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Hannah Chun, PharmD Candidate 20201; Alyssa M. Peckham, PharmD, BCPP1,2

1School of Pharmacy, Bouvé College of Health Sciences, Northeastern University, Boston, MA
2Department of Pharmacy, Massachusetts General Hospital, Boston, MA

Unbroken Brain, written by Maia Szalavitz primarily aims to reframe the way we think about and treat addiction. As noted by its title, the overall notion that Szalavitz aims to dispel is that of a broken brain, or rather, that addiction is a choice, moral defect, or a brain disease in the traditional sense. Instead, Szalavitz argues that the brain has simply undergone a different course of development, and as such, is more of a developmental disorder like Autism or Attention-Deficit/Hyperactivity Disorder (ADHD). Specifically, she argues that one component of addiction can be classified as a learning disorder, an alternation in brain development based on experience. Relearning, Szalavitz argues, should be a component of addiction treatment in addition to medications. In-line with her mission, Szalavitz does not focus on pharmacotherapy in Unbroken Brain, which makes this an excellent read for pharmacists and trainees who are already medication experts seeking additional insight into the totality of addiction treatment.

To tackle the learned behavior component, Szalavitz initially describes her personal journey with addiction, highlighting self-identified predispositions to addiction from both a genetic and environmental standpoint. Szalavitz notes that she carried many diagnoses and “labels” throughout her childhood and into young adulthood which ranged from Asperger’s Syndrome to ADHD to obsessive-compulsive disorder, to name a few. She also notes environmental influences of bullying during adolescent years which led her to develop isolative behaviors and become labeled “not a people person”. Szalavitz begins her story in childhood to highlight to chronicity of her maladaptive behaviors that were used to “self-soothe” or carry her through difficult situations. These early maladaptive behaviors, according to Szalavitz, trained her brain to self-soothe in unproductive ways and acted as a sort of catalyst or vehicle toward her heroin and cocaine addictions.

This notion is well-connected with addiction as use of substances may serve as a quick fix or substitute for a productive or otherwise safe coping strategy to process life’s adversities. With this, Szalavitz argues that what has been learned must be unlearned and written over in that new, productive, and safe coping skills should be learned in order to hasten the path to recovery. Here is where she highlights the importance of medications, noting that it is unreasonable to strip someone away from their known coping skill (i.e. drugs) without proper treatment and except them to flourish in the development of new coping skills.

In addition to reframing addiction as a learning disorder, Szalavitz focuses on harm reduction strategies, treatment-related myths, and proposed changes to law enforcement involvement. During each discussion, she recalls what was done and what could have been done in her own case. First, it is important to take a step back and understand the severity of Szalavitz’s use disorders to respond accordingly.

I. Diagnostic criteria

Szalavitz inadvertently walks the reader through her own diagnostic criteria of opioid use disorder and cocaine use disorder. By following along with the 11 criteria of a use disorder from The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), it is easy to identify how she would be classified for both opioid and cocaine use disorders by recounting a 12-month history of use at any point in time. She describes how her initial use was purely social and never via injection route, though this quickly escalated (Criteria 1) as she developed tolerance (Criteria 10) and was taught proper injection technique. Szalavitz walks the reader through her multiple attempts to cut down or cease use entirely (Criteria 2), though a strong desire to use always brought her back (Criteria 4). She describes the amount of time she dedicated to obtaining, using, and managing drugs (Criteria 3), recounting the times that her safety (Criteria 8) and/or her health (Criteria 9) was in jeopardy though she continued to use. Because of her addiction, she was dismissed from Columbia University (Criteria 5), created distance, strain, and pain in the relationships with each of her parents (Criteria 6), and experienced multiple run-ins with withdrawal if her use pattern was interrupted (Criteria 11). Altogether, her story can be dissected and linked to an assessment of severe opioid use disorder and severe cocaine use disorder.

II. Harm reduction strategies

Szalavitz was in the throes of addiction during a time where harm reduction was nearly absent, and almost half of intravenous drug users in the New York area were positive for HIV. She notes that despite engagements, albeit brief, with many addiction-related treatment centers and programs, she was never educated about how to minimize risk of overdose or prevent contraction of or spreading infectious diseases. It wasn’t until two months after she’d been sharing needles that she received formal education from a harm reduction worker who was visiting New York from the San Francisco area about how to sterilize needles if they are to be shared/reused. Szalavitz later learned that those that she had been sharing with or could have been sharing with were already positive for HIV. At this time, Szalavitz was also unaware that HIV can progress to AIDS, as she had only ever heard this term discussed in the context of men who have sex with men. Szalavitz was outraged that those who were involved in her care at various times had not cared to extend this knowledge to her. Given this, Szalavitz makes strong arguments for widespread naloxone access and training, needle and syringe exchange programs, safe injection kits, and safe injection teaching. Additionally, she advocates for the passing of supervised consumption sites (also known as safe injection facilities, safe consumption sites, and overdose prevention sites) as Szalavitz recalls her experience with an illegal, unregulated, underground group of harm reductionists who took to the streets to disseminate sterile needles. She recalls her ambivalence at first, thinking that the environment might be one of hostility and despair. To her surprise, the clientele was genuinely interested, appreciative, and “quietly protective”.

III. Treatment-related myths

Szalavitz also challenges well-believed myths related to addiction, many of them stemming from their own story or the stories of those she knew well. Although many can be identified throughout the novel, a few are highlighted below.

  1. The idea of needing to hit rock bottom

Szalavitz explains that even though the definition of addiction notes continued use of a substance despite negative consequences, many individuals still believe that incredibly harsh or humiliating consequences must be experienced before one is “ready” to engage in recovery. Szalavitz attempts to define what it may mean to hit rock bottom, though this vague milestone is indeterminate. Despite the lack of scientific evidence supporting this claim, “rock bottom” can never actually be identified in the moment but is only identifiable retrospectively. For example, one may have appeared to have hit “rock bottom” if terrible things are happening in their life, but in the event of relapse, one would be forced to assume that this individual must then experience even greater pain and hardship. Introducing repeated suffering has not been scientifically proven to motivate or prompt behavior change and therefore, “rock bottom” is not a requirement in one’s path of recovery.

  1. The idea of incarceration as the best treatment solution

Szalavitz discusses her multiple “drug court” appearances where, at one point, she was facing a 15-year jail sentence. Szalavitz notes the heavy involvement and influence the criminal justice system can have on the treatment-related decisions for individuals with substance use disorders, given that drug use is criminalized. She highlights the flaws of utilizing jails as detoxification centers or “treatment programs”, the most obvious one being that jails do no provide evidence-based treatment for those with a substance use disorder in the short-term during withdrawal, or in the long-term as maintenance therapy. In fact, the opposite can happen where incarcerated persons have died during withdrawal or have overdosed while trying to obtain drugs which may have been to prevent or self-treat withdrawal. In addition, in the case of opioids, without proper treatment an individual’s opioid tolerance may decrease during a period of incarceration and upon release, if they use the same amount of drug prior to incarceration they are at an increased risk of overdose. Szalavitz advocates for a different approach with less criminal justice involvement, which is discussed in the next section.

IV. Proposed changes to law enforcement involvement

Addiction has proven to be immune to punishment, as addiction rates either plateau or worsen with increased punitive measures. It is impossible to impose punitive measures into a disease course that is inherently resistant to punishment, yet we consistently rely on incarceration to “fix” issues related to addiction or addiction itself despite concrete data stating that it does just the opposite. We see this notion play out in Szalavitz addiction, as she had a few run-ins with law enforcement and eventually was facing a 15-year incarceration sentence, yet she continued to use drugs and engage in drug sales.

Instead, Szalavitz argues that the criminal justice system should be minimally involved, if at all, in drug possession or related charges where harm is absent to anyone other than the person using drugs. Szalavitz sites statistics from countries like New Zealand and Portugal, both of which have made drastic changes in law enforcement involvement with drug-related crimes. Outcomes include more engagement in treatment, less overdose-related deaths, less transmissions of blood borne diseases, and less cases of neonatal abstinence syndrome. Szalavitz proposes that programs like LEAD (Law Enforcement Assisted Diversion) which was started in Washington State should be more prevalent. LEAD is based on harm reduction and individualizes treatment plans for participants that help identify goals. Instead of arresting and re-arresting individuals, which is costly, unproductive, and does not have a positive impact on drug use or crime; the LEAD program would employ case management services to help participants connect with services that are needed to help them succeed. For Szalavitz, this could have been connection to addiction treatment, psychiatric treatment, or career building services as she was trying to enter back into Columbia.

Although this review only touches upon a few key take-home points from Szalavitz book, it is evident that addiction treatment does not stop at medications for some and perhaps most individuals. Many of those with addiction have many competing priorities, such as lack of housing, food, safety, income, and more. Given this, it is essential that we meet patients where they are on their path to recovery and empower them to be successful in this capacity. As pharmacists, we are often sought after for our medication expertise, but to have an in-depth understanding of the totality of addiction treatment can largely elevate our interventions from medication-based to patient-centered care.

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