Published September 30, 2021

Maia Szalavitz, author of Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction, discussed the story of harm reduction and its potential to tame the opioid crisis, mitigate future drug problems, and quell other pandemics, in conversation with Lawson Koeppel, co-founder of Virginia Harm Reduction Coalition.

Watch the video of this event here and read the transcript below:

This event was the first in a two-part series developed in collaboration with the Community Mental Health and Wellness Coalition as a part of National Recovery Month. At 4:00pm on September 30, the Coalition will host a panel discussion with local harm reduction champions, which will be moderated by Erin Tucker, executive director of On Our Own.

“The concept itself is surprisingly simple. Harm reduction applies the core of the Hippocratic oath—first, do no harm—to addiction treatment and drug policy… In essence, harm reduction is radical empathy.”

Maia Szalavitz, Undoing Drugs

“With characteristic flair Maia Szalavitz presents a vibrant personal account of recovery, a broadly researched history of how a fringe idea transformed into a powerful therapeutic and social movement, and a heartfelt, irrefutable call for a sane and humane approach to the devastation of substance addiction.”―Gabor Maté, MD, author of In The Realm of Hungry Ghosts: Close Encounters With Addiction

“One of the most inspiring and remarkable stories you will ever read. Small groups of stigmatized people all over the world pioneered a totally new approach to drugs and addiction—and they saved millions of lives. Their incredible story has not been told—until now. If everyone in the US read this book, the drug war and so many drug myths would end tomorrow.”—Johann Hari, New York Times bestselling author of Chasing The Scream

“Deeply researched and character-driven, Undoing Drugs is vivid social history.”―The Wall Street Journal

Community Partners

Thanks to our community partners for this event: Community Mental Health and Wellness Coalition, Virginia Harm Reduction Coalition

Transcript

JANE KULOW:   Hello, and welcome to Shelf Life, from the Virginia Festival of the Book. I’m Jane Kulow, Director of the Virginia Center for the Book, a program of Virginia Humanities. Thanks for joining us.

A couple of notes before I hand the program over to our speakers. Please share your questions using the Q&A tab on Zoom. This event has optional closed captioning, which you can turn on and customize at any time with the Closed Captions tab at the bottom of your window. If you haven’t already read today’s book, we hope you will. For details about how to buy it from a local bookseller or check out a copy from your library, visit VaBook.org, where you can also explore our schedule of upcoming programs and watch past events. While you’re there, please consider making a donation to support the Festival’s ongoing work at VaBook.org/give.

Today, we appreciate the opportunity to partner with the Community Mental Health and Wellness Coalition and the Virginia Harm Reduction Coalition to present this discussion as a part of National Recovery Month. Today at 4 p.m. the Community Mental Health and Wellness Coalition will host a panel discussion on harm reduction, featuring local advocates and organizations. Please see their Facebook page or the link in chat to register for that discussion. And we want to thank Ting for supporting our virtual programming.

Now, I’m pleased to introduce today’s speakers. Maia Szalavitz, author of Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addition, is an award-winning journalist who specializes in science and health. She is the author of Help At Any Cost: How the Troubled Teen Industry Cons Parents and Hurts Kids, and she coauthored Recovery Options: The Complete Guide with Dr. Joseph Volpicelli. Maia lives in New York City, and you can learn more at MaiaSC.com.

Lawson Koeppel, with a master’s in social work, is a person in long-term recovery whose focus is on active substance use, policy, and mental health. He cofounded Virginia Harm Reduction Coalition in 2018 to prevent overdose deaths and empower people who use drugs. Since its founding, the coalition has distributed more than eighty thousand doses of Naloxone from Charleston, West Virginia, to Virginia Beach. In this year, as of this month, 3,826 funerals were prevented due to that distribution. You can learn more at CarryNaloxone.org.

Maia and Lawson, thank you so much for joining us for Shelf Life. Over to you, Lawson.

LAWSON KOEPPEL: Thank you so much. Glad to be here. And I want to thank Maia. I think there’s a personal thank you to her as well for her book Unbroken Brain and the work that she’s done prior to Undoing Drugs, which set me in my path in harm reduction. And I thank you for that.

MAIA SZALAVITZ: Thank you.

LAWSON KOEPPEL: All right, Maia. So I want to start with this. You’re in an elevator with a policymaker who has a magic wand. They have no idea about harm reduction. What do you say to them? What’s your elevator speech about what it is and why it’s important?

MAIA SZALAVITZ: Sure. So harm reduction is the idea within drug policy that we should try to stop people from getting hurt and not try to stop them from getting high. And this is critical because what we have currently been doing is trying and failing to stop people from getting high, which we have done from before we even evolved into humans. Like animals do it. So this is a thing that can’t be stomped out. Every culture has it. The best way to deal with it is the way we deal with other risky activities like driving or skydiving: we create ways of making the behavior safer for the people who are inevitably going to do it.

LAWSON KOEPPEL: Why is this a radical idea?

MAIA SZALAVITZ: It shouldn’t be a radical idea, but we’ve been sort of brainwashed by the war on drugs for about a hundred years now. And the reason I call the book Undoing Drugs is because we have this concept that there are these evil things called drugs, but there’s also alcohol and caffeine and tobacco, and those aren’t drugs, even though they obviously are drugs.

And so when you look into the history of why we have the drug laws that we do, it turns out that basically the answer is racism and anti-immigrant sentiment. Because the drugs that were preferred for their own use or for sales by [unintelligible] people basically were the ones that became legal and profitable and commercialized, and the rest of them were either limited strictly to medical use or banned entirely. And as we can see from having the world’s worst overdose crisis at the moment and our worst ever in history, this has not been very successful in preventing what I think most people really want to prevent, which is harm. Like I really don’t care if you’re euphoric. I mean, it’s nice for you and good for you and whatever. But as a policymaker, I shouldn’t be concerned about your pleasure. I shouldn’t be trying to mess with that. What I should be concerned about is are you getting hurt, are you hurting other people, and what’s the best way to minimize that damage.

LAWSON KOEPPEL: Everyone deserves [unintelligible] actions or their choices.

MAIA SZALAVITZ: Sorry, for some reason that broke up.

LAWSON KOEPPEL: All right, I apologize. I said—kind of you touched on a point that folks had asked prior to this, in terms of folks I was asking about questions for you. One of the things that folks wanted to focus on is that race aspect. And you say tragically American drug [unintelligible] in an effective way of managing problems with [unintelligible].

MAIA SZALAVITZ: I’m not sure if it’s me or you, but I cannot—you’re breaking up badly.

LAWSON KOEPPEL: —through today.

MAIA SZALAVITZ: There seem to be some technical difficulties. Hopefully this is being sorted out right now.

LAWSON KOEPPEL: All right. Is this a better connection?

MAIA SZALAVITZ: Yes, that sounds a lot better.

LAWSON KOEPPEL: Outstanding. So when I was breaking in and out, one of the things that I got asked when I was looking and talking to folks about this conversation was about race. And you touched on it. And in the book, you said tragically American drug policy has always been more a tool of white supremacy than effective intervention. I was going to see if you could talk a little bit about the way—the role race played from I think 1914 to the policies that we have today in our approach to drugs and substance use.

MAIA SZALAVITZ: Sure. So politicians realized pretty quickly that if they could scare people about substances that were being taken by people that they were frightened of or hated, that this was a really good way to control them and to corral them without explicitly saying that we’re doing a racist campaign. And there are certainly people who genuinely believe that anti-drug crusades are the way to go and that prohibition is effective and that jailing people is the way to solve addiction. But that is not where our policy—those things are not true. Our policy doesn’t work in terms of that. And what it does work to do, as Michelle Alexander pointed out in The New Jim Crow, is that it gives police and others a way to search Black people and Brown people, to lock them up, to make them frightened, to make them submissive basically, as much as possible.

So the whole way we see this—if our goal was to stop addiction, why don’t we use jail for like dieting? Why don’t we lock people up if they have a doughnut if they’re diabetic? Why don’t we take rich people and put them in prison, if this is such a great way of reducing drug problems? What it really is is a way to stigmatize a group of people without explicitly naming that that’s what you’re doing. And then everybody else—I mean, in my own person story, I was arrested for selling cocaine when I was in my twenties. And I was facing in New York a fifteen to life sentence based on the cocaine that I had. And I did not get that, and part of the reason is that our system works out ways to spare privileged people. And that is wrong, and that is why I’ve been doing this work ever since.

It’s very hard for people to see this because so many people well intentionally thought that these drugs are dangerous, we need to keep them away from our kids, we need to protect our kids, and so they bought in to this. But when you look at what actually works to reduce harm in terms of drugs, it is not prison. It is not criminalization. And pretty much we do the opposite of what works. Because what we learned via harm reduction is that, like any other human beings, people with addiction respond really well to kindness and respect.  And that if you give somebody something like a clean needle or a dose of Naloxone and you say, “Look, I’m not judging you. I would probably prefer that you be healthier. But my point here is only to keep you alive. And you’re valuable, and you matter.” And that is much more powerful in terms of actually getting people to change their behavior than telling them that they’re a piece of crap.

Because by the time people are injecting drugs, they’ve been told that message probably since they were infants. And in fact, one of the best ways to cause addiction is to abuse and neglect children. So if you want to prevent it, the idea that more abuse would work is just pretty silly.

I think we’re having technical problems again.

LAWSON KOEPPEL: Is this any better? I apologize, y’all. I’m trying.

MAIA SZALAVITZ: No worries.

LAWSON KOEPPEL: So I wanted to talk a little bit about that. So you write about your experience kind of going in the first time and seeing what harm reduction was, handing out syringes. And I think we’ll talk a little bit more about the Minnesota Model and twelve-step things. But I think that moment where—you mentioned that folks would be afraid that that would be a trigger for you. And you don’t describe it that way. Tell me what you saw and how you felt when you first walked into that space.

MAIA SZALAVITZ: Right. So by the time needle exchanges existed in New York, I had been in recovery for a couple of years. And I wanted to be a journalist, and I wanted to get the message out to people. Because somebody had taught me to use bleach to clean my needles, and that probably is the reason that I’m here today and reasonably healthy. Because in New York at the time when I was injecting, 50 percent of my fellow IV drug users were already HIV positive, including the guy I was about to share a needle with when somebody taught me that I was at risk.

So I already knew that harm reduction was a good idea, but I was in twelve-step programs at the time, and I was repeatedly told avoid people, places, and things that are associated with your addiction. So, yeah, I was nervous going back to a neighborhood where I had bought drugs and to see people actively using and to witness all of that. But I was also firmly committed to not being a robot who sees a needle and picks it up or to being Pavlov’s dog or whatever. I knew that my purpose there was more important, which is to try to get lifesaving information to people.

And when I saw what was going on, it really moved me. Because here you have people that everybody else rejects. A lot of them are unhoused. A lot of them are really poor. A lot of them are very disabled in many ways. And yet here is somebody who, at that time, who were risking being arrested in order to try to save their lives. And the people just couldn’t believe that anybody would actually do something so crazy. And it was just incredible to see how much they wanted to protect the people who were doing the needle exchange and supported them and were moved by them. It was just a kind of spiritual experience in that sense because it was so pure. It was just an act of I want to help you, I don’t want anything back—all the kinds of things that we think about when we think about good religious or spiritual people. This is what you saw in real action—like kindness right there.

LAWSON KOEPPEL: That’s amazing. And I think that’s also some of the biggest conversions that we have—are folks seeing that engagement and that level of help and that level of meeting somebody where they are. And we’ll talk a little bit about those things too.

MAIA SZALAVITZ: Sure. Go ahead, sorry.

LAWSON KOEPPEL: I wanted to kind of talk about that piece for you. You start the book by finding the person or at least the organization or the place where that had come from, right? You attributed it just now to helping you be here. So tell me about tracking that down. Was that important to you? Was that a personal piece?

MAIA SZALAVITZ: Yes, it seriously was. So this woman who, at the time, all I knew was that she was a friend of my friend David, who had gone out to score heroin for us. And David, I later learned, had AIDS. Not at the time, but he developed it relatively soon thereafter.

Anyway, so he was going to try to get into rehab, and she was basically there—I didn’t know she was his girlfriend. But she actually was his girlfriend from when he’d lived in San Francisco. And her role was basically to try to get him into rehab.

So all I knew was that basically she was like a white woman who was roughly my age, and she was from San Francisco, and she knew my friend David. So that was not a huge amount to go on.

On the other hand, she possessed a very, very rare thing at that time, which was that most people who would be there to get a friend into rehab would’ve been, “Just say no. You must stop now. You’re at risk for AIDS. You’ve got to stop this.” They wouldn’t have been able to give me any practical, lifesaving information and wouldn’t have thought that was a good idea. They would’ve thought they were enabling me to use more.

So I knew that she had this rare, specialized information, and so that meant I was able to track down the group of organizations for which she may have worked. And then through a lot of emails and phone calls to people who worked at those organizations, I was able to work out who she was. I really still want to actually meet her in person. The pandemic has prevented that so far. But just on the phone we both cried. Because for me, obviously I was very grateful to this woman who’d saved my life, and I wanted to tell her that. And to her, hearing that—it’s like you often—even as a writer, you very rarely get to hear about the impact you have on people. When you said that in the opening before, it just really moves me. Because like so many times as a person who has addiction and has had depression, you feel like you don’t matter. You feel like what you do doesn’t do anything, and you’re just treading water, and you’re never getting anywhere.

So when you can give someone the gift of thanking them for these kinds of things, it’s remarkable. So it just reminded me of that thing with the starfish, where you have this little kid by the sea, and there’s all these stranded starfish, and she’s throwing them back in. And an adult says like, “Why are you doing that? You can’t save all of them.”

And she’s like, “Well, it matters to this one.”

And that really is the essence of harm reduction. If you save one person, you are saving an entire world. And you don’t know what other wonderful things they may be giving to the world. So one of the tragedies of our war on drugs is just that we throw away so much human potential by just thinking that people who use drugs are worthless, and they should either be dead or in jail.

LAWSON KOEPPEL: And I think folks who are outside the work of harm reduction don’t realize often how hard it is. And that gratitude from that piece, being part of the community, matters. It matters a whole lot. And that happens frequently. And that I think is part of having somebody on site—would be part of that changing mindsets to see that it’s a reciprocal piece, that it’s not just a provider and a participant in the community.

MAIA SZALAVITZ: Yeah. And when people aren’t valued, they just see themselves so terribly. And one of the worst parts of addiction is not only hating yourself but hating yourself for hating yourself. And just getting sort of caught up in that whole hamster wheel.

And it’s interesting because when you go to a needle exchange and you don’t know what’s going on—you see people who are clearly in some distress and who are not generally very healthy, and they are getting these needles and talking to people or whatever. And you would think that this might put people off or make people feel like this terrible, look what they’re doing, they’re not helping them. But you can see by the interactions that people are being helped and that recovery is a process—it’s not an event. And that really, when we change any kind of behavior, like if you try to go on a diet or change your exercise or whatever, it’s hard. And that’s not even an addiction. With diet, maybe. But with actual drug addictions, this behavior is ingrained because you have learned it. And you’ve learned it because you were trying to solve a problem within yourself. And obviously when you get to the point of addiction, it’s not working. But unless you can untie that knot and untangle those threads, you’re not going to be able to get into recovery. And that’s going to take time because the drugs were your way of coping, often with severe trauma or mental illness. And so in order to change that, just as it takes time to learn any skill, it takes time to learn recovery and to just move towards the best version of yourself that you can be.

LAWSON KOEPPEL: And I kind of what to move into that—so that reminds me of Dan Bigg saying humans are really bad at perfection, but we’re pretty good at getting better, right? And we talk about any positive change. So one of the things I want to talk about then is the movement and the individuals in the movement. As a harm reductionist, this was literally the family album. “Oh, this is what so-and-so did.” The stories I knew of but didn’t have documented.

So talk about the importance—you do a good job of highlighting it—the importance of people who use drugs being part of this movement and building it in substantial ways.

MAIA SZALAVITZ: Yeah. So from the very beginning, the very first needle exchange in the world was founded in Rotterdam by a man named Nico Adriaans, who was a person who used drugs. And in Liverpool, when their first harm reduction was coming into action, including needle exchange and prescribing heroin and all kinds of things like this, active drug users were very central to the theory and the practice of what became the movement. And the movement itself really begins in Liverpool, where they coined the term, and they defined it, and they came up with a way to package all these things that seemed, oh, we’re giving heroin, oh we’re teaching wound care, oh we’re giving needles. Like it kind of seemed like these were different things. And they were like, no, the goal here is reducing harm, and this is part of an overall strategy that can really change drug policy for the better. Because, really, if your policy is working, it should be reducing harm. And if your policy isn’t working and you need an alternative called harm reduction, maybe you’ve got a problem there.

So this was very apparent to opponents of harm reduction from the very beginning. That once you kind of let it be known that we’re not going to be able to kill people as examples to others anymore and that this is actually not a really good thing to do, that sort of the good guys and the bad guys flip. Because you have these crusaders who were helping the children, who were saving people from the depravity of addiction. And then you have people who are like, well, wait a minute, what are you doing? You’re incarcerating people. You’re making them homeless. You are not providing any actual addiction treatment. And you’re not deterring the kids anyway. So then somebody comes along and says, no, we don’t need to reduce highs; we need to reduce harm. And all of a sudden it’s like common sense.

LAWSON KOEPPEL: And those harms are often—most of those harms are based on policy. The idea of incarceration. The idea of not being able to get employment after that. There are harms, right? And I think having that honest conversation about substances and about drugs—there are harms, and there are ways to avoid those, or at least try to reduce those. But I think what we don’t do then is—anyway, I apologize. I kind of trailed off there. I wanted to continue talking about some of those folks in the movement. I think the most popular we see is Dan Bigg, but I wanted to see if you could talk a little bit about Dave Purchase, setting up something for the first time here in the States.

MAIA SZALAVITZ: Sure, sure. So he was out in Tacoma, Washington, and at the time he was on disability because he’d had this sort of horrible series of accidents, where first he had a motorcycle accident. And then just when his leg was healed from this, a building next to him blew up. So he at that point was kind of hobbling around. But he had the money and the time off, and he realized that the people that he worked with at the methadone clinic were at risk for AIDS, and some of them were becoming  sick. So he looked at what can we do about this and found that needle exchange is the thing to do. So he went, and he set up a little kind of TV dinner table, and he put out some syringes.

And the thing about Dave Purchase was he was this kind of guy that could get along with anybody. So whether it was like his fellow motorcyclists or Hell’s Angels or motorcycle kind of people or it was like the health department, people liked him. So unlike on the East Coast, he was able to get the health department to buy in and to support his work and to not oppose it and to not make a big political “oh my god, you’re enabling the addicts” thing over it. He knew the people, he did his thing, and within I think a few months, he was getting funding from the health department locally in order to provide this lifesaving information.

I think you’re muted.

LAWSON KOEPPEL: I am. 

MAIA SZALAVITZ: Don’t worry, all good.

LAWSON KOEPPEL: So again, as a harm reductionist, I’m trying to reduce the harm of me taking notes. But as a harm reductionist, this is what I was I think talking about, with seeing this as a family book, right? So there’s Dave Purchase, and then Comer comes in to fund that. I purchase our supplies from the Dave Purchase Project. We have funds from the Comer Foundation—the Chicago Community Foundation. And that’s kind of the fun, as somebody in the field kind of working through this and seeing the connections that were made that I knew about but weren’t documented.

MAIA SZALAVITZ: That was part of both the work and the fun of doing this book. Because I knew all these disconnected pieces, but I didn’t know all of them. And one of my biggest worries throughout this whole process has been that like there were lots of people I had to leave out, and I felt terrible about it, but it would not have been a readable book if I put everybody in.

But anyway, yes, Stephanie Comer is amazing. And she’s like this heiress to like Lands’ End money, which is this kind of Waspy, yachty kind of thing. And then here she is, like one of the few people who’s willing to fund this thing that nobody else wants to touch. Because for a while, until very recently, there was a federal ban on funding for anything to do with syringe exchange. Now I think it’s down to we can fund it, but we’re not going to fund the actual needles or something stupid like that.

But anyway, yeah, so there were all these people doing all these different things, and I’m still learning about—for example, I couldn’t figure out during my research process how bleach got from San Francisco to New York. And I now believe I have found this out because Sam Friedman told me that, in fact, it happened because of connections between NDRI, where he worked, which had connections with Yolanda Serrano and Edith Springer. And they actually were explicitly told by the San Francisco folks directly.

But, yeah, just like finding out how did this one meet that one. And also like a lot of stuff happened at conferences, and nobody can remember anything. So this was also like a research challenge. And part of the reason I realized that I had to do it as quickly as possible is because none of us are getting any younger, and it’s dangerous out there, and we’ve lost a lot of people, and we don’t—I wanted to give people a sense of their family history and of the people that have come before them.

And also one of the amazing things was just that I found that we actually have made progress. Like when you’re out there doing the day-to-day work, it’s really, really hard to see because you’re constantly running into obstacles. And yet if you look at where harm reduction was in the nineties, where you wouldn’t even dream of marijuana legalization, syringe exchange was illegal, the government was opposing it—in fact, the government was sending people to UN meetings to stomp out the term harm reduction. Now we have Biden saying this is what we want to do, and we want to support this. We’ll have to hold him to that. And the CDC goes to places that don’t want to have needle exchanges and tries to talk them into it, rather than the reverse.

So although obviously and especially in the South there continue to be huge obstacles, I think one thing you can get from reading the book is that we actually are getting somewhere. It is much lower than it should be, and we still have a really long way to go. But we have moved the needle, for lack of a better term.

LAWSON KOEPPEL: I like that. And it is difficult, I think, on the day-to-day basis for folks in the field to see those things, to see that progress. We’re able to see the narratives and the anecdotes of individual lives that are touched. And I think that that’s kind of the two audiences, right? We see the social justice piece of engaging with humans regardless. And then there’s the public health piece. And so we get to see the social justice piece on a daily basis. What we don’t get to see always are those numbers, whether they’re going down, in the right—you know, things that are of interest to our community. And that’s good to hear from you because most of the—one of the things that sold me on Unbroken Brain were the citations in the back. So it’s good to hear from you that things are moving.

MAIA SZALAVITZ: No, it’s really—again, it can be just so hard to see in your daily work. And one of the things that I’ve been thinking about—and I have an article coming out about this in The Atlantic at some point—is sort of how did we go from all the politicians saying, “Rah, rah, rah, drug war,” to, “The drug war—we can’t arrest our way out of this,” and blah, blah. Because when you were in that change, you didn’t see it happening. But now, if you look at comparing say the Democratic presidential debates now to the nineties, it’s just like 180 degrees. Now this doesn’t mean that they’ve actually changed the policy, but at least they’re saying better things.

LAWSON KOEPPEL: So on that piece, why is cannabis decriminalization important? I think you talk about that—about why that step is important.

MAIA SZALAVITZ: Sure, sure. So for one, the sky doesn’t fall. People legalize marijuana, and it does not become a party of two-year-olds running around smoking joints with screaming axe murders. So it just—it doesn’t—all the things that the prohibitionists warn about don’t happen. The second thing is that, because marijuana is less harmful than alcohol and tobacco, it makes visible the ridiculousness of the drug laws in general.

Also, when you legalize marijuana and you realize that locking people up for possession of marijuana does not prevent them from becoming addicted and does not help them if they already have an addiction, then you start to think why would putting someone in a cage for heroin work, either? I mean, that’s kind of harder to kick, right?

So it works on many ways to show that harm reduction is a good policy, and it can be done, and the things that it says are actually true.

One of the things that I was struck by throughout this is because harm reduction always had to fight for every little thing that it got, we had to have a strong empirical base. So the literature on needle exchange is just solid. It’s one of the most supported interventions in public health. We’re getting similar data on Naloxone now. And there has certainly been data on prescribing methadone and buprenorphine and even heroin for many years now. So all of the things that people who are in harm reduction say reduce harm, we can also show that they do. I mean, the needle exchange thing is just quite—again, to see the progress where like in New York when I was injecting, 50 percent or more in some neighborhoods of IV drug users were already positive. And now it’s like 3 percent or less. So this can be done.

LAWSON KOEPPEL: I think somebody—I can’t remember what the statement was, but they were talking about the back end of drug reform is boring. All the things that we’ve been warned about don’t happen. And it’s the getting there that’s the struggle.

There are so many places to go with everything you’ve said in this book, but I want to talk about the term recovery. I want to talk about CRA and the reason why the language there was so important and kind of the way that was built and why. And the effectiveness that it had.

MAIA SZALAVITZ: Sure. I actually just wrote a piece about this for Time. And one of the things that I was arguing in it is that there are so many different ways to recover. Just as there’s a zillion different ways to get addicted, there’s a zillion different ways to recover. And Dan Bigg and John Szyler of the Chicago Recovery Alliance realized very early on that not only did they need to redefine addiction and redefine drug policy, but they also needed to redefine recovery. And that was really important because, for example, there has historically been this clash where people whose recovery is abstinence only see things like needle exchange or methadone or buprenorphine as enabling people to continue their addictions instead of helping them to become healthier. So that clash and sort of allowing recovery to be owned only by abstinence was clearly a problem. And this remains a problem because, unfortunately, some twelve-step programs—not all, but some of the most relevant ones (Narcotics Anonymous, most notably) tell people on medication that they are not clean. And I won’t even get into the language debate. But the idea that you can be taking a lifesaving medication—the only thing we have that cuts the death rate by 50 percent or more—and people are telling you to come off because you’re not clean—this is not okay. This is actually killing people. I have heard from families who have lost people because of this kind of stuff.

So they knew they needed to redefine recovery, and they expected to have a big long argument about it because people have been having big long arguments about it for many, many decades. So they went to this Swedish restaurant in Chicago somewhere. And they sat down, and they were like, okay, we’re going to redefine recovery—what do we want to do? And nobody said anything, and then John Szyler speaks up and says, “How about any positive change, as defined by the person who’s making the change?” And nobody could come up with a really good objection or alternative. So they really had like a half-hour meeting instead of a five-hour meeting. So that was harm reduction right there.

But it became very clear that this is a really useful way to see it. And that if you can define it this way, you can really see how even before people even consider anything like abstinence or moderation, just by using a clean needle they are becoming healthier. And simply by taking actions to protect their health, they are becoming aware that they can do this and they can succeed in this kind of thing, when often they’ve been very demoralized about that. And so this is another reason harm reduction leads so clearly to positive change and does not, quote, enable people to extend their addictions.

LAWSON KOEPPEL: I just got a question from folks watching. Where can harm reduction grow, in terms of services offered that we haven’t been able to do yet?

MAIA SZALAVITZ: Now that’s a good question. One of the things that we’re seeing now is the availability of drug checking. So you can see if you have Fentanyl or god-knows-what in your drugs. That is obviously one of the sort of on-the-ground things that more harm reduction organizations should offer.

I think on a larger level—I think the next fight is really for decriminalization of possession. Because there is no way to justify criminalizing possession except for to create stigma. Because that’s the point of it. If you don’t create stigma, then it doesn’t deter people from using. And it’s not deterring people from using, even though you are creating tons of stigma. So this is not a good way of carrying out your objective if you actually want to help people, right? Nobody can give a good argument in favor of criminalizing possession other than to create stigma. Because it actually makes you more likely to die of an overdose, more likely to catch HIV, more likely to be traumatized, less likely to be employed. It takes away all of the things that we want people to have in order to get better. So it completely does the opposite of any of the things that you would want it to do.

So again, I will pay a lot of money if somebody can give me a good argument for criminalization other than to create stigma. Because it doesn’t—well, okay, I’m not paying for people saying enforced racism.

LAWSON KOEPPEL: Because that would be an easy win.

MAIA SZALAVITZ: Yeah, so, no. But in terms of a policy argument that makes sense, there just isn’t one. So we’ve seen states already start doing this, and more states are looking to follow Oregon. Again, in the nineties this was just mind-blowing. The idea that, like, of course we have to criminalize it. We have to tell the children it’s bad, and these people are bad. To move from that to we have to reduce stigma around addiction. Now part of that, of course, is because we now see addiction as affecting white people, and they have to be innocent. But we can expand that and just say we need to treat all people with addiction like human beings with a medical problem. And that will be more effective than anything else that we’re doing now.

LAWSON KOEPPEL: So much and so many places to go, and we’ve got fifteen minutes. I think that piece there, when you’re talking about race, again—Michelle Alexander. You mentioned that. The New Jim Crow. And she’s in the book several places, spread out a lot. So tell me why that was an important piece for you to kind of highlight.

MAIA SZALAVITZ: Sure. So her work obviously has had a massive impact within the Black community. And one of the things that it really did was allow people to see that prohibition is enforcing racism. And previous to that, there had been a lot of resistance particularly in the Black church, where the idea was drugs are a sin, and we need to lock them up and get harsher because drugs are destroying our community. And there wasn’t really that much of a vision of how prohibition was destroying the community. And so when she wrote that book, especially in a powerful way by telling her own conversion from thinking this idea was nonsense to thinking it really needed to be told about. She was able to bring along other people on that journey. And it was—the way the book spread throughout the Black church through word of mouth, through the community—I heard from people who talked about how they—like people in the church who talked about how they had gone from holding anti-drug rallies to going and meeting with prisoners because they realized how this whole thing fits together now. And that the only way to fight the oppression associated with this is to end the New Jim Crow, which means ending criminalization.

So once the Democrats didn’t have Black people saying this isn’t racist, they couldn’t say it wasn’t racist either. And so that sort of really led to a lot of different transformation. And meanwhile, also on the conservative side, people began to see, based on prison faith organizations and stuff like this, which conservatives haven’t gotten sent to prison for things like Watergate, they ended up really coming around to seeing that this is a problem. It’s not only that it’s expensive and ineffective, it is also racist. So this was one of the rare areas where you could have bipartisan support. And this is why we actually got—far from enough, but some criminal justice reform under Trump.

LAWSON KOEPPEL: And it is. It’s interesting—the cross there between I think the Libertarian piece of that side and the compassionate social justice piece across the aisle sometimes.

MAIA SZALAVITZ: Yeah. I think—sorry, go ahead.

LAWSON KOEPPEL: You’re good. So what I wanted to talk about is a tale of two cities, essentially. Liverpool and Edinburgh. Which Liverpudians?

MAIA SZALAVITZ: Liverpudlians.

LAWSON KOEPPEL: Liverpudlians and Edinburghers.

MAIA SZALAVITZ: Yes.

LAWSON KOEPPEL: That serves as a really good contrast on the same island for two different policies. And I think it also talks to the interventions that we aren’t able to do in the US yet. So kind of set that scene. Two cities, two hundred miles apart, taking on a task very differently, and the results are different.

MAIA SZALAVITZ: Yes. So it should be said that Edinburgh got hit first by HIV. But the reason that they got seriously hard hit—and when they first started testing people for HIV, they found infection rates similar to New York—like 50 percent. And they had a very large population of injecting drug users because the working class in the UK at the time was really under threat from Thatcher and deindustrialization and the whole austerity thing. So you had youth unemployment rates that were like 50 percent. You had all kinds of despairing responses to loss of jobs and loss of meaning and purpose. And people began shooting up. There was a lot of heroin available at the time from Iran and Afghanistan due to political situations there. And so you had this kind of perfect storm of you’ve got all these desperate, unhappy young people without jobs, and you’ve got this drug available. And, gee, I think we see something similar with opioids and people in the United States these days. But what happens in those situations is not only does the drug give the people who are using it some kind of comfort—obviously it does harm as well—but it does something for them, which is why they started. So not only does it do that, but it also gives people a way to make a living. And so when you have those two things combined, it’s very, very difficult to interrupt, as we’ve seen with what happened with opioids here. And we very dumbly went from let’s just cut the medical supply—that won’t do any harm—and like, gee, now we have lots of heroin, and gee, now we have Fentanyl.

So anyway, Edinburgh. So there were these young white people who—young couples—sixteen, seventeen, eighteen—who were HIV positive. And what had they done before they discovered this high HIV infection rate? Well, basically they were freaked out by the fact that so many young people were injecting, so they tried to clamp down on the needle exchange. They decided that the only way for people to recover would be abstinence, so they cut their methadone program, and they started arresting more people. And all of this caused a shortage of needles, which meant that HIV was very efficiently spread.

So Liverpool looked at this, and they had a huge population of injectors for the same socioeconomic reasons, but they didn’t yet have any HIV. And so they knew that they had to act quickly if they weren’t going to replicate the same thing. So they basically said, okay, we got to do the opposite. We’ve got to expand methadone; we’ve got to prescribe heroin. Because they had a guy who was already prescribing heroin: John Martin.

LAWSON KOEPPEL: So wait a minute. Prescribing heroin. Explain that to me. If I prescribe heroin, don’t all the folks kind of become useless and die? Like isn’t that what happens?

MAIA SZALAVITZ: No, so what is really kind of pharmacologically unique about opioids is that if you take a steady dose—the same dose every day at the same time—you will become completely tolerant to the psychoactive effects. So you’ll be able to drive. You’ll be able to work. You’ll be able to do everything like that so long as you don’t take erratic doses.

So if you have a safe supply, basically, you can do your job, be with your family, raise your kids—whatever you need to do. So this is very hard for us to believe because sort of the way we got methadone in this country in the first place was that we pretended it blocks the high. And there is actually a drug that blocks the high, but no one wants to take it because it also blocks your natural endorphins. So anyway, it was sold to the public that way because of laws resulting from 1919 or so, where the Supreme Court decided that prescribing for maintenance—just keeping people on the way they were doing in the UK—was not real medicine and could not be a legitimate medical purpose. And so in order to sneak back in these maintenance medications, we basically had to say they blocked the high.

But I think that is a mistake, and it’s done enormous harm to pain patients who can function perfectly fine on their doses of opioids until the government decides that, no, you can’t have this anymore because people are overdosing. And then of course that doubles the overdose rate. Because of course driving people to street drugs or suicide is not an effective way of treating either pain or addiction.

So Liverpool had heroin prescribing because the British in around 1919 or that same period—they went in a different direction. They said, yes, it is legitimate medicine to prescribe heroin, cocaine—whatever the person is using—to stabilize them. And until the sixties, this worked really well. The only people with addiction were basically kind of older working people who had encountered the substances either through medical use or through being part of a drug store robbing gang. But in the sixties, drug use just became so much more popular in all its forms that this completely broke down. And instead of realizing that, well, this is a social factor that is affecting our system, they blamed that system for it. Even though, of course, the sixties happened worse in the United States, when we didn’t have prescribing anymore.

So anyway, the bottom line was that Liverpool did have some remnant doctors from the twenties or people who had taken over from them still prescribing. It was still legal. It was never made illegal. And so they were able to expand that. When they were threatened by HIV, they were able to expand methadone access. They were able to do needle exchange and really get the whole country behind a policy of harm reduction. Like Thatcher basically backed it as of 1988 because she realized that you would see things like Edinburgh in many cities. And that, even if you didn’t care about the people who use drugs, they looked like everybody else. They could have sex with people. So as horrible and racist as that is, that is why the UK was able to respond to AIDS in a way such that the Edinburgh—there have been a few other outbreaks, but they never had 50 percent HIV infection in large populations of IV drug use. In fact, in Liverpool the HIV rate among IV drug users is the same as the population rate in the United States, which is like 1 percent. And it didn’t go higher than that. This statistic may be a few years out of date, but I haven’t heard about any HIV outbreaks there, so I think I’m probably safe still using it.

LAWSON KOEPPEL: So I have—we’ve got five minutes. I have so many other directions I can go. But for you, what are some of the important things in this book that folks should take away?

MAIA SZALAVITZ: I just think that people should recognize that harm reduction is about kindness and is about treating people well, and that whether it’s somebody with an addiction or somebody without an addiction, if you want to help them be healthier, and you want them to survive, and you want them to be able to use whatever gifts they have, whatever talents they have, whatever abilities they have, whatever social skills or whatever they have—everybody has something. If you want them to be able to give that and to be able to make society better, then this is the way we need to go in terms of drug policy.

Harm reduction threatens the idea of the war on drugs because it says we care more about keeping people alive and healthy than we do about stopping them from getting unearned euphoria. And again, I don’t see why we should care about unearned euphoria. Capitalism has plenty of it. So this makes no sense. It does more harm. And if we really want to overcome the overdose process and help people genuinely recover, harm reduction is really the way to go.

LAWSON KOEPPEL: So the things out there on the horizon that have your interest, that you haven’t had a chance to document and put into a book or put into new articles—what are the things that you’re curious about in terms of new interventions or new things that are on the horizon?

MAIA SZALAVITZ: Well, I really do want to see decriminalization in action in Oregon. And I really—I think there’s amazing stuff going on in the South that I don’t even know about. But I know that there’s people doing really, really good stuff. I mean, I was able to highlight Louise Vincent in the book, and she just got this very fancy drug-checking machine from the photographer Nan Goldin, and it saved her life. She was about to use some drugs that were poisonous.

What I also really want to see—we need to do safe supply. And the only way we can do safe supply is to get rid of these laws that block maintenance that are built in from the 1919s onwards. And so basically they’re baked into the Controlled Substances Act now, and we need to just challenge that and say this is very clearly legitimate medicine. We have data from decades now. And there’s no reason somebody shouldn’t be able to prescribe Dilaudid just as much as they can prescribe methadone. And every doctor should be able to do this. And if you get people starting to sell doses for dollars, then you crack down. Not because somebody is getting a higher dose than you think they should have.

LAWSON KOEPPEL: That judgment piece. There is so much in this book, so much in your work in general, that we have left out. So many names that are in there that are important and so many ideas. And so it’s a lot—we weren’t able to get to all of it, but I want to say thank you for being a part of this, talking to us, and having the book out.

MAIA SZALAVITZ: Thank you so much for having me. And it’s really great to see the work you and other people are doing in an environment that can often be hostile. So all I can say from my perspective is it does get better. The work matters.

LAWSON KOEPPEL: Thank you. And I want to thank everybody here for being a part of this conversation, for attending. Please keep in mind we encourage you to purchase this book, Undoing Drugs, from a local bookseller. You can find those on VaBook.org. And you can also see a schedule of upcoming conversations for the Virginia Festival of the Book. I appreciate being able to be here, and I appreciate your time, Maia, and I appreciate the Virginia Festival of the Book hosting us. There is more on VaBook.org.

MAIA SZALAVITZ: Thank you.

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