Hooked on a Stigma: Maia Szalavitz on Understanding Addiction

May 23, 2016

Maia Szalavitz is an author and award-winning journalist specializing in science, public policy, and addiction treatment. Most famous of her several books was her 2006 exposé, Help at Any Cost: How the Troubled–Teen Industry Cons Parents and Hurts Kids. Her latest book is Unbroken Brain: A Revolutionary New Way of Understanding Addiction.

As a recovering addict herself, Szalavitz knows about the stigma of addiction first hand. She spent much of her teen and young adult life addicted to drugs like heroin and cocaine, but now with over 20 years of sobriety under her belt she’s dedicated a large portion of her career to investigating and reporting addiction treatment. Szalavitz’s research suggests that addiction is actually an emotional learning disorder, which, if true, could revolutionize not only the way we treat addiction but also the way we perceive addiction treatment.

This is point of inquiry for Monday, May twenty third. Twenty sixteen. 

Hello and welcome to Inquire production of the Center for Inquiry. I’m your host, Lindsay Beyerstein. 

My guest today is Maia Salivates, author of the new book Unbroken Brain A Revolutionary New Way of Understanding Addiction. My is an award winning science journalist. She’s also a recovered addict with over 20 years of sobriety at the height of her addiction. She was injecting heroin and cocaine dozens of times a day as a college student. My adult cocaine models and Wall Street executives then broken brain. She uses her own remarkable story of addiction and recovery to illustrate her novel theory that addiction is an emotional learning disorder in which our instinctive pursuit of interpersonal connection becomes misdirected to us. The book is a really unusual combination of addiction, memoir and science writing. How did how did you get the idea for a book like this? 

Well, I’ve been sort of figuring I didn’t thinking about addiction for a really, really long time. And I actually did it sort of earlier version of this book in the early 90s when I had just started my recovery. So that version of it was sort of based on the idea that we can be the addicts perspective on drug policy. But then I thought of the more I learned, the more complicated it got. As is the case in general. But what I what I found was that over the years of writing several other books in between, is that actually combining memoir and science can be a really powerful way to write a book. I’ve done several books like this. The thing that was different was this one was I thought, oh, this will be a lot easier because I don’t have to interview anybody or like, you know, make them, you know, nag them to get their parts done. But it turned out, of course, to be very different to that. Obviously, I did interview scientists and stuff, but there wasn’t like this one person I was collaborating with. But the, you know, the emotional impact of working on it was something that I should have predicted but did not. 

What’s it like to write a memoir where you put out the most intimate details? I mean, there’s a lot of very intimate stuff in the book about your sex life, about drugs, about crime, about all of the most personal stuff, family. 

Well, I feel a funny. It makes me feel much more vulnerable than I thought because I’d written a million times about bits and pieces of my three. But yeah, this was much more in-depth. And it does make me feel really vulnerable now. And I think it makes me prone to getting in fights with people online. 

I feel like I’m becoming slightly compulsive about that. 

And I have to, like, stop fighting with just like, you know, random people who like what has been especially annoying to me is just that there are people who think that I’m completely a shill for AA and that I’m pushing twelve step program and then there are twelve separate who think that I hate AA and I’m trying to stamp it out. And my position is that I think A is wonderful for those who like it, but I think that it should not be part of medical treatment, just like any other spiritual program should not be required in medical treatment. 

It’s interesting that we have such a fixation on dealing with addiction as a spiritual problem as opposed to a social or biomedical problem. 

I mean, it’s astonishing to me. The American Society of Addiction Medicine, which is the biggest group of specialists in addiction, actually defines addiction as a bio psycho social spiritual disease. And I have cited that a few times because it seems like the dumbest way to convince people that it’s a medical school. You know, it’s like we don’t say that depression and schizophrenia are spiritual diseases and we don’t require them to, like, sit in meetings and confess their sins and make restitution and find a higher power and surrender to that higher power. So my feeling has been and this does clearly anger a lot of people in Tulsa programs that we can’t have this as part of medical care and that as much as it means to many people. And I found value in that. It should never be forced on people. People should have a right to, as secular, a recovery from addiction as they have from any other medical condition. And if we single out addiction to be the only treatment in medicine that requires basically moral inventory, this means that we actually think addiction is a sin, not a disease. 

And what do you ultimately think that addiction is? Where did you get out on the true nature of it? 

I think that addiction is an emotional learning disorder. And what I mean is that you can’t become addicted without learning. You have to learn that the drug is what gives you relief or pleasure or some kind of comfort. And so in that very fundamental. Addiction is learned behavior. But what I think is another reason that learning is so critical. Is that an emotional learning in particular? Is it what happens in addiction is your brain falls in love with the wrong thing. It falls in love with a drug or an activity or something other than a human being. And that means that all of that biological energy that is devoted to ensuring survival and reproduction is going to be focused on drug or activity. And so that’s a very different kind of learning then. You know, when you’re learning some dry facts in school, this kind of learning basically changes your priorities. And people do for love or for survival, things that they would never do in any other circumstance. And we see the same kinds of behavior occurring during addiction. 

Do you think that addictions are all equally real, regardless of whether they’re organized around a drug that gambling addiction or sex addiction are just as much addictions? 

Or is that more of a metaphor? 

No, no, I think I think they are. I mean, I think love is basically the template for addiction. And if you engage in certain patterns of behavior, they can be addictive. The only one that I question I don’t really think there is love addiction. Like, I think that love is one of the most wonderful and powerful human experiences and emotions, and that even if you know you’re in love with the wrong person, it’s still an important part of humanity. And I don’t see that as addiction. I think that certainly people can become entangled in very dangerous and horrible and abusive relationship. And I suppose you could call it an addiction in those circumstances. But I think, you know, this idea that, like, you can be addicted. Being in love with somebody and this is bad, I don’t know. I could feel like it ends up pathologies in love, and I don’t want to do that. 

What do you think is missing from the traditional sort of accepted definition of addiction now, the continued use despite negative consequences model? 

Well, that’s actually how I define addiction. I just think that we’re on that sort of tells you what to look for and the learning part tells you what it actually is. Because if you just say compulsive behavior to cite negative consequences, that doesn’t say anything about how it’s caused or develop. And the learning part tells you about how it’s caused and develop. So I agree with both of those definitions. 

And what’s the relationship between things like tolerance and dependance to a drug and addiction? 

Well, dependance is simply needing something to function. And the DSM and the medical community did a great harm to pain patients and to people of addiction by labeling addiction and substance dependance, because that gave people the idea that physically needing the substance was the problem. And that’s simply not the case. You can have dependance about addiction, for example, you can have dependance on an antidepressant where you’ll get withdrawal if you stop it. 

But nobody, you know, robbing drug stores for Prozac. You can also have dependance on blood pressure medications which will actually die without if they are ceased abruptly. So dependance also. The other thing is you can have addiction without dependance because if you become addicted to cocaine, you’re not going to get physically ill if you stop taking it. You’re going to have terrible craving and you’re going to want to persist despite how bad your cocaine habit has become. But you are not going to be sick and peeping and shaking the way you would be with alcohol or opioid withdrawal. So the idea that physical dependance is a critical part of addiction has been a very harmful idea. It led to the idea that cocaine was not addictive, which is what we believed in the 80s before crack. And it led to the stigmatization of pain patients. 

And it also just leads to this false idea that, like, if you just could get through the withdrawals and people will be fine. And, you know, I kicked heroin a bunch of times and I never relapsed when I was in withdrawal. I always relapsed like a few weeks later when I decided, oh, just doing it once would be OK. So it wasn’t like it isn’t like physical withdrawal, OK? I’m not saying that it’s a good thing, but it is you know, I’ve had physical illnesses that are way worse than that. 

And the thing that makes withdrawal unbearable is the idea that you’re giving up the only thing that gives you comfort and hope that psychology is what makes the puking and the shaking, while not fun. That’s not the problem. There’s a problem is your loss. 

So. People go on opioid maintenance. Are they through the maintenance? Do they still get that sense of comfort from from their methadone that they were getting from the street drugs before? 

Well, I think there’s several things going on with maintenance. One is just that it basically replaces the compulsion and obsession of addiction with simply being physically dependent. 

Because you’re no longer getting the intoxication from the opioid, you’re not getting the euphoric rush or the high. You’re simply maintaining steady state. This changes the psychology, the variance. So you’re not escaping from your emotions. You’re not using it to tune out everything. You are just as present as anybody else if you are on a stable, steady growth. So it really basically removes the compulsive behavior despite negative consequences, i.e. the actual addiction, and replaces it with physical need for a drug to avoid withdrawal. 

Two people on methadone feel as if they were sober. Is it exactly like being sober? Except you take the drug every day? 

Yeah. 

I mean, I was on it, but I kept shooting coke and doing like heroin on top and I was on too low dose. So, you know. And the thing is, like, I cannot tell you about the experience of methadone because there are many experiences of epidemic. The thing is that like some people may be deficient in endorphins or some other part of their opioid system before they ever get addicted to opiates. And that’s why they get addicted to opiates. And that’s why maintenance feels like they’re safe and OK. Other people, you know, will find horrible side effects. Other people will find that it’s, you know, pretty good. But the human response to drugs, I think like the idea that, like, this drug feels this way. Well, you can sort of generalize about the things you might expect. But people’s reactions to things are just so different. And I think we really need to keep that in mind when looking at addiction, because only 10 to 20 percent of, you know, recreational drug users of drugs like cocaine or painkillers become addicted. 

I was really shocked to learn in the book that Dan Rather actually shot heroin for a news story. Can you tell us about that? 

Yeah, that was a bizarre incident. 

Apparently, the police let him shoot some of the drugs and they I guess they had concentrated clean needle and some drugs. I every need seems completely absurd. 

But, yeah, he said it was like when the police just kind of knew how to shoot up, like, OK, Officer So-and-so is going to administer the shot. 

Now, I have no I mean, like I think somebody should interview him about this. But yeah. I mean, you know, he described it and said it gave him the worst headache of his life and it was awful. 

And I love that anecdote because it you know, there’s a lot of people who really find opioids unpleasant and, you know, something like between fifteen and thirty percent of people who take them to think yuck. And so this idea that, like, there’s a source of incredible bliss that, you know, if you haven’t experienced them, you will never experience that. I know it’s like some people experience bad things from them and some people do experience euphoria. But what’s also interesting there is that most of the people that take an opioid or take a drug like crack cocaine and feel this intense bliss say, oh, my God, this is dangerous. I don’t want to ruin my life. I’m never doing this again. And so they don’t get in trouble. The people who do get in trouble are the people whose lives are missing something beforehand. 

What kinds of things are people’s lives missing that make them vulnerable to addiction? 

I mean, one of the biggest things is childhood trauma and having, you know, either been abused or neglected or having wonderful parents who happen to die. You know, like any kind of human tragedy that can be experienced in childhood, you know, has the potential to harm children. 

And the more traumatic experience you have, the more likely you are to become addicted. Now, this still leaves the majority of people with trauma not addicted, but your eyes go up exponentially. 

If you have trauma, what happens in the brain of a traumatized child that predisposes them? I mean, not all of them, but at least some of them to developing addiction later on? 

Well, I think, you know, opioids are basically the stuff that comes your stress system down. And they also are how the brain codes the ceiling for warm faith and love. So if you didn’t have enough of that as a kid, you’re going to find them incredibly amazing. Or if you have a stress system that’s always set on high alarm, which is what happens to kids who are traumatized often. The other thing can happen to where people can get sort of numb and dissociated and they might actually like. More stimulant drugs generally. And it sort of makes them feel alive. So, you know, I mean, there’s obviously a lot of different things that go on in the brain. But when you mess up the stress system. Drugs that interact with it often become attractive. 

In your last book, Born for Love, you talked about how trauma can predispose for all kinds of abusive relationships in terms of things with food and stuff like that, too. Right. It’s not just it’s not just chemical drugs. 

No, no. What I mean, I think food is really one of the most interesting addictions. I mean, most people are not addicted to food, but lots of people have difficulty controlling their appetite. And when you think about how hard it is to, like, not eat when food is in front of you and you’re hungry, that’s what it’s like when you’re addicted, but sort of turned up a notch in many cases. So the thing with food, again, you know, food releases opioids and dopamine. And just as we have brain systems that are there to make sure that we fall in love with somebody and make sure that we are attached to people and especially our children, we also have systems that drive appetite for food because otherwise we would start to make sense. 

The other thing that’s really interesting in the book is the idea of some developmental trajectories and the idea that addiction is very much a developmental disease for a lot of people, that it strikes in certain critical periods in life. Can you talk about that? 

Sure. I mean, I find development in general really fascinating because there’s just so many variables. And like a kid can hear some offhand remark by somebody and decide that it means they’re a terrible person and then they can ruminate on that for the next three years. And you have no idea. 

And it can just happen on any given day. 

Well, I mean, that’s the thing. 

I mean, this is what I don’t have kids, but this is what terrifies me for parents because they’re obviously you can’t predict, like, what stupid thing you say might be horrible. You also can’t predict, on the other hand, what, you know, offhand compliment you give. That may, you know, turn a kid into an artist or something. But there are all these, like, little processing. 

I never say enough or a little kids. I’m always afraid I’m going to physically maim them somehow. Now I have to worry about psychologically maiming them, too. 

Right. Right. Well, I mean, I think this is why parenting can be so obsessive. I mean, we have that obsessive persistence and compulsion in order to make a TV feel with parenting. 

You know, I mean, nobody would I would ever be able to deal with the diapers and the screaming and all that kind of stuff if they couldn’t, you know, despite negative consequences and they didn’t feel rewarded by their connection to the child. So, yeah. No, I mean, that remark is not intended to say that parents be perfect or anything like that or that you might say something once and that’s going to turn your kid into an addict. Like, no, that’s not what I mean. I just mean that development is an enormously complicated process. And a lot of it depends on invisible things like how the child interprets third variant. 

Like one child could have an amazing experience from something that could traumatize another child. 

And there are just so many ways of interpreting the world. And then when you interpret it one way early on, that affects how you interpret again later. And so to me, development is such a fascinating process. And really any mental or psychiatric illness is a developmental disorder because the same process and so on. And you’re not going to find a gene for addiction or for depression or for any of these things. You’re going to find a gene that makes your stress system, you know, a little bit more oversensitive. And then in X environment, you will end up responding to, you know, an experience in a different way than you would if you had a different gene. And that may play out as depression. That may play out as addiction. That may play out as depression and then addictions. 

Or, you know, you could fall in love and it could be nothing at all. 

So why is adolescence such a critical time in the development of addictions? 

For many people there, psychological, cultural and physiological things going on feel like physiologically your brain is in one of the most active periods of development. Like three of them. One is prenatal. The other is like the first three to five years. And then the other is within his early 20s. And at this point, your brain is myelin eating certain areas, which means it’s sort of enhancing the transmission of impulses in these areas. And it’s also working on growing new connections and pruning away ones that are useful. So, like, there’s an enormous amount going on in the brain at this time. And one of the things that is happening is that your brain sort of suddenly make life really boring so that you will move out into the social world and, you know, desperately want a girlfriend or a boyfriend. 

So the brain is actively dialing down adolescence ability to be stimulated by their their nest, essentially to encourage them to fledge. 

Yeah, basically you can see I mean, I don’t have enough data for this, but I feel like that Candy is never as good as it was when you were a little kid. Like something changed. 

So here’s the really sweet trashy candy, like Skittles. I totally agree. 

Yeah, it’s like really weird. And like you you like it because of the memory of how you like it, but it’s it’s not as good. 

Yeah. I will never eat sour cheese again, but I liked him as a kid. 

But yeah, I think it’s a funny thing. 

I burned the skin off my lips. We had this one glorious summer where we had a giant tub of Syracuse from Costco and and a lot of membership to the community pool. And we would just lie there on blankets. And secondly, Syracuse. And by the end of the summer, a different citric acid had eaten with skin. 

Wow. Wow. No, I don’t mean like. I think so when you you know, there’s a lot of changes that go on. But one of the changes is that, like, you know, how teenagers are always complaining of boredom. Yeah. You never are as bored ever in your life as during one of the most exciting of life, oddly enough. 

But, you know, that is really to get you out there, to get you taking risks, to get you engaged in the peers that you know evolutionarily are going to be where you’re going to find your mate and the people that are going to keep you alive. So, you know, adolescence psychologically and culturally is is huge as well. But the physiological stuff that’s going on helped drive that. 

One of the biggest addiction related news stories in the past couple of weeks has been the tragic death of the rock star prince. And what do you think? Do you think that there are things that we can learn from his possible drug overdose in terms of drug policy or in terms of responding to people who are in distress from addiction? 

Yes, absolutely. One of the things that’s killing me about the fact that we lost this great artist is that, you know, he was scheduled apparently to go in to maintenance treatment with buprenorphine the next day. And that and methadone, indefinite use of either methadone or using arcane are the only treatments they currently have for opiate addiction that cut the death rate by 50 percent, 70 percent, even more depending on the setting. But it’s Oida and 50 percent. And if it was any other medical condition, we would be providing this in the water supply, although this is obviously not practical. But the thing here that’s really sad is that, you know, most of the celebrity think that abstinence only treatment is the best possible treatment. And people think, oh, the rich and famous go to these, you know, 28 day rehabs. And B, you know, that must be the best treatment because that’s where the celebrities go. And in fact, that treatment does not cut the death rate. The only thing that we know that keeps people with opioid addictions alive reliably is maintenance with buprenorphine or methadone. And so it’s a double tragedy in terms of print, because if he had lived and entered treatment and been out about it, it could have been enormous help in destigmatizing condition and the treatment for the condition that is actually the best treatment but is the most stigmatized. 

At the same time, do we know, though, that he had a psychological compulsion to take drugs? I mean, it seems like all the anecdotes that came out in the big New York Times story were so describing what seemed like a chronic pain problem as much as a psychological compulsion problem, that he had these degenerative hip problems that were causing him excruciating pain all the time. And the reason that his opiate use became public was because he overdosed. But do we know that that was because of addiction as opposed to simply over medication for a physical problem? 

I mean, you know, there is this guy is claiming to be his drug dealer who says that he started on opiates for stagefright. 

So it’s not a toy 20 years ago. And everybody who’s a man or some people peripherally who’ve worked with Prince in various capacities and everyone said he never acted addicted. He never acted high. He was not interested in any recreational drugs. So it sort of seemed like this weird disconnect to me that people are saying, oh, well, he was he was an addict as opposed to he was badly managed for chronic pain. 

I mean, that’s an interesting perspective. And it would be more realistic if he just died of the overdose in the first place. But then he went on to presumably overdose again the second time. 

Yeah, that’s. 

She doesn’t think it’s a bad thing to me. So, you know, again, we don’t know. 

And if it was badly managed chronic pain, then that is another story that really needs to be told, because, you know, the people are just saying that, oh, opioids don’t work for chronic pain. So we just got to call these people off and let them suffer. The reality is that they do work for some people with chronic pain. And we don’t know which people those are going to be. And it’s an enormously complicated problem because for many people, there is nothing. Well, and seeing people who are physically dependent on opioids for pain as being addicted is wrong. And we should not stigmatizing people either. But we’re now stigmatizing both. 

Right. It’s kind of the worst of all possible worlds. What do you think of the new CDC guidelines that are that have come online in the past couple of weeks in terms of prescribing opioids for chronic pain? 

I think that they’re going to end up with more people in pain and they’re not going to end up with fewer people addicted. We’re already seeing people, you know who and these were people who were addicted before they got chronic pain treatment. Generally 75 percent of cases. These those people know where to buy heroin and they will be buying it once they get cut off from their legal supply. So the simply stopping the supply is never the answer to addiction. It really ends up with people suffering. And if you stop the supply for people in chronic pain who are benefiting from opioids, which is already clearly happening, I hear from such people all the time. 

You know, if you go on any kind of chronic pain, you know, communities on Reddit or anything like that. People are just freaking out and getting cut off and going through withdrawal because their doctors have simply said, OK, I’m not going to treat you for this condition. I’ve been treating you for four months or years because the CDC says you shouldn’t. 

Right. And that I mean. And you know this I you know, it was very predictable. This is going to become the standard of care regardless of individual differences. And that is not the way medicine should be practiced. But basically, now that the CDC put out these guidelines, the DEA will use them to say, if you’re not with them, then we’re going to prosecute you and doctors, you know, like anybody else, they’ll want to go to jail. They don’t wanna lose their license. You know, they don’t be charged with murder for some person that they prescribe to in good faith. And that person goes and shoots the drug in combination with cocaine, which actually happened in California and again in Florida recently, I think. 

Yeah. I mean, if murder four for practicing, there’s been many of these cases before that as well. 

You know, it’s like we do not handle complexity well in this country. We can’t understand that the same drug that might kill you might save me. And we’re gonna see, unfortunately, I think, a lot of suicide in chronic pain patients who are cut off and they just can’t find any alternatives. If I were a chronic pain patient, I would really find it offensive that people are saying, oh, well, you can just do yoga like mindfulness meditation. 

Right. Right. And people go, fines are falling apart. I mean, you can find them in these Reddit communities of people who’ve had like 16 back surgeries and people still like, you know, meditating. 

I don’t understand. Like I mean, I really feel like this is a massive failure of empathy. I guess people think that people with chronic pain are just kind of whiners who don’t really have a problem. But like, if you look at the physical suffering of some of these people, it’s pretty much unbearable. And anything that can make that better, as far as I’m concerned, is fine. I just think that provide naloxone with prescriptions in case people in case, you know, the drug, it’s diverted. But you know, something like. There is a big study of thousands of people who went to the E.R. for opioid overdose. Only 14 percent had a chronic pain diagnosis. So this is not a situation where doctors turn pain patients in to addicts. This is a situation where recreational drug users are getting in trouble with opioids that they’re getting from the medicine cabinet in the first place. It’s not their prescription. And so trying to solve it by creating prescribing guidelines is not really going to be the most effective way of dealing with it. What we really need to do is expand access maintenance and expand it in such a way that it can be either a harm reduction where you just go and get a dose and you don’t have to do counseling or any of that other stuff. And you can just, you know, reduce harm. And then with counseling and all kinds of other support for people who are ready to stabilize their lives, if we have both of those systems available, we can dramatically reduce the overdose death. If we don’t. We’re just going to have all this diversion and people are gonna be like, well, we can’t expand it cause people are going to divert the drug. The diversion is going to people who are addicted, who don’t want to go through the hoops of treatment or who don’t have access to treatment. And, you know, we should not be creating these who we should be getting people into medical care and reducing the harm and going from there to further reducing his hyperalgesia. 

Real thing. Every time we talk about opioids and chronic pain, some doctor in the back of the room will say, but. But opioids actually cause more pain long. Is that actually true? What’s the research behind that? 

There’s some animal research. There’s some human studies that suggest that, you know, you can get this thing called opioid induced hyperalgesia from long term opioid use. 

It doesn’t seem to occur with all types. The pain. It certainly doesn’t occur in all people. The clinical relevance of it. For most people is hard to say. I feel like it’s being used as an excuse for doctors who feel bad that they’re tapering people or cutting them off because they’re scared to just say, oh, well, you know, this was actually making worse. 

Is this something that supposedly lasts forever or just while you’re on the drug? 

Oh, I’m you know, I think it’s just while you’re on a drug, I mean, presumably if there is a danger, if the physiological mechanism would be similar to, you know, tolerance to like if you have these opioids in your system, presumably you’re like tolerance to them to such an extent that, you know, normal stimuli are becoming more painful. 

So they’ve opened up the pain sensation get somehow, paradoxically, where the opiates used to block them. 

Yeah, I mean, like I have, you know, again, like, it doesn’t seem I know that there’s cities that are showing it in animals. And I know that there are one or two studies that show it in humans on maintenance. But, you know, again, it’s a question of we can figure this out by raising the dose and seeing if you get better or worse or lowering the dose and see for yourself. 

And there would be no rational reason for long term opioid use to, like, destroy your pain system. And so then once you stopped it, you would still have this extreme pain. But, you know, there’s no data. 

Well, that’s all the time we have for today. Thank you so much for coming on the show. 

Oh, I’m delighted. And thank you so much for your wonderful question.