'Unbroken Brain' Explains Why 'Tough' Treatment Doesn't Help Drug Addicts
Tough love, interventions and 12-step programs are some of the most common methods of treating drug addiction, but journalist Maia Szalavitz says they're often counterproductive.
"We have this idea that if we are just cruel enough and mean enough and tough enough to people with addiction, that they will suddenly wake up and stop, and that is not the case," she tells Fresh Air's Terry Gross.
Szalavitz is the author of Unbroken Brain, a book that challenges traditional notions of addiction and treatment. Her work is based on research and experience; she was addicted to cocaine and heroin from the age of 17 until she was 23.
Szalavitz is a proponent of "harm reduction" programs that take a nonpunitive approach to helping addicts and "treat people with addiction like human beings." In her own case, she says that getting "some kind of hope that I could change" enabled her to get the help she needed.
On her criticism of 12-step programs
I think that 12-step programs are fabulous self help. I think they can be absolutely wonderful as support groups. My issue with 12-step programs is that 80 percent of addiction treatment in this country consists primarily of indoctrinating people into 12-step programs, and no other medical care in the United States is like that. The data shows that cognitive behavioral therapy and motivational enhancement therapy are equally effective, and they have none of the issues around surrendering to a higher power, or prayer or confession.
I think that one of the problems with the primary 12-step approach that we've seen in addiction treatment is that because the 12 steps involve moral issues, it makes people think that addiction is a sin and not a disease. The only treatment in medicine that involves prayer, restitution and confession is for addiction. That fact makes people think that addiction is a sin, rather than a medical problem. I think that if we want to destigmatize addiction, we need to get the 12 steps out of professional treatment and put them where they belong — as self-help.
On the efficacy of maintenance treatment
Buprenorphine and methadone are the two most effective treatments that we have for opioid addiction, and that is when they are taken indefinitely and possibly for a lifetime. So these medications are opioids themselves. They each have slightly different properties ... but what they do is they allow you to function completely normally. You can drive. You can love. You can work. You can do everything that anybody else does. ...
The way they are able to do that is because if you take an opioid in a regular steady dose every day at the same time and the dose is adjusted right for you, you will not experience any intoxication. The way people with addiction experience intoxication is that they take more and more and more, they take it irregularly, the dosing pattern is completely different. But if you do take it in a steady-state way — which is what happens when you are given it at a clinic every day at the same time — you then have a tolerance to opioids which will protect you if you relapse, and will mean that the death rate from overdose in people who are in maintenance is 50 to 70 percent lower than the death rate for people who are using other methods of treatment, and that includes all of the abstinence treatments.
So maintenance is a really important treatment option for people with opioid addiction. It should be the standard of care. No one should ever be denied access to it. Unfortunately, we have this idea that if you take methadone or buprenorphine, you are just substituting one addiction for another.
On using harm reduction instead of tough love to help addicts
We do know from looking at the data that if you are kind and supportive and empathetic — if you do things like provide clean needles, provide opportunities for people to reverse overdose, provide safe injecting spaces — those things do not prolong addiction. And if tough love was the answer, and the idea was you shouldn't enable addiction, if that theory was correct, those things should all prolong addiction, and the exact opposite is true. When you go into a needle exchange, one of the most amazing things is people are just treated with dignity and respect. And when you're an active drug user, when you are injecting, everybody crosses the street to avoid you. And here you're just seen as a person who deserves to live, and you deserve a chance. And it's that that gives people hope. And it's that that shortens the period of addiction.
On not serving any time in prison after being caught with 2.5 kilos of cocaine when she was 20 years old
I have to say that being white and being female and being a person who was at an Ivy League school and being privileged in many other ways had an enormous amount to do with ... why I was not incarcerated and why I'm not in prison now. I think our laws are completely and utterly racist. They were founded in racism, and they are enforced in a thoroughly biased manner. I was extraordinarily lucky to have an attorney and a judge that saw that I was getting better, and that allowed me to avoid that.