Discourse with Maia Szalavitz
T. Virgil Murthy and Maia Szalavitz talk about addiction, policy, and public health.
This week I held the second Discourse entry in this series with journalist and author Maia Szalavitz.
Maia Szalavitz is an award-winning author, journalist, and opinion writer at the New York Times. Among her published books are Unbroken Brain: A Revolutionary New Way of Understanding Addiction, in which she characterizes addiction as a learning disorder, and the recent Undoing Drugs: How Harm Reduction Is Changing the Future of Drugs and Addiction, which presents both a history of the harm reduction movement and a persuasive argument for its widespread adoption. She is perhaps best known for her 2006 book Help at Any Cost: How the Troubled Teens Industry Cons Parents and Hurts Kids. This exposé kickstarted a national discourse and helped launch government investigation into the ongoing deaths of children at teen residential treatment facilities. The link she drew between the Synanon cult and modern teen residential treatment has since become a mainstay of public-facing work on the troubled teen industry.
In my interview with Maia, we discussed harm reduction, navigating multiple objectives in community advocacy, pain medication, withdrawal, personality disorders, the public desire to differentiate drug dealers from drug users, twelve-step recovery, and Maia’s learning disorder characterization of addiction.
Harm reduction, homelessness, and Housing First
TVM: Maia, thanks so much for chatting, and welcome to Discourse! I’d like to start by talking about harm reduction, your book, and in particular, the pervasive myths that various harm reduction initiatives incentivize or enable drug use.
My current research on this topic concerns Housing First. I’ve been looking at some centrist and right-wing media discussions of it—there’s actually a new federal bill aimed at reducing funding for Housing First—and the associated misunderstandings of the VI-SPDAT tool. For instance, I’ve written on the belief that it gives people points toward housing for committing crimes. So I wanted to ask you this. What are the perverse-incentives myths you’ve heard most frequently, and how do you think we as a community—journalists, activists, drug users and former users, advocates—can combat them?
MS: The crazy thing about the Housing First myths is this: the reason Housing First was developed is that “treatment first” approaches failed. Putting all these hoops for people to jump through while they’re still unhoused and expecting people to have instantly perfect abstinence is completely unrealistic. Housing First actually got adopted under a conservative administration, Bush’s I think. This was not some airy-fairy, hippy-dippy policy! It was rather, “All right, what we’re doing has completely failed. Let’s try another way.”
It’s really, really difficult for anyone to go from chaotically using drugs in the street, without a home or job or support system, to perfect abstinence and employment. That’s not how human beings are. Even people who have all the advantages in the world tend to relapse during early recovery. Basically, when you’re learning anything—from playing piano to learning how to manage your drug use better—if you don’t practice, you won’t improve. And if you practice but don’t get taught how, you’re not going to get better as quickly as you would if you were taught techniques. That stands as a general principle.
As Americans, we tend to be hung up on this idea that you must deserve a house, that “hardworking” people can’t afford housing. But “hardworking” people being unable to afford housing is a different problem than what to do about somebody who is unhoused and in chaotic use. There’s a great quote from the former mayor of Houston in a 2022 NYT piece: “The homeless guy on your doorstep who spits on you when you leave your house and is always spouting from Revelations may be the least sympathetic character in the world, so you may not like the idea of paying to house him…But you can’t complain about him being on the street and also complain about getting him off it.” The guy on the street, yelling at you—you can complain about his being there, or you can complain about policies intended to house him. But you can’t complain about both.
If you actually want to successfully house people in desperate straits with all kinds of challenges, you are not going to be able to assume that they can achieve perfection immediately. Constantly throwing them in and out of dangerous situations will not help. But that’s exactly what we do! We arrest people over and over. We don’t offer them any support, and then we feign surprise when they don’t get better and in fact get worse.
TVM: I call it the “carceral-clinical seesaw.” There’s this 1-2 punch between forced institutionalization and reincarceration, this ping-ponging. And of course people can’t get their lives in order—they’re being whacked from all sides.
MS: We have to treat people like people. We have to recognize that whether you’re on the streets or the richest person in the world, nobody likes being told what to do. If you want to actually achieve behavioral change, you have to meet people where they are and welcome them. Whatever person you’re dealing with, wherever they’re at, if you meet them with respect, they’ll overwhelmingly give you that back. Obviously, some people have mental health challenges, but even then, often underlying conditions are worsening that, like hunger. It’s Maslow’s hierarchy: provide for basic needs, and then you can deal with people’s more sophisticated and complex challenges.
It breaks my heart to see what’s going on now—all this ridiculous backlash. “Oh no, the hippies in San Francisco invented this terrible Housing First thing.” No! First of all, San Francisco does not have the world’s worst homelessness problem. Actually, the overdose death rate in California is less than in many of the states whose representatives are criticizing it. We have to start from the same slate of facts, rather than making up explanations and picking facts to fit them. Some of the people who are shouting about crime aren’t paying attention to what’s really going on, and with whom.
We just had a global pandemic. This affected everyone, across the world. It was a big shock to everyone’s system. After a long time of not seeing increases in crime and disorder, we had lots of increases. Now, you might say that’s due to hippies in San Francisco. Or you might be rational and say it’s due to the pandemic. Because it’s happening everywhere, and it’s not better in places that are doing crackdowns. We have done these crackdowns for the last hundred years, over and over. We create mandatory minimum sentences, we lock a lot of poor people up, and then we say, “Oh, wow, this didn’t solve the problem, let’s undo this.” And then we do it again! You saw this in the ‘50s, in the ‘80s, and we’re starting to do it again now. Shouldn’t we learn from experience?
People are always claiming that people with addiction aren’t learning from experience and are just doing the same thing and expecting different results. The reality is that the criminalizers are doing precisely that. “This didn’t work before, but it’ll work now.”
TVM: I think this dichotomy you raise in the carceralist headspace is very evocative—the anti-Housing First types seem at once to not want to house people and also not want them to be on the streets. My worry is that—I think we’re already starting to see this in NYC with Eric Adams—they square the circle by calling for mass institutionalization. This seems to be a “solution” to the homelessness crisis amenable to the deeply rooted impulse you identify: we don’t want to reward bad behavior.
MS: All of us grew up with pull-yourself-up-by-your-bootstraps, hard-work-is-what-matters rhetoric. All of us have, even hidden in our minds as we try to fight it, that baggage. “Why should we give a house to a homeless person on drugs when there’s a family over here that can’t get one?” The answer is not “Okay, let’s just house the family and jail the other guy.” The answer is to deal with housing in a more holistic way, recognizing that we’re not rewarding anyone for anything, but doing the things that will work in the long run to get people stably housed (and get them away from the neighbors and businesses that are calling for them not to be there in the first place). Studies show that 85% of people who are severely mentally ill and unhoused and have drug problems can be housed if you do it right. It’s not even more expensive than what we’re currently doing! Cycling people through ERs and jails is incredibly expensive. Some people say, “We just need to coerce them more.” Well, where are you going to coerce homeless people into? We’re not willing to spend the money on decent services because we don’t want to “reward” people who are “lazy” or “bad.” But mental illness and addiction aren’t about being lazy and bad. If you cut through that stigma and actually talk to anyone who’s been unhoused and learn their stories, in my experience, there’s this world of pain that comes out. When we come at it with a compassionate view, we recognize that the vast majority of people in these circumstances have had terrible incidents in their lives. For lack of a better way to say it, they’re sad people, not bad people. Most who use drugs are not in these situations, and are using drugs for a wide variety of reasons. But on the street, it’s generally people who have addiction, mental illness, or a history of trauma—usually all three. If you want to help and make the situation better for everyone, you have to figure out how to help people cope with accumulated trauma, mental illness, and addiction. Changing all that stuff is a slow process. It doesn’t happen overnight! It has forward and backward steps, just like anything else in politics.
Navigating the objectives of harm reduction and sobriety
TVM: There are so many pernicious dichotomies that are operationalized in anti-intervention rhetoric. An addicted homeless person versus a family (assuming we can only house one). One of the things I’ve written about is this invention, this canard, of the perfect homeless person who’s uniquely disadvantaged by societal focus on addiction as a public health crisis, on Housing First, et cetera. The story goes that we’re giving higher priority to the interests of bad people than to those of this imagined person. Another way this narrative arises is with a question I see a lot about balancing objectives in addiction remission among homeless people. The person advocating against Housing First pits the interests of active drug users against those of sober people. “We really need to have sober shelters rather than low-barrier shelters,” they’ll say, “because these sober people might relapse if they come in contact with drug use.”
I have a lot of concerns about this. I fear such narratives reflect a general tendency in the way people think about marginalized groups: “Oh, you want self-determination? You need to be a monolith, then, politically. You must all agree about what you want and what your interests are.” That sentiment comes across in other contexts too. “Black people are really the people who want more policing!”
MS: Right. In terms of abstinence versus harms reduction, we obviously need both. Someone in early recovery is probably not going to do best at attaining remission while living in a needle exchange. Now, of course, some people do! There are AA meetings in bars, I’m told.
TVM: Really? Huh. That would never have worked for me!
MS: Right! So we need to recognize the interests of both—who are often the same person! Sometimes you’re struggling really hard to be abstinent, and sometimes you’re in chaotic use. What we want to do is have places that support the best outcome in those situations. You can’t instantly turn one person into another. So, yes, we do need places that support abstinence.
TVM: Absolutely—and if we don’t have sober shelters, active users are forced to compete with abstinent people for limited resources. It backfires.
MS: Something like ninety percent of people will relapse. We’re all the same people. So let’s just create ecumenical environments that allow the pursuit of everyone’s good. It’s definitely reasonable to separate people who are really committed to active use from those who are newly trying to be abstinent. But in the long term, that separation probably isn’t as necessary. Once you have a solid foundation in recovery, you develop the skills to deal with those situations. People start by exposing themselves to triggers gradually in safe situations, so they become less potent. At first, that’s a bad idea! But once you have a base and some support, you can become more involved. Some recovery support organizations will have twelve-step meetings around the corner from a needle exchange.
TVM: I know a lot of people who are involved in both twelve-step groups and harm reduction volunteering.
MS: That’s always been the case! Most of the harm reduction founders in the U.S. were, at one point or another, twelve-steppers. We don’t need absolute segregation; what we need are ways to manage the fact that when you are newly abstinent or controlled-use, being in chaotic situations is not going to be helpful to you. But that means recognizing that we must respect each other where we are. If you are actively using, don’t try to convince someone who’s trying to be abstinent to return to use. If you are abstinent, you gotta get off the case of people who don’t want to hear it.
TVM: That second part is often neglected!
MS: If we can agree to those terms—I’ve seen organizations that are integrated in this way and it works great. One person’s path is, maybe, being totally abstinent from X and Y but using a bit of Z.
TVM: Absolutely. It’s not a dichotomy between not touching anything and unmitigated use of everything. There are all sorts of relationships to different substances and behaviors that people can pursue simultaneously, without it being any sort of contradiction.
MS: Even in twelve-step, caffeine and tobacco are allowed! So nobody’s totally abstinent, really. Whatever works for an individual is good. Some people might want to give up sugar—but I don’t feel like doing that!
Addiction and chronic pain
TVM: Another one of these pernicious, uncritically reproduced dichotomies is the demonized “drug-seeking” addict versus the chronic pain patients who are responsible medication users.
MS: I think the narrative has changed somewhat. We completely ignore the pain folks. In the past, often the pain patients have been valorized. But now increasingly you see them being told, “Shut up, you caused my kid to get addicted.” A lot of pain patients are being withheld access to opioids, and are suffering. I’ve never seen this before—traditionally, it’s been the evil addicted people and the good innocent pain patients.
TVM: You’ve written about the crackdown on prescriptions, and also the way that the government has treated people with opioid prescriptions during the pandemic—another recommendation for Discourse readers.
I’m writing something about the Overdose Detection Mapping Application Program (ODMAP). It’s a digital tool—you’re probably aware of this—that first responders and police use to track the locations of overdoses and adjust their responses. One of the things I’ve learned is that some police departments track not just all the overdoses, but all the opioid prescriptions in the county or state, ostensibly to crack down on pill mills. Before I knew this existed, I would have guessed it would be super illegal.
MS: It’s incredible that Americans, who are supposed to care about privacy, have sanctioned a national database that can check whether you’re taking testosterone, valium, an opioid. Police can look into this, in many states without a warrant. I wish we’d put Viagra on it—I think then suddenly people would realize how invasive it all is. It’s ridiculous that these databases exist.
Currently pain patients have zero rights; they’re being thrown off medications. Addicted people and pain patients should unite here. As long as there’s a category of person you can treat like absolute dirt, be it addicted person or person in pain, misidentification will become a problem. If there’s no such category, we treat both groups with dignity and respect and won’t be throwing away either. It’s ridiculous to pit these groups against each other. For one, some of them are the same people. Secondly, if you happen to need a substance to function, that shouldn’t be a reason to discriminate against you. The way we look at risks concerning addiction and prescription opioids is ridiculous. Medically, you’re allowed to choose a surgery that could kill you! Why aren’t you, then, allowed to say, “I accept the risk that addiction will happen?” Just like you’d accept any other medical risk. But no—in this case paternalism is somehow warranted.
TVM: There’s tremendous double standards around autonomy in this context, yeah. Opioids and HRT, you need oversight. But for many extremely risky surgeries, not so much.
MS: What’s wild about the overdose crisis is that when we had actual pill mills in large numbers, we knew who everybody was. You had to have your ID to get in. When we shut down the mills, instead of asking whether people were in pain or had addiction and then providing ongoing appropriate care, we basically said: “Go for it, gangsters! Here’s a whole new market for you.” How did anyone think shutting down pill mills and doing literally nothing for the patients would work?
TVM: You’ve critiqued that policy response in your writing.
MS: We still do this—the CDC has a response program, but to my understanding, it doesn’t work very well. I hear from patients who’ve had three doctors shut down by the DEA, and now nobody wants to prescribe for them because the last guy got arrested. What are you supposed to do? These people have documented severe pain. We just cut the supply and thought that would solve it. Well, do you believe addiction exists or not? If you don’t, why is this a problem worth addressing? And if you do, why do you think cutting one source of supply is going to fix the issue? All it does is push people to a more dangerous source of supply.
TVM: I have a forthcoming piece about this. I’m trying to explain to hardline prohibitionists why their whole proposal is illogical. As long as these economic incentives exist, which they profoundly do—the exploitation, the production of economic capital through addicts is inseparable from the way our country is set up—when you create a deficit in supply in one area, another market is going to swoop in and eat your lunch. It’s not going to be effective in reducing access.
MS: It’s extremely obvious to me too. What has obscured this fact for a lot of people, I think, is this idea that the people who became addicted to opioids were these “innocent” pain patients who had no prior contact with street drugs. For 80% of cases that’s false, according to government statistics. Most people who misused prescription drugs did not have a prescription for the first drug they misused.
TVM: I get the sense that, because addicts are generally not viewed sympathetically, people feel like they have to interpret opioid-addicted people as angels in order to conclude that the Sacklers are bad.
MS: That, and in order to think that Black people with crack addiction deserved it.
TVM: Yes! The crack crisis, the meth crisis—addiction crises where the victims are Black or Indigenous get handled totally differently. You’ve done some great work clarifying the relevance of crime statistics in addiction epidemics to push back against the myths here.
MS: The white people who misused prescription opioids had to be innocent, because otherwise how could we justify the way that we handled the crack epidemic? “Well, those were bad people using illegal drugs. These are people who got addicted by their doctors.” But in order to be addicted rather than physically dependent, you have to use more and in higher doses than prescribed.
Addiction versus physical dependence
TVM: Speaking of that, I’d like to discuss the article you coauthored in Annals of Medicine on addiction and dependence. I loved that article—I keep sending it to people who don’t recognize the distinction. Can you talk a bit about the difference?
MS: That DSM conflation has done serious harm, in many bizarre ways. For one: cocaine! If dependence is addiction, cocaine isn’t addictive. You don’t puke and shake when you quit. Of course, I can tell you personally that it’s very addictive. It’s never the case that physical dependence is the only barrier between you and quitting. If that were the case, you’d quit once and be done! I’ve never met a person with addiction for whom that’s true. I’ve met lots of people with dependence who go through withdrawal, it sucks, and then they go on with their lives, because they don’t have addiction. There may be difficulties when you’re trying to taper but you still have the pain. But the idea that withdrawal symptoms are the worst thing ever and that’s the reason people don’t quit: if that were true, people who were forcibly separated from their drug of choice for three weeks wouldn’t relapse.
TVM: So, I tend to be pretty agnostic about the generating mechanisms of addiction. I think there are a variety. My definition of the addict category is reductive and ameliorative: it means being subject to these kinds of oppressions that are very similar in kind, namely being oppressed in light of atypical use patterns of substances or processes.
You wrote a public-facing piece in Pacific Standard a few years back in which you drew a comparison between addiction and ADHD. ADHD kids, you wrote, grow to more behaviorally resemble their neurotypical peers over time, either because “their brains catch up to those of their peers” or because “they develop workarounds for coping with their different wiring.” To me, it’s clear I’m in the second camp. Most of my active use of alcohol occurred when I just didn’t understand what was happening. I was raised in a relatively sheltered context. I went to college; a year and a half later I’m compulsively drinking constantly and have all the hallmarks of alcoholism. I had no idea what was happening to me! I didn’t know what alcoholism was. Once I figured out what was going on—which is to say, once I started facing censure and penalties for my use, and there was obvious concern in the air about me that was explicitly linked to my drinking—I began recognizing the relationship between my perceptions and compulsions and my use patterns. For me, it was a lot of strange beliefs. I had odd ideas about my obligations concerning alcohol. I’ll ask you more about that later, but for now suffice it to say: I got a better understanding of my own experience and then started devising strategies I couldn’t have come up with before.
Earlier in our conversation you brought up how people look at those who are addicted and say, “Why do you keep doing the same things over and over and expecting different results?” One of the reasons I find this so misguided is that you need to have a hermeneutics and a self-understanding in order to start putting strategies in place to prevent yourself from using. A big mindset change needs to occur; you have to associate the behaviors with the results, and that’s difficult to do in a cultural context full of bizarre and unrealistic media representations of addiction. I see alcoholics on TV: they drink when they’re sad. I had no emotional problems, no history of trauma, all of that was downstream of my active use. The risk factor for my drinking was that alcohol be present. It took a lot of introspection to figure that out. To nonaddicts, of course, it sounds easy. But it’s not.
Anyway, back to withdrawal. Alcohol withdrawal symptoms are terrible, and can be super dangerous. But nonetheless, with alcohol, as with cocaine, some people who are addicted don’t have withdrawal symptoms. So the withdrawal itself wouldn’t be sufficient to explain why addiction exists. I think one of the reasons withdrawal symptoms are so often discussed within addict communities is not that they’re really the reason for relapse, but that they can interrupt and frustrate those strategies we’ve devised to manage our compulsions, beliefs, et cetera. The way in which withdrawal interferes with remission is not via the mechanism most people assume: “Oh, they relapse because withdrawal sucks.” It’s rather that when you’re dealing with physical symptoms, it’s much harder to focus on implementing the guardrails you’ve put in place to prevent using. It defeats a defeater of active use. That’s true also for other things that are associated with relapse: homelessness, emotional troubles, trauma.
MS: Yes. I’m not saying we should ignore withdrawal and let people suffer. But if you want to deal with addiction in the long run, solving withdrawal does not solve it. We have Ibogaine, which eliminates withdrawal for some people. Does that mean none of them ever relapse? No! Putting it in context, sometimes people with addictions appeal to that explanation: “Well, I had to avoid withdrawal; that explains my use”—and that can be complicated. It can depend on your economic context, past abuse, what situation you’re in, the skills you have. All manner of things can strain people’s responses. But the concept that anyone in withdrawal is a dangerous person who’s likely to mug a grandmother is just ridiculous.
Carceralism and the public health response to addiction
TVM: I want to touch on addiction and public health. One of the things I’ve been thinking about recently is carceral involvement in narratives around addiction as a public health crisis. I see a lot of exhortations toward this all-hands-on-deck approach: we have to integrate law enforcement with the clinics and the therapists and the harm reduction efforts. I tend to be pretty cynical about any proposal in which law enforcement plays a central role. It brings drug users in contact with legal oversight—especially with post-overdose followup or “door-knocking” policies, which police are frequently involved in. This persists despite abundant empirical evidence that carceral involvement corresponds to worse health outcomes.
MS: I’m a hundred percent for total decriminalization and no involvement of police in overdose situations. Figuring out how to regulate sales of substances is more complicated, but there’s zero reason not to decriminalize possession. All that does is put people into the system, make them more likely to overdose, become ill, spread COVID into the community (carceral situations spread like 20% of the COVID in the country!). It also increases the likelihood of HIV, suicide, homelessness, and unemployment. Basically, it creates barriers to recovery. It also doesn’t make people more likely to get treatment. One of the more sickening things I’ve noticed recently is that the Black community is among both the most-incarcerated and the most treatment-underserved groups. If locking people up were such a great way to treat addiction, then that wouldn’t be the case. There are the same rates of use and selling among Black people and other racial groups, so it’s not like we’re comparing apples and oranges. It just demonstrates that incarceration is not an effective treatment avenue. If it worked, we’d see it working here. But we don’t see an advantage.
TVM: It’s this holdover from the Scared Straight era. You often see, in police resources, very explicitly: “We’re going to arrest drug users because that can be used to pressure them into treatment.” I was looking at one the other day which pretty blatantly stated that the threat of legal consequences has operational value to get people into recovery programs. I was like, huh, they’re saying it out loud?
MS: What’s funny is that addiction is defined as compulsive drug use despite negative consequences. How are negative consequences going to fix it? That’s, by definition, not going to work. Do people sometimes enter recovery because they’re terrified of legal consequences? Yes. But do people often not get into recovery in that situation? Also yes. And if we actually believe it’s a medical problem, a disability, we should treat it differently. We don’t have a Cupcake Police! We recognize that if you’re trying to go on a diet, arresting you and putting you in jail for eating a cupcake is not a good way of solving the problem.
TVM: Right. Of course the detractors will come in with “Oh, that’s not the same,” but I quite like your example: it highlights the irrelevance of the empirical information here. Even if arresting people did curb cupcake consumption, it would be facially absurd and flagrantly immoral. We’d look askance at anyone who said, “But it works!” You’re not allowed to treat people this way.
MS: We don’t have this idea that you ate too much sugar, now you go to the Donut Court and do a day in jail for every “relapse.”
TVM: The whole Project HOPE-style approach, where polities briefly reincarcerate parolees and convicts who have positive drug tests, is very dystopian. I talked about this a bit in my interview with Owen Flanagan. That targeted catch-and-release can’t be justified; claims that it “works” are out of place.
MS: If we’re stuck with arresting people and can’t get anywhere toward reform, then drug courts at least give an escape valve to some people. Harm reduction always relies on context. If we’re comparing the Rockefeller drug laws to drug court, the second is clearly better. At least some people are able to make a change this way. But is it a good idea in general? No.
With Project HOPE, the idea was supposed to be: you get arrested for possession, do a day in jail, and then that’s it. And after a few times you get offered treatment. But that’s not how it actually plays out! After a few arrests you’re forced into treatment. You don’t have a choice. That’s not in any way sensible. For people who don’t have problems and are arrested for possession, testing negative will be easy—for others, not so much.
TVM: This is another thing I write about a lot. It relates to this general sentiment that addiction is an active choice. People who’ve never been addicted to anything are inclined to view mandatory drug tests as unproblematic—they think, “Oh, I just wouldn’t use.” It’s very difficult to get across to them the ways in which it can be really, really difficult to pass a required drug test if you are addicted. There’s a disability oppression here, and a standpoint problem: from the outside, people just can’t imagine why this would be hard.
MS: It really has to do with how you’re learning. It takes time to learn new skills to avoid relapse! Having to pass a drug test and satisfy a linear, straightforward progression—that’s not how change happens. People do really well for awhile, and then they screw up for awhile, and then they do well again. It’s different for everyone. Having these required goalposts will harm people. In a genuinely nonpunitive system, maybe some people will want to take drug tests to mark their progress. But then you wouldn’t even need the test; you could freely admit your use.
TVM: Right. The whole reason you’d need drug tests is that people might lie about their drug use. But they do so out of fear of punitive consequences, and that would be absent in such a situation.
I think what you just said is really important. Often the way these mechanisms, like drug tests, are described is that they’re giving people responsibility—creating avenues for holding to account, or what have you. But they really aren’t given any sort of accountability. All the relevant decisions are made externally to them, on their behalf. There’s no self-determination in this system. It’s a fundamentally wrong way to interact with people.
MS: There are some situations in which someone’s been so disbelieved so much of the time might say, “I’ll prove it to you, here’s my urine.” But that is because of having been oppressed. Are there people who are going to lie about their use when they’re going to be punished for use? Yes; everyone will do that, pretty much. What we want to do is have people feel safe saying, “Yeah, I relapsed.” You don’t need the tests most of the time in that case.
Addiction and personality disorders
MS: You do get people who have antisocial personality disorder. They are overrepresented among people with addictions. There’s some such people within every population in the world. Dealing with that can be very difficult. So, we should admit that not everyone will respond the way we’d like.
TVM: Now that you’ve brought up ASPD: I’m interested in the project of liberation for people diagnosed with Cluster B personality disorders—what the hermeneutics and plans for that might look like. I haven’t discussed that much aside from Twitter threads. But I have written about the very strong conflation between cluster B personality disorders, ASPD in particular, and addiction. A trifecta, really, of homelessness, addiction, and sociopathy. What do you make of this? I tend to be pretty conservative in my conclusions—addiction treatment for people diagnosed with ASPD is just one more regard in which the current system isn’t working, rather than a contextually independent unique problem.
MS: I just think we don’t know how to deal with it, basically.
TVM: Right, agreed. I definitely don’t think people diagnosed with ASPD are “dispositional liars,” or immoral people, as addicted people in general are often called.
MS: Not at all! I don’t want to stigmatize or be mean to these people, just recognize the inherent challenge. I think for many years, every person with addiction was assumed to have antisocial personality disorder, which is ridiculous. Is it a concept that should exist? That’s another question.
TVM: Yes, I think that’s the operative question!
MS: But the thing is, to be realistic, we have to grapple with the fact that there are some people who will behave poorly even when they have other choices. Such people exist, unfortunately; how to deal with that is another whole question.
TVM: Right. I think the estimates that put it at 70% are just wild. In my piece for this blog, I postulated that the reason this correlation emerges is that a lot of addiction treatment is hyperfocused on getting people in recovery to evaluate their character flaws and admit they’re narcissists.
MS: Yeah, there’s that. But nonetheless, not every addicted person is a nice depressed person self-medicating. I don’t know what to do with that fact. I’d like it to be the case that nobody enjoys exerting power over others. But I’ve come across such people. And we’re politically up against such people, sometimes. It’s difficult to manage this. Again, thankfully, 99% of the time we don’t have to worry about such moral questions. And I do think a lot of it is conflation—I mean, I got called antisocial in rehab! Anyone who knows me knows that’s not the case. But we must admit that such people exist. We see them.
There is a difference between ASPD and psychopathy or zero empathy. Some people are just antisocial because they’re impulsive, which is a completely different thing.
TVM: As with pretty much any diagnosis, it’s multiply realizable. All sorts of people get shoehorned into the same category because they tick off the qualifying number of boxes. And many of them have atypical ways of expressing emotion or care, but are misread as just having no emotions. I think that as communities devise better mechanisms for accountability, we won’t see such people ad infinitum just lie for the heck of it.
MS: The vast majority of people with addiction do not fit any of this and may be falsely accused of it. But the people that exist pose a very difficult problem.
TVM: The community of addicted people in general is so diverse and multifaceted that often we need specific mechanisms for specific subgroups. Different oppressions, experiences, personalities, even different interests! From one standpoint, it’s kind of intimidating, but that’s only if we think we have to design a “one size fits all” panacea. If we’re working on a smaller scale, to make the lives of actual people easier, it’s exciting! It means there are all sorts of different opportunities to get involved and make a change.
MS: Most people with addiction, when given resources and the opportunity to do the right thing, are not going to do this. It’s just that tiny minority that you have to deal with—and that people will always confront you with. I’d be happy to say they don’t exist, but you’ll hear from parents, or about people on the street who continue to do terrible things.
TVM: This is a great point. If I understand correctly, you’re saying that these kinds of tricky situations, these edge cases, are things we can’t ignore in the context of devising policy and communicating with doubters. It’s important to stare them down.
MS: Right. Otherwise, people will say, “This is unrealistic; you have an idealistic view that every problem can be solved.” Again, vast majority—yes, I think it’s true. But I don’t know what to do about these edge cases. Addressing the fact that they exist allows you to communicate with some of the people that might not take you seriously if you don’t admit their existence. You’re 100% right that overcategorizing people like that has done enormous harm to people with addictions, and people who are unhoused, and all oppressed groups. But the presence of them among the oppressors as well is another issue that is complicated.
TVM: On that last point, I think this: There may be certain kinds of “personality traits,” insofar as those exist, that might confer opportunistic benefits in society—although perhaps drawbacks as well! But in the context of marginalization, having a diagnosis on the record is usually a further mechanism through which you are penalized.
MS: Right! I also don’t think people in active addiction should be diagnosed with anything permanently. I mean, if you take the history and they clearly have depression, they should probably get antidepressants. But to just say, “You have X” while somebody is actively withdrawing is going to lead to a lot of misdiagnoses.
Drug dealers and drug users
TVM: So you’ve brought up that people are inclined toward this view on which everyone with an addiction is a depressed person self-medicating. There’s something else you described in Undoing Drugs which I found really useful: the way harm reduction reduces the pressure to sell, the user-to-dealer pipeline. This relates to this Pollyanna narrative in public health. People say, “We have the hapless users versus the demonic dealers, and there is zero overlap between these two groups,” which of course is very rosy.
MS: Ridiculous, right. I once had a debate with a boyfriend about whether if you’re actively using and need money, it’s more ethical to shoplift or deal.
TVM: It’s a good question!
MS: He was saying, “Shoplift; you’re just stealing from big corporations that have insurance.” But I said deal. You’ll be a person committed to getting good product to yourself and those who need it. Not the kind of person who’s going to kill someone if they owe you money!
User-dealers—I was one of them; they absolutely exist. The way to handle that is going to be very different than if you have someone who is dealing simply because they have no other economic opportunities, versus the edge case of the evil criminal genius, which again is vanishingly small proportionally.
TVM: It’s a fanciful kind of case, yeah. But there certainly is such a thing as a predatory dealer.
MS: There do exist some; the vast majority are not. Most cases you can solve by managing the addiction and getting the person resources so they can support themself. Oftentimes that’s about education and job training. That concept of the evil dealer who’s just there to prey on people—often it’s people who have no economic opportunity, or are addicted, or people who think drugs are good and our drug laws are stupid. You get more of that on the psychedelics/marijuana side. All of these things are multifaceted. When you do safe supply, you may incidentally reduce dealing; those who were subsistence dealing won’t do that because they’re now supplied. We did see that in Liverpool where they had pretty good heroin prescribing for awhile.
TVM: Right. You discussed that in your book.
MS: To say that will solve the issue is a bit Pollyanna. To say that it will reduce dealing, though, is accurate!
TVM: This two-pronged approach where we have to save this one population but punish the other is just unrealistic. Again, it plays into this idealization people have of what drug users must look or be like in order to merit help. And, as you pointed out earlier, it’s a racist characterization. Much of it stems from the maybe-subconscious desire to justify the feeling that the crack epidemic is relevantly different from the opioid epidemic. That racism on the backend plays in; classism plays in; people want to scoff at subsistence dealing. You also see this with the rehabilitation of cannabis—I think it is good to fear the use of weed-empowerment narratives to further subjugate and demonize users of “hard drugs.”
MS: It’s interesting that rather than that, we have rapidly moved toward the legalization of psychedelics.
TVM: Not where I expected it to go.
MS: Nor I. There’s still a sort of marijuana and psychedelics exceptionalism, “these are the good drugs and you guys are taking the bad drugs.”
TVM: And, of course, alcohol exceptionalism—although increasingly, people are getting weird about alcohol.
MS: Yeah. It’s really interesting. People are subject to fashions and trends on top of the fact of our dispositions, on top of capitalism and systems and all that.
With all of this said: we’re not going to fix the world. But we can reduce harm, and with drug policy there’s so much low-hanging fruit, especially with decriminalization. Nobody has ever been able to give me a good argument for criminalization of possession aside from “we need to stigmatize it so people won’t use.” Since that patently hasn’t worked, it’s not a good argument either! Or, we need to use criminalization as a stick to get people into treatment. But, again, people don’t actually get treatment. So you’re spending all this money coercing people who may not even need treatment, whereas those who want treatment can’t get it.
TVM: And the evidence shows it makes people’s lives worse, not better!
MS: When you’re feeding people into a system but giving them no say in choosing the system, it’s not going to be responsive to them. There’s many bad things about capitalism, but when there’s consumer choice, you do tend to get better service! If everyone is going to get the same thing, why should they bother to be nice to you? If they have to attract people, they’re going to make a better product.
Twelve-step recovery
TVM: I hadn’t really thought about this concept of consumer choice, but I get what you mean. Anyone who’s ever been in active addiction knows that the twelve-step paradigm and the Minnesota model is dominant. It’s the way we as a society treat addiction. It’s becoming increasingly vogue to criticize it from external journalistic and research perspectives, but that’s no matter—it’s still totally ubiquitous if you’re in active use. As soon as it became obvious I was an alcoholic, it was expected that the thing I would do was go to AA. Nothing else was suggested.
MS: What year was this?
TVM: 2017.
MS: I always hear, “You’re out of date! It’s not that dominant anymore! You’re stuck in the eighties!” But then I keep hearing from young people like you that I’m not out of date.
TVM: No, you’re totally not. Both the founders of this site are in our twenties and were uncritically handed into the care of twelve-step programs. This is the way nonaddicts relate to addicted people: “Get a sponsor. Go to NA.”
On the other side, there’s also a motivator that’s not so much coercive as just an eventuality of the way our society is set up. As a person in remission, or a person who self-identifies as an alcoholic or addict, the way you make friends and get involved in community is by going to AA or NA or CMA or GA or so on. I know so many people, young people, who’d already been in remission for a long time, who’ve mentioned to me, “Oh, when I changed cities I did 90-90.”1 People who have a five-year chip2 do it.
MS: They don’t say they have zero days—they just do 90-90 again?
TVM: Yeah. It’s very much a youth thing.
MS: I know they now have these sober apps where you can meet friends across styles of recovery. I just happened to read about this, which sounded like a good idea, but might also produce the predatory behavior you hear about—“thirteenth stepping,”3 that kind of thing.
TVM: I’ve seen some behavior like that, but not as much as you’d think, and usually levied by opportunistic outsider nonaddicts to take advantage of women in early recovery. That was literally a plotline on Always Sunny, and yet happens in real life.
On the topic of twelve-step groups more generally: As a point of good form I don’t disclose my current membership status in twelve-step recovery groups, but obviously I’ve been to them, we all have. The way I generally feel about them is this. I have a lot of problems with twelve-step doctrine, but twelve-step communities were founded and are perpetuated—much like harm reduction groups—by and for my marginalized community, and that in itself means there’s a baby in the bathwater.
MS: I agree completely. We need community.
What’s really funny is that in the early nineties, New York Magazine had a piece suggesting women go to AA to pick up men—“it’s the hot happening thing!” It was the hot happening thing at the time. I don’t know if you’ve seen the movie The Player. In Hollywood, it was such a big thing, it was just kind of trendy. Everyone in the program at the time was like, “Huh? I don’t think this is a good idea.”
TVM: I’ve written on the phenomenon of nonaddicts thinking addiction is cool; it’s sort of the modern consumptive bloody handkerchief, an indicator of artistic creativity. But this strikes me as almost a different thing.
MS: At the time, there was this whole iteration of the controlled-drinking-is-evil mindset. If twelve-step is dominant now, it was even more dominant then, absolutely. I stopped going when I got more annoyed by things I disagreed with than serene from the companionship. But, yeah, I think it’s interesting that people do that when they change cities—and it can be a good thing! I suppose other people are doing it by joining a board game or video game group or bar scene.
TVM: Right, exactly. This is one of the things people don’t talk about when it comes to recovery. It’s not just alcohol—weed, club drugs, coke, ket—they’re inseparable from a lot of youth scenes, so young people trying to stay away from them have a hard time developing friend groups where their drug of choice isn’t around. I don’t know if that was true to your experience. I know a lot of people who were addicted to cocaine and really wanted to stay away from it, but found it omnipresent in social settings among young adults.
MS: I’m imagining it was worse in my day: if you look at the national surveys from the eighties, 50% of people in their twenties had tried cocaine. Nationally, and that was self-admission. Which also goes to show that our estimates of how addictive things are at first use are very overblown!
TVM: There are so many wrong models of addiction in the air. Which is why I’ve become so disillusioned that at this point I just say, screw generating mechanisms. I think some work in that field is cool, but much is just unverified speculation.
MS: “It’s all mental illness.” “It’s all trauma.” It’s not all anything! Often it’s mental illness or neurodevelopmental difference; often trauma is involved; trauma can turn neurodevelopmental difference into a condition, but none of those is exclusive or exhaustive. And for some people it may be straight pharmacology. I have yet to meet those people, but maybe!
TVM: I have yet to meet them either, but agree that we should leave space for their potential existence.
Learning disorder and perceptual model
This gets to the content of your earlier book Unbroken Brain, in which you postulate the learning disorder theory of addiction. To my understanding, you don’t intend for your view to be conflated with the hijacking hypothesis, and are indeed extremely critical of the hijacking hypothesis.
MS: I think someone could read the book and find my view not incompatible with a mild version of the disease concept—the way someone might say, “Depression is a disease.” I prefer disorder, just because “disease” is so inseparable from the twelve-step model in the American mind now. “Chronic progressive condition only treatable through abstinence.”
TVM: Right. No, I appreciate your work! We have got to get out of the disease/choice dichotomy.
MS: That’s what the point of the book was. It’s a learning problem; even the hijacking theorists will acknowledge that people don’t tend to shoot up in front of the cops. That means people are choosing to delay use, which could not happen if you were a zombie, if your brain were truly hijacked.
TVM: A lot of people advocating for disease models hybridize them to toggle the boundaries, accounting for the cases the first pass theory doesn’t fit. Even Khantzian, the architect of the self-medication hypothesis, backs off the ledge and says, yeah, hijacking is involved.
MS: I felt the learning characterization could accommodate all of that. It can accommodate self-medication; you can learn that this substance helps you cope with your despair; you can learn it’s the only thing that works for your trauma; and so on. You can’t have addiction without learning. You have to learn that the substance does something for you, and then continue to take it despite harm.
I could make somebody physically dependent on opioids, but I couldn’t make them addicted. If I didn’t tell them what I did, then when released they’d think, “Yay, I’m free, I have the flu now.” They wouldn’t know they were experiencing withdrawal symptoms! Not that I’d ever do this, of course.
TVM: I really wanted to ask you whether my theory of addiction—to the extent that I’d call this a theory of addiction—is compatible with your learning model. Because the example you just gave strikes me as something I’d also use as a golden-event case.
Again bearing in mind my heavy caveats against generating mechanism theories, I think at least many cases of testimony from addicted people describes what I’d call a form of neuroatypicality corresponding to perception. Many of us report having atypical ideas—bizarre from the standard standpoint—about our substances of choice, its properties, our relationship to it, and so on. But a person physically dependent on opioids but not aware of the genesis of their reactions couldn’t have strange perceptions about them.
MS: I start Unbroken Brain by discussing neurodivergence. One of the things I’d like to see more research on is the relationship between sensory sensitivity and addiction. I’ve seen parents on addiction forums describe that their kids needed to have the tags cut out of their clothes. In fact, non-intellectually-disabled people on the spectrum have much higher rates of addiction than neurotypicals. (For intellectually disabled people on the spectrum, nobody will sell to them and they have no access, so we don’t know what their actual risk is.)
TVM: Right—the data there is missing because of the social invisibility of intellectually disabled people.
MS: Both the autistic spectrum and ADHD are definitely linked to addiction; sensory sensitivity in particular may set you up for this. You get easily overwhelmed and have difficulties with socializing. Then you find that, oh, drugs can work on this. There’s a network in the UK that’s starting to do work on that connection.
TVM: There’s also a new book that just came out by David Gray-Hammond—Robert Chapman sent me this intel—giving autistic testimony of addiction. I’ll send it to you.
I think we may differ slightly here. In my firsthand experience and the testimony I’ve collected, the mechanism is the atypical perception, the sensory sensitivities themselves. For example: there really wasn’t a time when I conceptualized alcohol in the way nonalcoholics do. This was true before I ever started drinking. Of course, it’s not independent of cultural concepts; it’s tightly tied to my seeing the social role of this substance. So, I’m not saying “born this way,” which I think is often unhelpful.
MS: Right, though genetics is definitely part of it. You might have a gene for some kind of sensitivity, or that would, in certain contexts, cause you to have one.
TVM: If the role of alcohol in society weren’t what it is, who knows if I would have had the relationship to it that I do. There’s an ineliminable social element, hence why I share your skepticism toward “addiction is all hijacking,” “all withdrawal,” et cetera. That social, environmental, political context is irreducible. But anyway, I just always thought alcohol was really cool in a way that did not resemble the way that nonalcoholics felt about it. I didn’t realize at the time that I was a manifestation of this cultural concept that you can see irresponsibly portrayed in any mainstream TV show. So it took me awhile to figure out.
To give a more explicit example: A lot of my active use anecdotes involve being instructed, over and over again, to pour out my liquor. I’d stand over the sink feeling like it was deeply morally wrong to pour it out, like a taboo. Like vacuuming up small amounts of powder that have fallen on the floor and using them. Or, finishing people’s abandoned drinks—almost every alcoholic I’ve talked to has done this, I’ve obviously done it—
MS: It’s like, why would you not finish it?
TVM: That’s what I always say! Within this community of people who are or have been addicted to drugs or alcohol, there’s this overarching commonality, regardless of substance of choice. It’s like, I think, the double empathy problem. It was long thought that autistic people are just bad at empathy. But no, actually, autistic people are excellent at empathizing with other autistic people, something that neurotypicals are terrible at. There’s something similar with addiction. Every time I’ve described consuming unattended drinks to someone else who’s experienced addiction, even if their drug of choice was different, they always say something like, “Oh, totally makes sense.” But then you tell it to someone outside the community and they are just confounded.
MS: I think you might be able to get a sense of who’s at risk by, when people read these cultural touchstone like, say, Burroughs for heroin—a lot of people who don’t have addictions read it and say, “Yuck, horrible!” whereas the people who are prone will say, “Sounds great.” It sounds like you’re describing that sort of experience with the culture of alcohol even before you started drinking.
TVM: The Burroughs analogy is really right. Also—here I may be out of date; this isn’t the “Gen Z perspective”—but I was definitely forced to read Go Ask Alice.
MS: Which we now know is fake, written by a Mormon housewife.
TVM: Like, of course it’s fake! Once you’re in active use and you read something like that, you’re like, “This is so silly.” I was talking to someone a few months ago about the new Sex and the City reboot. One of the plotlines is that one of the four women has conspicuously become an alcoholic.
MS: Miranda, right? The red-haired lawyer?
TVM: Yes. So I was at a dry event and someone told me one of the things Miranda does in her active use is, she carries around those little airplane bottles of vodka in her purse. Which is just—I’ve never heard of any alcoholic doing that. It’s a nonaddict projection of how they imagine they’d behave if they were me. A canard refracted through non-addicted sensibilities. You see it so much with media representations of heroin addiction these days: a fetishistic, otherized, alien portrait of what people who aren’t addicted imagine it must be like.
I think, really, the question that occupies a lot of minds is why addicted people behave the way we do. People say they want to help those with addictions. But what people really want is to understand this behavior they find totally inexplicable. That is the mainstay of research into addiction by people who’ve never been addicted.
MS: There’s also a fear: how could somebody be so out of control? “I want to distance myself from that; I want to understand it to make sure it never happens to me.” Many people who go into the field have siblings or parents with addictions. Sometimes it can be bad; sometimes, it can be really good. The ones who aren’t sympathetic to the addicted person—that can be a problem. The ones who are can do amazing stuff.
TVM: Oh, I can be very mean to people who I feel hate an addict they know and went into studying addiction to take it out on the rest of us. It’s a real phenomenon—I call it “Addict Parent Syndrome.”
MS: There are many of those in the treatment field; thankfully less in research. Though I strongly disbelieve in the concept of codependence, I do think there are some people with unhealthy relationships with people with addictions who are trying to work that out in their counseling practice.
TVM: This is why I think it’s so important to have interviews with people like you and to platform and celebrate the work you are doing. Firsthand experience is so crucial in this field, to combat the omnipresent urge to view addicted people as fundamentally objects of study, unlike the researchers.
Thank you so very much for talking with me. It’s been amazing to get to chat with you about your work!
MS: It’s been great talking to you as well—take care!
Twelve-step parlance for going to ninety meetings in ninety days.
Twelve-step parlance for receiving home group recognition for five years’ sobriety.
Twelve-step parlance for the phenomenon whereby an “old-timer” in recovery forms a romantic connection with a newcomer.
Very good interview. Thank you both Virgil and Maia