A new definition of addiction, part 4 of 6
An opening in the ice beckons to spring….
Having processed Szalavitz's book Unbroken Brain in three previous installments, covering the philosophical, biological and temporal evidence she presents supporting the idea of substance use disorder as a learning disorder, the important part "what to do about it" arrives. To me, I'm all about implementation; if no action is taken to correct poor situations, then there is no point to the discussion. That said, I'm all for thoroughly understanding a situation before launching into action, in hopes of putting energy in the most effective places. Szalavitz's work is compelling, and also not the only thing out there, so I look forward to weighing these ideas with others before choosing a path of action.
I had hoped I could finish out this coverage in one more post, but it'll need to be three posts: today, harm reduction; tomorrow, legalization; and Friday, education.
One of Szalavitz's key recommendations is to widely deploy harm reduction, or, implement policy that "minimize[s] negative effects of drug use" over and above "use itself" (p. 232). At the core of such programs is giving users the dignity of their own decisions, and the information they need to make decisions about their health (p. 233). Recognizing that drug use needs to be voluntarily left behind as a result of learning, not in anticipation of it, "[h]arm reduction does not try to remove a person's primary coping mechanism until others are in place." (Szalavitz quoting Alan Marlatt, p. 241) Note that this is based in providing information - education - and access to basic human needs like food, shelter, hygiene, safety.
Harm reduction tactics were highly visible during the COVID pandemic - "wear a mask to reduce your exposure and that of others", "get vaccinated to reduce risk". They were first developed in the battle against AIDS (needle exchanges, education in sterilization, safe sex, etc.), reducing the rate of disease spread until medical research could develop effective treatments. Harm reduction tactics to address drug use include things like:
needle exchanges and safe places to administer drugs under medical supervision,
access to methadone or buphenorphrine to reduce the impact (and deadliness) of opioid withdrawal,
mental health assessment and treatment (because substance use is co-occurring with mental health disorders about 50% of the time),
ready access to trusted counselors and 12-step meetings, and,
help getting food, shelter, and a shower, even help getting a job.
Fundamentally, the approach needs to be about teaching and dignity, not punishment; Szalavitz repeatedly states the very definition of addiction is "a learned compulsion that continues despite punishment." Thus, and data has shown, punishment and shame are not answers. Most people understand that they do not facilitate learning.
This is a great New York Times article about a real-life example of harm reduction, a place and program in East Harlem. The article outlines some of the benefits of a harm reduction program, and also the societal/cultural barriers to dispersing such programs.
Following Unbroken Brain, Szalavitz wrote a book on harm reduction exclusively, called Undoing Drugs. I recommend it as a great read on the subject.
Tomorrow’s post: legalization.
