction with regard to this. One is that we are really recognizing that people with addiction exist across class, across race, and we are beginning to move past the terrible racism that has often marked our drug policy. There’s that going on. The marijuana legalization movement I think has made people realize that, “well gee, if putting somebody in a cage doesn’t work to stop their marijuana use, maybe it’s not going to be especially effective for heroin or cocaine either. So that alone sort of moves the debate towards decriminalization of possession, which would be an enormous positive for people with addiction.

Maia: Because one of the reasons that sustains the moralistic perspective about it is that, the reason we make things into crime is to stigmatize them. We want to say as a society, “this is bad, we do not want you to do this. Bad people do this.” So therefore if you make drugs illegal and you cannot be addicted to illegal drugs without committing the crime of possession at some point, we are giving a mixed message that is saying to people that this is really not a disease, this is really a moral issue. So if we could move towards decriminalization of possession, and I think we are because I think we are also realizing, and this is reason number two, this is very expensive and very ineffective and, just locking the same people up over and over again.

Maia: And just seeing that every 10 years we get a different drug problem but we still always have one, seeing that – and I have to say opioids are particularly bad because they kill you when you relapse often. When we had crack in the 80s and 90s, that was really bad, but it wasn’t killing people at the rate that this does. But, sort of, traditionally, in the American drug history we go stimulant, depressant, stimulant, depressant, so we had speed in the 60s, heroin in the 70s, coke in the 80s, heroin in the 90s, meth in the 00s, and opioids again. So, there is also a predictable – which is important as a community to know because when you stop one thing you can’t lose your focus, you need to make sure that you continue because people will just be like, “well, that drug was bad but this one is good.”

Audience member: This kind of dovetails with what you were just talking about – the Syracuse/Ithaca –

Maia: Yes, it is actually Ithaca, I flew into Syracuse so I confused it.

Audience member: Has Ithaca been successful with their efforts, their alternative efforts, and if so why have they been successful?

Maia: They have just started. So I can’t say yet that they have been successful, but I went there, flying into Syracuse, must have been 3 or 4 months ago because it was cold. They were doing a panel after having created as a community, with the mayor and all these different people, they created this report and they were presenting it and I was moderating this panel about these issues. And one of the things I found really heartening in that was that during the audience question part, this guy spoke up and he was very clearly high, and he had actually overdosed and nearly died that afternoon and then gone back and got high, but what was amazing was, people were interested in hearing what he had to say. They were not reacting like, “oh this is a pariah, let’s get rid of him. Oh my god, he’s an example of the problem.” They were like, “if we’re going to solve this problem, this exactly the person we need to listen to.” It may feel weird, it may be very uncomfortable. It made me realize that even though there were some people in that room that very much disagreed with some of the tactics that were being agreed to try – one of the things they’re trying is a safe injection facility, which is pretty radical, and there were definitely some people in the room who were not down for that. But they treated each other with respect and there was a real sort of community building that had occurred, so I hope to be able to give you, in 6 months, some kind of progress report, but as of now I don’t know what’s happened.

Audience member: Why do you think there is such opposition to medication assisted treatment in the United States? Why do we see politicians trying to dictate treatment content or patient limits?

Maia: I think there’s two reasons for that, for one, the way medication assisted treatment has been presented to the public has not been very clear. When methadone was first introduced the idea was, “it blocks the high.” And yes, that is indeed what it does, but let’s not kid ourselves, if you give methadone to a drug naïve person, that person’s gonna get wasted. So people did not really believe what they were being told, because they were not informed about the reason it blocks the high is because it creates an enormous tolerance. And this is true of buprenorphine as well. If you are taking these drugs every day at the same time in a dose that works for you, you will not be high. But if you are taking these drugs sporadically, if you’ve never taken an opioid and you take them, you might actually die on a dose that some people are on. That doesn’t mean those people shouldn’t be on that dose.

Maia: But, I think we need to be straight with people about what these medications can and cannot do. And what they are really good at is keeping people alive, and they are also good at reducing relapse and moving people to become stable. Some people are stable that way for the rest of their lives, some people move to abstinence. So I think some of the opposition comes from that, I think some of the opposition comes from the fact that people don’t understand what the point is. They don’t understand that addiction and dependence are different things and the former DSM diagnosis of substance dependence didn’t help any with that, but it is now called substance use disorder.

Maia: And then, frankly, there’s just the moralism, there’s just the idea that, “why don’t we just get over it? I don’t do this, why don’t – you should not do it.” And often times people don’t realize how different it can be to be a different person. I might experience the exact same thing as you – you might, like, love being in large crowds of people and love bright lights and parades and all this. Whereas I’d be like, “ouhhhh I don’t want to deal with that.” This doesn’t make me bad and you good or anything like that, it just means we’re wired somewhat differently and we prefer different things.

Maia: But we don’t think about that when it comes to drugs, because we think, like, “oh, if you take a drug that makes you less sensitive that must be bad for everybody.” But if you’re oversensitive up here and it brings you to here, that’s great. But if you’re under sensitive down here and it brings you here, that drug could make you suicidal. So we need to realize that the way people are wired will make them react very differently to different things. So me saying “snap out of it,” about something I can easily snap out of is just as ridiculous as you saying it to me about something that I can’t. You know, and it’s hard to describe that to people sometimes I think. Did I answer your question?

Audience member: I think so, yeah.

Audience member: I’ve got a question about, ok, I’m old enough that I remember in the 70s when we were hearing on the news on a regular basis about people who were dying from doing heroin. I remember when I was very young that was kind of the message – if you do heroin, you had about two years to live before you would be overdosing. So I did many things but heroin was not one because that was the one that was deadly. I wonder now, with all the pharmaceuticals that are pushing opiates – opioids – I was very surprised to see advertisements now on TV about how to deal with your constipation that you get from opioids, that means these things are pretty prevalent. What kind of messages can we get out there to maybe discourage people from accepting what is now acceptable – taking a lot of opioids?

Maia: Well, I think that we have to separate something out there. There are actually people who are in severe chronic pain who do benefit from ongoing opioids. And that’s a much larger population than we want to think about. I know that since we’ve had the crackdown, since there’ve been the CDC guidelines, I’ve heard from many people with chronic pain who were doing very well on high dose of opioids, and that’s the only thing that allows them to go to work, and now their doctors are saying “the CDC says I can’t do this” – the CDC isn’t actually saying that, but what they are obliquely saying, “If you want to prosecute the people who are prescribing above this level you now can do so in a way that will work.” And the doctors know that and they are going to cut off people who need…

Maia: So I think that that is a little bit of a red herring, I think that for the most part if you look at what caused this opioid epidemic, certainly Purdue did not do a good thing by massively increasing the supply and by being dishonest about the addiction risk, but the people that tended to get addicted are overwhelmingly kids who got them from other people not from doctors. So if you look at the research, 75% of people who become addicted to prescription opioids, it wasn’t their prescription, it was somebody else’s prescription. Somebody got that prescription from a doctor, and you need to – but oftentimes, the person who got that prescription from a doctor, it was a dentist who gave it to them, it was a surgery you had 20 years ago and you forgot it was in your medicine cabinet but you kept it in your medicine cabinet because you were sort of afraid that if you ever needed it again you might never get it.

Maia: Like, half the people in this country have an opioid stash in their medicine cabinet. And this is so ironic, but part of the reason they continue to have it is because they’re afraid that they’re never going to be able to get it if they need it. If we were able to be more sensible about this and actually gave the drugs to the people who needed them and treated the people who don’t need them as patients, not addicts, we would have – I mean, like, why is it the case that, let’s say I go to the doctor and I’m on the list of people who are doctor hopping and I’ve gone to 20 doctors and now you catch me. Why can’t you write a prescription for Suboxone for me right there? Why do you instead, and this is what happens, instead you give me a lecture and tell me what a horrible person I am and now I’m back on the street and I have to find a heroin dealer.

Maia: We have not done this in a smart way. We have cracked down on these pill mills, but these pill mills, they were getting insurance. They have lists of everybody who came there. Why wasn’t every person that was attending this pill mill given a referral to treatment and given access to treatment? That didn’t happen. We still, when the DEA goes to raid a doctor’s office they should have in place, in advance a treatment plan for those people instead of just assuming if we cut them off, they’re no longer addicted. Because we know that that’s not true. I think that, yes, we certainly need to be more careful about opioid prescribing, but if we focus on the supply too much we’re not going to be able to help the people that want help. We’re going to instead be cutting them off randomly.

Maia: So are there people on chronic opioids that are not benefiting that need to get off? Yes, but are we going to solve that problem without – we’re not going to solve that problem by the doctor just saying “no, you don’t get anymore.” Because, either that person might kill themselves, or they might go to street drugs, or they’re simply going to become dysfunctional for a long time and they’re not going to want to deal with the medical system. The level of pain, which I’m sure you guys know in this community, but the amount of horrific car accidents and on-the-job injuries and back surgeries gone wrong and horrible diseases that you’ve never heard of – I encourage everybody that is concerned with this problem to talk to at least one chronic pain patient for whom opioids are the only thing that keeps them from killing themselves. It’s important to know that side too.

Maia: I feel like as a person who’s had addiction, it makes me feel incredibly guilty if anybody with pain is made to suffer because I exist. I think that if you have an addiction and you have pain we need to deal with that, but don’t punish other people because other people are abusing drugs – that’s not right. But at the same time, we shouldn’t have consumer advertising for drugs. That shouldn’t be – whether it’s an antidepressant or an opioid or a constipation drugs. We and New Zealand are the only two countries in the world that allow this and this is one of the many things that allows pharma to have way too much power. There are definitely things we can do to cut back on that commercialization, but it’s more of a, “let’s fix the FDA and the excess power of the pharmaceutical companies” rather than opioids in specific for that.

Anne: Wonderful, one last question.

Audience member: The common reaction of anyone in charge of someone that has an addiction is anger, and anger is probably the worst thing to do. So how would you address, to the person in charge, to not be angry, but be supportive and be helpful to the person who has an addiction?

Maia: That’s a great question. I think that all of us who have known people with addiction have been hurt by them whether the person was intending to or not. I think the first thing to do is acknowledge that anger and recognize that it may impair your judgement and it may, you know, acknowledge it and let yourself know that you have a right to be angry because this was a messed up thing to do. Whatever the thing was. And I think also that a lot of parents are angry

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Maia: So I think with that you need compassion for your own anger so that you can be like, “right, I’m pissed, I have a right to be pissed, but this is not what I can use to guide this particular action because it won’t be productive.” And that’s a lot easier said than done, but if you think about the addicted person the way they were when they were a little kid and you think about all the promise that you see, you know, when you have a newborn baby, and you think about what you want is to get that promise back and the best way to do it is by acting with compassion rather than anger as much as you can. But it’s also completely fair to be angry and to also at some point when the person is more stable, talk to them about it and tell them why. Because I think one of the things that is actually really useful about the 12-step process is that there is that whole amends bit, and that allows people to heal relationships that have been damaged by some of the stuff that goes on during active addiction and I think in very early in recovery that is probably not a good idea because that person is probably still so filled with shame. Also just thinking about how horrible it feels, if you’re at all a compassionate person, to know that you did this to your parents, or to your loved ones, if you can realize that they probably feel more crappy than you can make them feel, that will also probably help. But yeah, I think even thinking about that question means that you will behave better.

Anne: We’re just about out of time.

Maia: Do you want to get this one person back there?

Anne: We’ll talk to you after, we’ll just get together afterwards, we’ll have time –

Maia: You just want the definition? Yeah. Compulsive behavior despite negative consequences.

Anne: This is a public address for everyone, but this is Maia’s fourth talk in Blacksburg. We’ve had small group meetings and she has met with everyone who is interested and she’ll meet tomorrow at breakfast. So I am just so grateful to you for your generosity, and the word I’ve heard every time you have spoken is compassion. So thank you very much.

To continue this conversation, all are invited to meet on Wednesday, August 31, 2016 at 7:00 PM in the Community Room at the Blacksburg Library. Details are at handshakemediainc.com.

SMART Recovery meets in this room, here at NRVCS, every Sunday at 4:00 PM. Information about this meeting and other local addictions recovery resources can also be found at handshakemediainc.com.

Again, we thank NRVCS for donating meeting space for this wonderful event.

If you have a copy of Unbroken Brain with you, when we adjourn, Maia will be available to sign your copy up here at the podium.

We’re looking forward to continuing this conversation! Thank you so much for being here! Good night!

Full details about the event and links to more of Maia Szalavitz’s work are here.