MAIA SZALAVITZ: Addiction is compulsive behavior
despite negative consequences, and it's really
important to start by defining addiction because,
for a long time, we really defined it very
poorly.
We used to think that addiction was needing
a substance to function and what that resulted
in was that cocaine was not addictive because
cocaine does not produce physical withdrawal
that is noticeable.
You may be cranky and irritable and crave
cocaine, but you won't be puking and shaking
and have the classic symptoms that you would
see with alcohol or heroin withdrawal.
So, cocaine wasn't addictive.
Then crack came.
And we realized that defining addiction in
that way not only harms people by telling
them that cocaine is not addictive.
It also harms pain patients because people
who take opioids daily for pain will develop
physical dependence, but they are not addicted
unless they have compulsive behavior despite
negative consequences.
CARL HART: Addiction.
Typically we think of it as people may exhibit
tolerance to a substance.
They may go through withdrawal when they don't
have the substance.
They may spend an increasing amount of time
engaged in the behavior to obtain or use the
substance.
They may have had unsuccessful, a number of
unsuccessful attempts to cut down their use
of the substance.
They may use despite the fact that they are
having psychological or physical problems.
These are the hallmarks of addiction.
MAIA SZALAVITZ: Addiction is a learning disorder
because it can't occur without learning.
You have to learn to associate the drug with
some kind of relief or pleasure, and you need
to do that repeatedly over time before you
can become addicted.
CARL HART: Crack in the mid-1980s, one of
the worst myths is that one hit, and you are
addicted for life.
We saw that in the 1980s and we are seeing
it again with methamphetamine today: 'One
hit and you are addicted.'
And it's simply not true.
Addiction requires work.
Not that people should go out and experiment
or do this themselves, but the fact is that's
a myth.
And the concern is that it's dangerous because
when people perpetuate such myths and then
when young people or people actually try methamphetamine
or crack cocaine and find that that doesn't
happen to them, now they disregard everything
that comes from these official sources.
MAIA SZALAVITZ: So the learning is involved
where you learn that this works to fix a problem
and you basically then fall in love with the
substance.
And once you've fallen in love with somebody
or something, you will persist despite negative
consequences in order to sustain that relationship
because the biology is going to tell you that
your life depends on this.
It basically acts in a brain region that is
involved in survival and reproduction and
those are the two fundamental purposes of
biology.
So that creates really, really strong cravings
and it changes your priorities tremendously.
This is a condition that can affect not just
anybody but people who are in some sort of
emotional pain.
Addiction kicks people who are already down.
In order to overcome addiction you need to
figure out what purpose the addiction was
serving.
In my case I had a lot of depression and I
was very, I had a lot of difficulties connecting
with people.
I was also sort of overwhelmed by my senses
and emotions a lot of the time and opioids
turned that down very nicely.
So I needed to sort of figure out what was
up and deal with those issues in order to
be healthy and comfortable in recovery.
And that's going to be different for different
people because they are going to have different
issues that they are medicating with the drugs.
So, I think that the way to get beyond that
and the way to help people with addiction
is to understand that people with addiction
are not seeking extra pleasure.
They are not hedonists who are just out there
having so much fun using that you can't stop
them unless you put them in jail.
People who get addicted, which are only 10
to 20 percent of the people who use drugs
like cocaine and heroin and prescription opioids,
those people have problems.
The drugs seem like a solution to them.
Until we recognize that those people are seeking,
reasonably rationally, to deal with emotional
and psychological problems and sometimes economic
problems we are not going to solve this problem.
And one of the things that I think we're actually
in denial about with regard to the opioid
epidemic is that while big pharma certainly
didn't do anything good here, what they—to
say that this is caused by Purdue Pharma selling
Oxycontin is to miss the fact that the people
who are overwhelmingly becoming addicted are
people who are either falling out of the middle
class or never managed to get into it.
If you actually look at the economics of this
problem it's not that middle class people
certainly don't get addicted and it's not
that rich people don't get addicted, it's
just that if your life is despair and you
feel like it will never get any better, which
is often the case when you lose the American
Dream or you lose the hope for your future,
opioids are going to become very attractive
and the idea that we can solve this by taking
away the supply is just ridiculous.
I mean as soon as we started cracking down
on the pill mills we started seeing a rise
in heroin use.
This is not an unpredictable outcome.
ETHAN NADELMANN: Why are some drugs legal
and others illegal?
Why are cigarettes and alcohol legal and pharmaceuticals
in the middle and these other drugs, marijuana,
illegal?
Some people sort of inherently assume 'Well,
this must be because there was a thoughtful
consideration of the relative risks of drugs.'
But then you think well, that can't be because
we know alcohol is more associated with violence
than almost any illegal drugs and cigarettes
are more addictive than any of the illegal
drugs.
Heroin addicts routinely say it's harder to
quit cigarettes than it is to quit heroin.
So, it's not as if there was ever any kind
of national academy of science that a hundred
years ago decided that these drugs, these
ones had to be illegal and those ones legal.
And it's not as if this is in the bible or
in the Code of Hammurabi.
I mean, nobody was making legal distinctions
among many of these drugs back until the twentieth
century, essentially.
So, if you ask how and why this distinction
got made, what you realize when you look at
the history is it has almost nothing to do
with the relative risks of these drugs and
almost everything to do with who used and
who was perceived to use these drugs.
So, back in the 1870s when the majority of
opiate consumers were middle-aged white women
throughout the country using them for their
aches and pains and the time of the month
and menopause and there was no aspirin, there
was no penicillin, lots of diarrhea because
of bad sanitation and nothing stops you up
like opiates.
I mean millions, many more, a much higher
percentage of the population back then used
opiates than now, but nobody thought about
criminalizing it because nobody wanted to
put Auntie or Grandma behind bars.
But then when the Chinese started coming to
the country in large numbers in the 1870s
and 1880s and working on the railroads and
working in the mines and working in factories
and then going back home at the end of the
night to smoke up a little opium the way they
did in the old country—the same way white
people were having a couple of whiskeys in
the evening—and that's when you got the
first opium prohibition laws in Nevada, in
California, in the 1870s and 1880s directed
at the Chinese minorities.
It was all about the fear 'What were those
Chinamen with their opium do to our precious
women addicting them and seducing them and
turning them into sex slaves' and all this
sort of stuff.
The first anti-cocaine laws were in the South
in the early part of the twentieth century,
directed at black men working on the docks
and the fear of 'What would happen to those
black men when they took that white powder
up their black noses and forgot their proper
place in society?'
The first time anybody ever said that cops
needed a .38 would not bring down a negro
crazed on cocaine, you needed a .45.
I mean, The New York Times, the paper of record,
was reporting this stuff as fact back in those
days.
That's when you got the first cocaine prohibition
laws.
The first marijuana prohibition laws were
in the Midwest and the Southwest directed
at Mexican migrants, Mexican Americans, taking
the good jobs from the good white people.
Going back home to their communities, smoking
a little of that funny, smoking marijuana,
reefer cigarette.
And once again the fear: What would this minority
do to our precious women and children?
I mean it's always been about that.
And it wasn't as if the white Americans weren't
also consuming.
It's just many of them knew that when you
criminalize a vice that is engaged in by a
huge minority of the population and you leave
it inevitably to the discretion of law enforcement
as to how to enforce those laws, those laws
are not typically going to be enforced against
the whiter and wealthier and more affluent
or middle class members of society.
Inevitably those laws will be disproportionally
enforced against the poorer and younger and
darker-skinned members of society.
So, to some very good extent that's really
what the war on drugs has been about.
MAIA SZALAVITZ: So, this is where our laws
come from and we have to be honest about that
and we have to stop pretending that there
is some kind of rational basis for the laws
that we currently have.
The reason that we continue to have these
stereotypes about who drug users are is because
of the ongoing racism of our society.
And until we acknowledge that, like, I am
the typical drug user if there is such a thing.
I don't look like your stereotype, but that
doesn't mean that the stereotype is accurate.
So, I think that's a really important thing
that people really have to learn because for
too long the media has enabled the racist
view of addiction and has enabled people to
say, oh, I'm not the typical addict.
And I used to say that and then I realized
wow, that's kind of racist.
And it comes from images that we shouldn't
have ever had.
What I do think is interesting about the future
of drugs is that we can make better drugs.
Part of the reason that prohibition is collapsing
at the moment is because of what are called
new psychoactive substances or legal highs.
And basically you can make a new recreational
drug by tweaking molecules of the other ones
and it will be technically legal because it
hasn't been made illegal.
And what this reveals is that our system for
making drugs illegal is completely irrational
and based on nineteenth-century prejudices.
It has nothing to do with science.
This idea that we could use a drug that will
block the effects of the drug of choice is
generally misguided because the problem isn't
the drug of choice.
The problem is why you need that drug and
why those drugs appeal to you and why you
are trying to get out.
Why you are trying to escape and what you
need in your life in order to feel comfortable
and safe and productive.
MAIA SZALAVITZ: I think the most important
place to start is that addiction is a learning
disorder.
It's not a sign that you are a bad person.
And if you want to have a safe and addiction-free
or at least lower level addiction workplace
or school, you want people to feel included
and comfortable and safe and you don't want
this to be an adversarial thing.
The research shows that the best way to get
people help is through compassion and empathy
and support.
And absolutely not tough love.
Help them realize that this is not a sin.
I am not trying to control you.
What I want to do is for you to be at your
best—at work, at home.
And you're not being at your best right now,
so what can we do to help?
And I have to say, it's almost never going
to be easy because people whether they have
addiction or mental illness or anything else
going on with them, often don't want to admit
to themselves that there's a problem.
In the addictions field, there's been this
whole thing, 'We've got to break through denial'
and everything like that.
Well, people have denial for good reasons.
If we didn't have denial everybody would be
sitting around obsessing about death—or
at least I would be.
It's a defense mechanism because we need defending.
So, recognizing that can allow you to approach
somebody not from an attacking stance; approach
somebody from a befriending sort of stance.
And that is hard to do and some people are
going to get very defensive no matter what
you do.
And it's not going to be a pleasant conversation
most of the time, but you can minimize harm.
This whole thing always comes down to reducing
harm, making things less unpleasant if you
can't make them non-unpleasant.
And I think really important in getting people
into any kind of treatment is that—and I
always say this to parents or anybody who
has an addictive loved one—the first step
should always be a complete, thorough psychiatric
evaluation by somebody who is not affiliated
with any treatment organization.
So that you can know going in what the problems
may be and what kind of services you should
be seeking.
I should say methadone and buprenorphine,
the opioid agonists, are the best treatments
that we have for opioid addiction and what
they do is two things.
The first thing is they cut the death rate
by 50 percent which this happens whether you
continue using on top or not.
So that's sheer harm reduction and that's
wonderful.
If we can keep you alive long enough that
you stabilize your life that is a lot better
than having you die.
The other thing that they do is they allow
people who are ready to stabilize their lives—so,
you couldn't tell right now if I was on a
maintenance treatment or not because basically
once you get a tolerance to these drugs you
are not high or impaired and you can drive
and you can work and you can love and you
can do all of these things.
What we don't understand is we think oh, you've
just substituted one addiction for another.
No, what you've done is you've substituted
compulsive behavior despite negative consequences
and now you just have physical dependence
and that's not a real problem as long as you
have a safe and legal supply.
We also have this idea that you can't provide
these medications without also providing counseling,
and we don't do that for any other medical
service.
We don't say, 'Oh, you can only get your insulin
if you do X counseling on diet' or whatever.
We realize that people need the tools to stay
alive regardless of if they're improving as
quickly as we would like them to do and forced
counseling doesn't actually help anyway.
So, what we should do is we should have different
thresholds for treatment.
So with buprenorphine some people may just
want to show up and get a dose and that's
it.
And that will work as sheer harm reduction.
That should be available in emergency rooms.
Then what we need to do is realize that you
can't make policy based on, 'I think it's
bad for you to have unearned pleasure.'
MAIA SZALAVITZ: You have to make policy based
on: Does this hurt you, does this hurt other
people?
And that's where harm reduction comes from.
The basic idea of harm reduction is: What
policy will most reduce the harm related to
drugs?
And once you start to focus on harm you have
to look not only at harm associated with drugs,
but harm associated with drug policy.
And this is why so many harm reduction people
rapidly become legalizers, because the harm
associated with drug prohibition has not produced
the results that people would like.
It does not stop addiction.
It does not prevent kids from using drugs.
It makes the kids who use drugs be at higher
risk of dying from them.
It doesn't save society's productivity by
keeping people from taking substances that
will make them not work.
It just doesn't work and when you think about
it, if addiction is defined as compulsive
behavior despite negative consequences and
you're trying to use negative consequences
in order to stop it, something is seriously
wrong there.
So our drug policy has to acknowledge the
reality that punishment doesn't fix addiction
and that putting drug users in cages does
nothing but worsen the problem, and it doesn't
deter kids.
Kids are going to do stupid risky things.
You want to reduce the chances that those
things will kill them.
The idea that we can prevent adolescents from
having sex or prevent adolescents from doing
some kind of risky behavior is just absurd.
This comes out before humans even evolved.
CARL HART: People who are young today won't
be the same folks tomorrow.
And so as new generations come about they
have to find their own way, not only with
drugs—they find their own way with fashion,
they find their own way with the way they
wear their hair.
A wide range of domains in which they find
their way, and drugs is just one of them.
It's not special, it's not unique.
You see some generations really being into
LSD or into psychedelics in general whereas
other generations are really into the stimulants.
By that same token you found that some generations
were into bell bottoms, other generations
were into straight-leg pants.
And so I think that as each generation finds
their way they will also select their psychoactive
intoxicants similarly.
JEFFREY MIRON: By trying to discourage people
using drugs and trying to discourage the genuine
unfortunate circumstances which happen sometimes
because of drug use, we incur far worse negative
outcomes, far worse cost than would result
simply from the use of drugs in a legal framework.
So, what are all these adverse consequences
of attempting to prohibit drugs?
Well, to begin with we don't actually eliminate
drugs.
We drive the market underground.
And the underground market for drugs is violent,
it's corrupt, it has poor quality control
and in the attempt to enforce it we have to
infringe civil liberties by basically shredding
the Fourth Amendment to the Constitution.
We reduce the ability of people who are sick
to use drugs like marijuana or opiates freely
to reduce pain, to relieve nausea from chemotherapy
and a whole range of other symptoms.
We interfere in other countries.
The violence that we observe in Mexico, the
profitability underlying the Taliban in Afghanistan.
All those result from the fact that we've
driven drug markets underground and so terrorist
groups make a profit by selling their protection
services to the drug traffickers.
The drug traffickers get protection and the
terrorists get profits, so that's another
ancillary cost of trying to wage the war on
drugs.
So my view is that if we had a fully legal
market for all of these substances we would
observe roughly the same set of things we
observe now for alcohol, for caffeine, for
tobacco, for other products which can be dangerous.
We would see a large fraction of people use
them in moderation, use them reasonably responsible
with at most mild negatives for themselves
or for others.
We would see a small fraction who would misuse
them in bad ways but mainly they would adversely
affect themselves, not the rest of society.
And that's a far better balance, and in no
way, shape or form a solution in the sense
of eliminating all negatives, but a far better
balance than the current policy of trying
to prohibit drugs.
