Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction, by Maia Szalavitz (Hachette Go, 2021)

In a chapter of her new book, Undoing Drugs, Maia Szalavitz profiles a legendary clinic in northern England operating, oddly enough, during the administration of Margaret Thatcher. There, people with heroin and cocaine problems could get doses of those drugs prescribed by a doctor. The program’s director, Dr. John Marks, had a detached, psychiatric view of addictions. He described them as “repetitive behaviors that people… involuntarily choose to pursue, called obsessions or compulsions.” 

The clinic, in a town outside of Liverpool, was conducting research into drug-related crime rates: Would an accessible, regulated drug supply reduce crime, compared to a neighboring town that had no such program?  The results showed ancillary benefits, like more stable employment and better overall health. Even more counterintuitively, the rate of new addictions seemed to be reduced as well.

That clinic is a long way from the United States, both physically and metaphorically. In 2019, when Szalavitz began work on Undoing Drugs, there were about 50,000 deaths in the U.S. attributed to opioids – classic drugs like oxycodone and heroin and “synthetic” opioids, of which the strongest is fentanyl. In 2020, that number was close to 70,000, by far the biggest annual increase of overdose deaths ever. In 2022, overdose deaths are almost certain to top 100,000 for the second year in a row, with two-thirds of them coming from synthetic opioids. 

Drug overdose deaths in the U.S. and other countries have been climbing steadily since around 1999, with sharp increases in heroin overdoses starting around 2012. As states cracked down on prescription painkillers, addicted people resorted to heroin and black-market pills. Heroin use jumped as prescription pill supplies plateaued, making them more expensive on the street. Many applauded the prosecution of doctors whose opiate prescribing was deemed by law enforcement — not medical experts — to be too nonchalant. But erratic procurement and unreliable dosage both increase the risk of overdose. And overdose deaths by all drugs continued to rise. In other words, we made it worse.

In this respect, Undoing Drugs is both right on time and a decade too late. Szalavitz, a neuroscience journalist, writes about why and how people use drugs. In columns for Time, Scientific American, WIRED, and the New York Times, among others, she criticizes journalists and editors for reinforcing stigma and misconceptions with terminology and misguided moral emphases. 

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Szalavitz has been banging her keyboard for a long time, producing books about how policymakers and media have ignored evidence and expertise about addiction and trauma in favor of top-down, punitive approaches.

One way of treating opioid addiction that is non-punitive and evidence-based is medication-assisted treatment, or MAT (also called medication for addiction treatment). In this approach, a primary care doctor prescribes drugs such as buprenorphine to stop or control cravings, along with counseling and cognitive behavioral therapy, to treat opioid addiction. Although the government tends to put MAT in a different service category than, say, needle exchanges, many activists group it with harm reduction and a broader continuum of care.

Harm reduction – an evidence-based approach to addiction – is Szalavitz’s area of expertise. With Undoing Drugs, she tells its history. Originally a strategy devised by activists to slow HIV transmission among injection drug users, harm reduction evolved into a philosophy, an activist network, and a public health principle founded on the idea of “trying to keep people from getting hurt, rather than attempting to stop them from getting high,” as Szalavitz preached in a recent article.

Szalavitz gets readers to imagine the pain we could have been spared if we strained the moral judgments out of our approach to addiction and simply tried to keep people alive.

This uncomfortable adjusting of lenses is one tool Szalavitz uses to get readers to reexamine entrenched personal beliefs and to face hard truths — to imagine the pain we could have been spared, if we strained the moral judgments out of our approaches to drugs and addictions, and simply tried to keep people alive.

Because the book catalogs how the repeated sounding of alarms fell on deaf ears — it was 2017 before the government pronounced the opioid epidemic a “public health emergency” — it evokes And the Band Played On, reporter Randy Shilts’ meticulous chronicle of the early AIDS epidemic.  Both books detail activists’ struggles to change an insidious narrative that separates people into different moral categories: some are worth saving, others are not.

A powerful accounting of missed opportunities and damaging misconceptions, Undoing Drugs profiles key characters and local organizations that spawned channels of harm reduction between demographics: gay and straight, Black and white, and, in the case of a Lands’ End heiress who funded harm reduction’s first major national organization, rich and destitute.

The author focuses on injection drug users not only because of their decimation by AIDS, but also because needle exchanges; naloxone, the medication that reverses opioid overdose; and maintenance treatments like methadone and buprenorphine, are all harm reduction strategies that history has borne out as inarguably life-saving.  

Overturning the myths of needle exchange

Harm reduction takes many forms, but the program that put it on the map was the needle exchange.  Early in the AIDS epidemic, case reports of injection drug users presenting with a strange new and deadly virus went ignored by major medical journals and health institutions. 

Like gay men in the same cities, drug users were unknowingly contracting AIDS, but had significantly fewer resources. Szalavitz, addicted to heroin and cocaine at the time and injecting daily, knew that drug users did not want to die of AIDS or anything else, but they didn’t know how they could avoid it if they couldn’t quit injecting drugs. In a word, they felt powerless. 

The basic idea [of harm reduction] is that, regardless of whether people continue to use illegal drugs or engage in other problematic behaviors, their lives have value.”

Maia Szalavitz

A few key players – including one charismatic gay man who also happened to use drugs –   eventually convinced the well-organized ACT UP advocates to address the safety of people at risk of contracting HIV due to their addictions.

HIV, nearly 100% fatal before treatments existed, was far more deadly than COVID-19. When the public understood how HIV was transmitted, normal social conduct continued, including sex and drugs. Either out of naiveté or Puritanism, some authorities touted sexual abstinence as the only way to avoid AIDS, ignoring the well-established inclination of humans to seek pleasure. “In fact, one of [harm reduction’s] key concepts is the ‘abstinence violation effect,’ or more colloquially, the ‘fuck it’ response,” Szalavitz writes. The ideal of abstinence can create new risks and breeds self-defeating shame. 

She refers to an activist who designed a workshop for gay men called “Eroticizing Safer Sex,” to help men break a cycle of “celibacy interspersed with sprees of high-risk sex. He had recognized that the same binge pattern found in addiction relapses also occurred in gay men who had tried to take a total abstinence approach to sex during the HIV epidemic.” 

Sometimes, stories from the past serve to demonstrate that we have progressed somewhat as a society. Contrary to assumptions by medical professionals at the time, it is now widely accepted that injection drug users prefer to use new needles than to share with their friends.

Ironically, many who led harm reduction efforts agreed with axiomatic twelve-steppers that abstinence is the only (or best) way to live a productive life, one drink or hit is “too many,” and that addicts are powerless over their substances.

One important activist, the son of a fundamentalist preacher, found harm reduction through his involvement with ACT UP and went on to co-found Housing Works, a program for people with AIDS and drug addictions that offered stable housing regardless of addiction status. He espoused the tenet of harm reduction that “if you can’t keep people alive, you’re never going to be able to help them into recovery,” but soon observed that tenants had issues more pressing than quitting drugs. Housing Works “evolved to recognize that other outcomes like decreased or less chaotic [drug] use and improvements in health also counted and mattered.” 

Rethinking approaches that don’t work

In the 2000s, Finland realized that it had a major problem with homelessness, one that seemed intractable. But when the country’s leaders rethought their assumptions and agreed that people did not have to be drug- or alcohol-free to live in subsidized housing, Finland was able to solve its homelessness problem. Part of it involved creating more affordable rental housing and using its existing stock of government-subsidized social housing, but the biggest accomplishment was agreeing that housing is a fundamental human right and should be the first step to solve other problems, such as unemployment or drug addiction – not the last.

Being able to step out of the shadows into a circle of relative safety is another important step. Szalavitz interviewed clinic patients in the innovative clinic near Liverpool decades ago, and she uses their experience to make an argument: that the security of knowing when and where a user will get the drug they need, and being able to rely on its quality, removes a big part of the stress that fuels the addiction cycle. The independence it begets allows people to make plans for their lives beyond drugs.

Back in America, the modern war on drugs had started in 1971 and reached a fever pitch in the 1980s and 1990s, dictating harsh mandatory sentencing and increased penalties for even minor drug crimes. The result was that more than two million people were put behind bars by the early 2000s – with Black and Latinos hugely overrepresented. Mass incarceration of Black Americans, largely for nonviolent drug offenses, led to chronic unemployment and ruined lives and sent inmates’ families into deeper hardship and despair. 

Szalavitz traces the history of America’s “war on certain drugs” from the 1914 Harrison Narcotic Act, through Nixon-era anti-hippie zealotry, to Reagan’s political manipulation of the CIA-fueled crack epidemic. Still gaining ground during the Clinton years, “Just Say No”-style messaging created a new cultural legacy that shaped the way mainstream society views people who use illegal drugs, and even the way we view ourselves – at least the part of so many of us that craves, seeks, or depends on drugs. 

She encourages readers who only consume legal substances to take stock of the drugs in their own veins, from coffee to alcohol, and think about how different life would be if those drugs became illegal. As an example, she invokes a period during the Ottoman empire in which coffee was banned; coffeehouses, the sultan feared, fomented class revolution. 

The modern history of opiate consumption is a more elusive tale. The neurobiology of opioids places them among similar “love chemicals,” naturally produced from mother-infant bonding and familial affection. When people depend on opioids to maintain a feeling of well-being, they are — like pain patients — treating an affliction; experts such as Dr. Gabor Maté know that most frequent opiate users have suffered childhood trauma, sexual abuse, or both.

“Physical and emotional pain blend inside the brain,” Szalavitz writes. “The sting of social rejection literally activates many of the same regions that respond to a bee sting.” Being cast out and excluded from decisions about your own life makes addictions more severe. 

What’s missing from the public discourse

In the chapter “Undoing Pain Care,” Szalavitz makes points that are strangely absent from most public discourse about opiate addiction.

By the time public health institutions and the media expressed alarm at rising opiate addictions, pharmaceutical companies had already flooded the market with powerful painkillers. Data show that more prescription opioids were being consumed by young people and street buyers than by the patients for whom they were prescribed.  

One could be forgiven for blaming the whole mess on the greed of a few pharmaceutical companies, but Szalavitz makes a strong case that the reaction to the overprescription of opiate painkillers made things worse. States going hard after those who prescribe opioid painkillers got the “chilling effect” they intended – opiate prescriptions declined sharply, and overdoses implicating opiate pills started to plateau. Foreign suppliers and counterfeiters seized on the new scarcity of prescription pills, and people who depended on opioids for years entered a more dangerous situation. The dam on opiate prescribing did a good job of leveling out prescription opioid overdoses, but it diverted the flow of opiate demand to the black market. Heroin overdoses soared. 

But the worst was still to come. However you crunch the data, blame won’t do anything about the situation we find ourselves in now. It is hard to overstate how much the landscape of drug use in the United States has changed in the past several years, and how dangerous even occasional drug experimentation has become, with the sheer diffusion of fentanyl into the drug supply. Fentanyl – and its increasingly potent compounds – is so cheap and insidious it has public health experts feeling nostalgic for the days of black tar heroin.  

In 2016, deaths caused by fentanyl compounds skyrocketed to almost 20,000, outpacing all other opiates. In 2020, that number was over 56,000 – a number that climbed to more than 71,000 in 2021.

In spite or because of this epic catastrophe, Szalavitz tries to keep things upbeat by telling as many success stories as failures, and her enthusiasm is a welcome beam into the dismal panorama of overdose deaths. But she repeatedly reminds us that harm reduction, by definition, isn’t about solving problems. It’s about comparing risks and curbing the worst outcomes. 

Of course, the logic of simply reducing harm applies to every human behavior that carries risk, and it can be applied as a policy strategy anywhere people have ever tried to “cut back.” In case after case, there is usually blowback – shrill, self-righteous and wrongheaded.

Consider this case. In 2019, an old high school friend of mine, also a prominent animal rights activist and former director of the Humane Society partnered with meat producers Tyson and Perdue Farms to market meat-vegetable hybrid versions of burgers and chicken nuggets. The product was designed to appeal to meat eaters interested in cutting down on the environmental impact of beef production; if they weren’t ready to give up beef, they could still help cut meat production, by cutting the beef in each burger by 50 percent. He drew fire from vegan dogmatists as a “meat-enabler” whose collaboration with meat vendors was tantamount to treason.  

The hybrid meat campaign epitomized harm reduction. The goal wasn’t to end the consumption of animals. It was to limit the bad effects of meat consumption by cutting down on meat, burger by burger, while acknowledging that it is not realistic to expect every American to give up meat entirely.

Szalavitz does well sussing out the organizational tensions within the harm reduction movement with mottos like “Nothing about us without us.” Harm reductionists value organizers who are active or former drug users. The advocacy movement is comprised largely of people who live and work in a landscape of trauma and unpredictability; and several beloved figures in the harm reduction community have died from overdose. Szalavitz doesn’t spend time on their deaths. What’s to say? The movement suffered loss, and carried on.  

Instead, she chronicles how their work affected others, and how their lives became more meaningful by getting involved with harm reduction. The energy of activism helped many people check their most problematic drug use, even if the loneliness at the heart of addiction eventually returned to overwhelm them. Like an eternal spring from dark places, Undoing Drugs puts hope at the center of every chapter, in the form of characters and coalitions that choose to play their parts, in lieu of stealing the whole show. For Szalavitz, and the others tirelessly spreading skepticism and pushing harm reduction, that which angers you makes you work harder. 

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