Fresh Air with Terry Gross

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. We're going to talk about new ways of understanding and treating addiction. My guest, Maia Szalavitz, is the author of a book that examines scientific, behavioral and medical research about addiction. She says the methods of treatment and punishment haven't caught up with the research.

Szalavitz is a journalist who's been covering addiction and drug-related issues for nearly 30 years. She writes a column for VICE and has been a health reporter and columnist for Time magazine. She was addicted to cocaine and heroin from the age of 17 to 23. She stopped using in 1988, about two years after she was arrested and charged with cocaine possession. She faced a mandatory minimum sentence of 15 years to life. A little later, she'll explain why she never served time. Her new book about addiction is called "Unbroken Brain."

Maia Szalavitz, welcome to FRESH AIR. So you see addiction as a coping behavior - for coping with what?

MAIA SZALAVITZ: It could be anything. And this is why it gets so complicated. Some people might be using it because the world is too intense and too much, and they feel overloaded. Some people might feel just the opposite. They might feel that nothing means anything - nothing stimulating - nothing is exciting.

So it's - there are so many different individual reasons why people become addicted that it's really important. You know, in the past, everybody has just said all addiction is this and all addiction is that. And, you know, we would never say that about any other kind of disorder. In the autism world, there's a saying that if you've met one person with autism, you've met one person with autism.

And we need to import that into the addiction world - rather than assuming that I, because I have had an addiction, can speak for everybody with addiction.

GROSS: But you do refer to longitudinal studies that have looked at who's at risk for addiction. And those studies, you say, have found three major pathways. Do you want to describe what those are?

SZALAVITZ: Sure. So there is one pathway where children are oversensitive and overstimulated and very anxious and really kind of nervous. And these kids are looking for a way to calm down and a way to feel safe and a way to connect. There is another pathway where people are understimulated and they feel almost like nothing feels like anything. They feel very disconnected or very numb. And those kids are looking for excitement and stimulation and to feel more.

And then the third path, which is kind of the most interesting, is where you sort of swing back and forth between the two. Sometimes, you're understimulated. Sometimes, you're overstimulated. But all three of them have in common that there is that a dysregulation of the ability to control emotion and sensation.

GROSS: So you were addicted for several years when you were a teenager and young woman. Where did you fit in, in terms of what you were trying to get out of drugs?

SZALAVITZ: I was one of the - I tended towards the more oversensitive, overstimulated person who was looking for a sense of relief and comfort. Ever since I was a young child, the world has seemed sort of overwhelming to me. Like, lights were too bright. Sounds were too loud. Sweaters were too itchy. I always felt some sort of sensory discomfort. And I was always looking for a way to sort of turn down the volume and to, you know, not be so wrapped up in my own experience.

GROSS: So how old were you when you first started using? And you were using heroin and cocaine.

SZALAVITZ: Yes. I first started using - well, before that, I was using marijuana and psychedelics. But I first started using cocaine when I was 17. I was in high school. I had a boyfriend who was selling it. And his brother actually sold to Jerry Garcia, which is how my first drug experience with cocaine happened to be with Jerry Garcia backstage - or at his hotel after a Grateful Dead concert.

GROSS: So you were 17 the first time you snorted coke. Had you already used heroin?

SZALAVITZ: No, no. I had been, you know, your sort of little deadhead. I had discovered that I was always a kid who had some kind of obsessive interest. And so this ranged from opera to science fiction to - I wanted to be a symphony conductor for a while. These interests were not generally of interest to other kids.

Drugs, however, were an interest that a lot of my peers shared. And so when I became involved in drugs, I became able to socialize a lot better. So I started out - I mean, in the sort of hippie psychedelic community, there was this saying that - don't mess with white powders - that as long as you stick to marijuana and psychedelics, you're not likely to really get in horrible trouble with drugs, which is good harm reduction advice to this day - not to say that you can't get in any trouble, but you will get in far less trouble with those drugs compared to heroin and cocaine.

And so the advice was avoid white powders. So the first thing I did was marijuana and hash and LSD. And I have to say I learned a lot from that. One of the weird things about my experience was when I had a psychedelic experience with LSD. I learned that, wow, other people have vastly different perspectives. And, you know, it's not such a big deal to be nice to people. You can just do what people want without rebelling so much.

You can - you know, if your mom wants you to do the dishes, you can just do them. So unlike many kids who begin experimenting with drugs in order to rebel from their parents, I actually found - I actually became a much more manageable kid after using drugs, which is very odd.

GROSS: OK. So you were 17 when you started using hard drugs. And what do we know now about the brain development of teenagers and why teenagers are more vulnerable to becoming addicted?

SZALAVITZ: Well, there are three critical periods of brain development in the human. The first one is obviously prenatally. The second one is 0 to 5. And the third one is adolescence into young adulthood.

And what's going on in the brain at that time is that the areas that give you drive and motivation and that get you out of the house and that get you seeking boyfriends and seeking friends and, you know, seeking to interact with your peers more than your parents - those areas are growing really strong.

And you are learning, you know, how to seek thrills and pleasure and how to maneuver amongst your peers and how to have relationships. Unfortunately, the stuff that develops later are the regions that are involved in self-control and in reining in that motivation and reining in that desire. So when you're a teenager, you have sort of a very strong engine with weak brakes.

And the brakes don't really develop until your 20s or so. And that means that if you are engaging in a highly pleasurable or highly comforting experience as a teenager, you're going to be more likely to get addicted because your brakes aren't developed that much yet.

GROSS: So you quote a couple of things. You say 90 percent of all addictions begin during adolescence. And addiction is less common in people who use drugs for the first time after they're 25. And addiction often remits with or without treatment among people in their 20s just as the brain becomes fully adult. What do you extrapolate from those statistics?

SZALAVITZ: Well - that this is a developmental disorder. And that there is a period of extreme risk. And this is not to say, of course, that you cannot become an addict later in life. But the most common time and the most likely time for you to develop an addiction is your teens and early 20s.

And another thing that's going on at that time is - if you aren't using drugs or escaping into something else excessively at that time, you are developing social skills and self-soothing skills and other skills that allow you to live comfortably in your body. And if you spend that time escaping with drugs, you aren't learning those other things - so that when you try to stop, you won't have those ways of dealing available to you.

GROSS: So another question about your addiction, if you feel that you used heroin and cocaine to help you cope - in a way to cope with sensory overload, how did it help you?

SZALAVITZ: Well...

GROSS: When I say help you, I realize it didn't really help you but how did you feel (laughter) - how did you feel...

SZALAVITZ: Oh sure.

GROSS: ...At the time, that it was helping you cope?

SZALAVITZ: So I was always very scared of people. And I was really good with ideas. I was reading at three. I was - always did well in school. I had no problem with academic information. But social information, I really did not know how to process.

And I always felt rejected and different and isolated and left out. And I would walk into a room, and I would think, oh God, they don't want me here. And when I took heroin that just went away - I felt OK, I felt safe, I felt loved.

And I was loved even without it - in fact especially without it - but I couldn't feel it for some reason. I was always thinking that, well, they're just pretending that. And it took a long time to unravel the intense self-hatred that I had developed. And what heroin really did for me was just shut that up and calm that down and make me feel alright.

GROSS: You suggest in your book that if you were a girl today - growing up today - and you had seen a doctor, you'd probably be diagnosed as being on the autism spectrum. But instead, when you were young, you were diagnosed at the age of 3 with attention-deficit/hyperactivity disorder, and you were given Ritalin. So you were put on drugs when you were 3. So say you are or were on the autism spectrum, do you think it's fair to generalize your need - you know, the whole that drugs are filling for you and how you were able to get off of drugs - is it fair to generalize that to a more - wider diverse population that isn't necessarily on the autism spectrum?

SZALAVITZ: I think that's a great point. No, you cannot generalize from my own experience to everyone else. But what's been interesting, as I've been talking to people about this book and people have been responding to it, I have heard from lots of people with addiction and lots of parents of people with addiction that early in life a lot of them had sensory issues.

Now, sensory issues don't always mean autism. But I think that that is an area that seems not to have been researched very much that needs to be studied more because, I mean, I was once on this discussion online of people who had unfortunately lost their kids to addiction. And the things they were describing about their children when they were young were identical to the things that some of the parents of autistic kids were describing, like they couldn't stand to have that tag in their clothing or they had to, like, live on peanut butter - which I did for a while - you know, these kinds of weird difficulties with sensory experience.

GROSS: Let's take a short break here. And then we'll talk more about addiction. My guest is Maia Szalavitz. She's a journalist who's covered addiction for nearly three decades. She's - she was addicted before that, when she was a teenager and young adult. And now she's written a book called "Unbroken Brain: A Revolutionary New Way Of Understanding Addiction." We'll be right back. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR. And we're talking about addiction. My guest is Maia Szalavitz. She's a journalist who's covered addiction for nearly three decades. She was addicted to cocaine and heroin as a young woman. She's been sober since she was 23. She's the author of the new book "Unbroken Brain" in which she draws on the latest evidence about the neuroscience of addiction and comes to the conclusion that addiction is a developmental disorder or a learning disorder and that the criminal approach to dealing with addiction is not a great idea. The new book is called "Unbroken Brain."

So getting back to your story for a moment - you were arrested when you were 23? Do I have that right?

SZALAVITZ: No. I was arrested when I was 20.

GROSS: OK. You were caught with 2.5 kilos of cocaine, most of which you say belong to your boyfriend's supplier. You were supposed to get a mandatory minimum sentence of 15 years on an 1986 charge. But you managed to not serve any time. How did that work out?

SZALAVITZ: Well, 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.

But it was - I mean, the judge in the case actually was known amongst people who are criminals as the dragon lady. And her memoir was actually titled "25 To Life." She was known for sending dealers away forever. And what happened to me was when I was arrested, I weighed about 85 pounds. I had tracks up and down my arm. I looked green and gray, and I had pulled out my hair because I sometimes did that on coke. It was this horrible bleach blonde. I just looked like I was dying.

And it was about a year between the arrest and my indictment, and during that year after getting bailed out, I just got worse. And I got sicker and sicker, and I was shooting up dozens of times a day. And I knew that I had to stop, and I couldn't stop. And it was awful.

And one day I found myself beginning to run out of money. I found myself begging a guy that I really didn't like for heroin. And even though I was in the room with him and his girlfriend and my boyfriend, I thought about, well, maybe I could seduce him to get the drugs.

And when I had that thought, something in me changed. I just realized all my excuses for saying I wasn't really addicted went away. And I just knew that I needed help, so that day I stayed sick. I didn't get heroin.

The next morning I had a court date. I went to court looking as horrible as I looked. I told the judge I know I need help. I got into treatment. And then about four months later, I came back for another court date. And I was tan and fat and still horribly blond, but there was life in my eyes again. I looked like a person who had a chance. I just - the physical transformation was so extreme that the judge and everybody else was just like this doesn't look like the same person.

And so she said to my lawyer, you know, I think she has a chance. If she stays in recovery, I'd like to try to, you know, keep her out of prison. But she's got to do something about that hair color 'cause it looks awful. And I'm now a redhead.

GROSS: So you were given the opportunity to get better, which you think is a privilege you were granted because of your gender and your class and your race.

SZALAVITZ: Yes. I mean - and obviously, it's not all that. But I just have to say that, you know, I have - if I had been black or Latina, you know, maybe I would have got that same chance. I think the judge absolutely did her best. She actually did give this kind of deal to some people of other races. But we just know from the statistics that white people are much more likely to get a break. And we also know from the history of our drug laws that they were born in racism. I mean, one of the things that absolutely distresses me when I learned the history of our drug laws is that they were made for racist reasons. Cocaine was made illegal because it supposedly made black men impervious to bullets and supposedly made them more likely to get involved with white women. Opium was made illegal because supposedly it made Chinese men more likely to get involved with white women. Marijuana was made illegal because Mexicans and white women.

And you look at this and it sounds absurd. You hear the rhetoric that led to the passage of these laws. Like there's this New York Times headline Negro Cocaine Fiends Are A New Southern Menace. I mean, the racism is that blatant and that obvious. And yet for a long time, people didn't question these laws, and we thought oh, there is a legitimate scientific reason why alcohol, tobacco and caffeine are legal and the other drugs are illegal. But when you look at the history, that isn't there. The thing that is there is racism.

GROSS: So at some point you knew that you had a problem. You knew that you were addicted. You knew you'd probably die if you didn't straighten yourself out. And you knew you had to stop, and you stopped. And that kept you out of serving a minimum of 15 years in prison. Some people don't seem to reach that point of knowing that they're addicted, they have a problem and they need to stop to save themselves. And that's where things like tough love and interventions come in, and it's also sometimes where, like, criminal interventions come in. I mean, there are people who do kick in jail and go on to, you know, get sober and eventually get out of jail and live a sober life. So...

SZALAVITZ: Well, let me say something here about...

GROSS: Yeah.

SZALAVITZ: ...This notion of tough love and hitting bottom. It was two years after I got arrested that I got into treatment. After I got arrested, I got worse and worse. I didn't hit bottom when I had the insight that allowed me to seek help. What I got at that point was some kind of hope that I could change.

And we have this idea that if we just are 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. Addiction is actually defined by the DSM and by the National Institute on Drug Abuse as compulsive behavior that continues despite negative consequences. That's the definition of addiction. So therefore, if punishment, which is just another word for negative consequences, worked to fight addiction, addiction actually wouldn't exist.

And so we just have this thing so wrong. Addiction is a problem with learning from punishment, and we expect punishment to fix it. There's something deeply wrong with that.

GROSS: My guest is Maia Szalavitz, author of the new book "Unbroken Brain." After a break, we'll talk about 12-step programs and about treating drug addiction with prescription drugs. I'm Terry Gross, and this is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR. I'm Terry Gross back with Maia Szalavitz, a journalist who's reported on drugs and addiction for nearly 30 years. Her latest book, "Unbroken Brain," is about recent scientific research into addiction and how approaches to treatment haven't caught up with the research. She was addicted to heroin and cocaine in her late-teens and early-20s. She stopped using in 1988, two years after she was charged with possession of cocaine and faced a mandatory minimum sentence of 15 years.

She thinks the punitive approach to addiction doesn't work, and she questions the value of tough love.

You're relieved that your parents did not practice tough love. Do you often think about what would have happened to you if they had practiced tough love?

SZALAVITZ: Yes, I do, because actually, an earlier book that I wrote called "Help At Any Cost" deals with the tough-love, troubled-teen industry. And in tough love programs where kids in the '80s and '90s and unfortunately still today were sent, in that industry, the treatment involves public humiliation, complete lack of privacy, sleep deprivation, intense emotional attacks and all kinds of things that would have been utter torture for somebody with - on the autism spectrum.

Also, they're absolute torture for most people, even if they're not on the autism spectrum. And I don't know how I would have survived something like that. I don't know how I would have survived just being cut off and left in the street. I really don't know. And 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 that 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. And we just have it so backwards in so many different ways.

But what has been amazing to see is the growth of these harm reduction and, you know, love love approaches that are not tough, that are not harsh, that treat people with addiction like human beings. And surprisingly, when you treat people well, they tend to treat themselves better.

GROSS: So what do you think of interventions? And interventions are usually organized by family or friends who have watched their loved one just really deteriorate mentally, physically and who won't recognize that they have a problem, that they're an addict, that they need help.

And they fear - they feel that the only way to save the person's life and the only way to prevent them from further hurting the lives of the people who love them is to force them to get help through an intervention.

SZALAVITZ: Well, I can tell you that there's a method that is twice as effective as intervention that has been shown in multiple studies to be twice as effective as that that doesn't do that confrontation, that doesn't threaten the person with being thrown out of the family, that doesn't have the potential risk that, you know, Kurt Cobain shot himself after an intervention.

Interventions often backfire. A lot of families don't want to go through with interventions because they feel like they're being cruel. And often, they are being cruel. So what is this alternative approach? It's called community reinforcement in family therapy. The acronym is CRAFT. And in this approach, what happens is parents and other loved ones are taught ways of helping the person with addiction see for themselves why change is a good idea.

And this is done through offering hope, through not rejecting the person. Now, obviously, if you have somebody who is addicted and is doing things like putting younger children at risk, stealing from you, being violent, any of these things, that's not acceptable. And you may need to cut them out of your life. The thing is you can't assume that cutting them out of your life is going to help them.

You need to help yourself first, you know, just like putting on the mask on the airplane. But you have to also realize that with addiction and particularly addiction combined with mental illness, putting somebody on the street is not going to be helpful to them. Again, there are times when it may be necessary.

But mostly, people find that if you help people develop their own motivation for recovery, they are much more likely to get into recovery and stay in recovery if you do it that way than if you do the big confrontational intervention.

GROSS: So, you know, a lot of people have been able to give up their addiction, whether it's drugs or alcohol, with the help of 12-step programs. And I think it's fair to say a 12-step program helped you, although there are things that you found were not helpful within the program.

But you say, like, just relying on 12-step programs is the equivalent of saying to somebody who has cancer, we're not going to give you any drugs. But here's a self-help group. It's really going to help you.

SZALAVITZ: I think the 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. We don't tell people with cancer that you must learn to surrender to a higher power, to pray, to confess to your sins, to make restitution.

If you went to a doctor for cancer and you were told that, you would think that you had found a quack. But in addiction, if you go to a treatment center, you will be told this is the only way. And the alternative is jails, institutions or death. So what I think is that we need to have within professional treatment no 12-step content.

That doesn't mean that professional treatment can't refer people to AA as a support group. But professional treatment should consist of things that you cannot get for free elsewhere. So it should consist of cognitive behavioral therapy or motivational enhancement therapy or any of a number of different talk therapies that help people with addiction. I am not saying if 12-step programs work for you, you should quit them and do something else.

I am saying that your oncologist is not your breast cancer support group.

GROSS: But, I mean, 12-step programs do help so many people.

SZALAVITZ: The data shows that cognitive behavioral 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 de-stigmatize addiction, we need to get the 12 steps out of professional treatment and put them where they belong as self-help.

And I think that if we also want to de-stigmatize addiction, we can't simultaneously criminalize drug possession because criminalization, the whole point of it is to stigmatize you.

GROSS: Let's take a short break here, and then we'll talk more about addiction. My guest is Maia Szalavitz. She's a journalist who's covered addiction for nearly three decades. She was addicted to cocaine and heroin as a teenager and young woman. She's been sober since the age of 23. Her latest book is called "Unbroken Brain," and it's about looking at drug addiction as a developmental disorder and a learning disorder.

So we'll be right back after a break. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR, and if you're just joining us, my guest is journalist Maia Szalavitz. She's covered addiction for nearly three decades. She was addicted to cocaine and heroin as a young woman. Her latest book is called "Unbroken Brain," and it's about treating addiction as if it were a developmental or learning disorder.

So people who are addicted to prescription painkillers, to those Opioids, one of the approaches being used now is Buprenorphine, which is - why don't you describe what it is?

SZALAVITZ: Sure, 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, which makes one better for some people and one better for other people. 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. In fact, if I was on it right now, you couldn't tell. The way they're 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, oh, if you take Methadone or Buprenorphine, you're just substituting one addiction for another. You're still high.

You know, they are just not really in recovery. There's all this prejudice. What people don't understand is that it's not like substituting vodka for gin. If you substitute vodka for gin, you're still drunk. But if you take an Opioid at a steady-state dose that is adjusted properly for you, you are not going to be high.

And so the analogy fails. And another thing that I think is important here is that addiction is compulsive behavior despite negative consequences. Physical dependence is needing a drug to function. So when maintenance works best, what it does is it replaces addiction with physical dependence.

And physical dependence isn't necessarily a problem. It's not destroying my life. I'm not robbing drugstores to get it. I am not addicted to it. Does that make sense?

GROSS: Yes, except that part of the robbing the drugstore thing is not even the addiction so much as it is it's expensive to support your habit. It's illegal to support the habit. So there's this whole underground lifestyle that is developed that also is a lifestyle based on desperation, which is where the robbing comes in.

So, you know, it's hard sometimes to see, like, what behaviors come from being driven underground, by being desperate for money to pay for drugs and what behaviors are just consequences of the drugs themselves?

SZALAVITZ: And that's a really important point. There are countries in Europe and I believe Canada as well that actually do heroin maintenance. They provide pure, clean heroin to people with heroin addiction. And you would think, oh, my God, this is the ultimate in enabling. This is going to be a disaster. In fact, what happens is they get their lives back together.

They take a steady dose. They're not getting high. In some instances, they are. But for the most part, they're just taking it every day. They can go to work. They can do the rest of their life. And what's really interesting is these people who do get access to heroin maintenance are more likely to get into abstinence recovery than people who don't.

GROSS: I want to get back to Buprenorphine. Doctors right now are limited to having a hundred patients who they're allowed to prescribe it to. President Obama would like to raise that to, I think, 250 patients that each doctor is allowed.

SZALAVITZ: Two-seventy-five. Two-seventy-five, thank you.

GROSS: So is this because buprenorphine is being sold on the black market and this is a way of keeping the drug off the black market by limiting it to a certain number of patients per doctor?

SZALAVITZ: Yeah. And, I mean, it's a really dumb idea. We have no...

GROSS: ...Wait, limiting it - you think that's a dumb idea?

SZALAVITZ: Yeah. We have no limit on the amount of opioids doctors can prescribe for pain, but we do have a limit on the amount of opioids they can prescribe to get people into recovery.

GROSS: So are some people buying buprenorphine on the black market because they want to get off of heroin or prescription opioids and they can't get prescription buprenorphine?

SZALAVITZ: Yes, that's exactly why they buy it on the black market. The black market would dry up if we actually provided enough access to buprenorphine treatment with low threshold for people who just want to take the drug and don't want to do counseling and just want that reduction in overdose risk and have different systems for people who do want to get into recovery. But yes, we're creating the problem of diversion by restricting it the way we do. Buprenorphine is no one's first choice in terms of getting high on opioids. Heroin is way better.

So the people who are using buprenorphine on the street are overwhelmingly people who are addicted and who either just want to avoid withdrawal, want to try to, you know, begin to straighten up their lives, but they can't get into a clinic, they don't want to deal with the hassles of the clinic. These are the kinds of things that create barriers to it. I think that we should have it so that if you walk into an emergency room and you're in withdrawal, you can just get a dose of buprenorphine no questions asked. And you can do that as long as you want. And then if you want to go into a more formal program, you can do that, too. So...

GROSS: ...Well, now what's the principle that's behind the buprenorphine?

SZALAVITZ: Well, there's two different principles. One is you can get into recovery and you're on a steady state, you're not taking anything on top, and you just go on with your life. The other is as harm reduction. And in this instance, you're taking the buprenorphine, but you're taking other stuff on top of it. But what the buprenorphine is doing is it's giving you a steady state of tolerance so that you are way less likely to die if you overdose. So the idea that we should be restricting this thing that reduces the death rate really drives me up the wall.

GROSS: People who have been addicted and who've gone through recovery tend to speak of themselves always as a recovering addict. Not, like, a former, but a recovering. Do you feel that way about your own life, that you're still in recovery and that you're still on some level an addict?

SZALAVITZ: I'm of two minds about this. You know, my addiction lasted between age 17 and 23. And I will admit that I am in my early 50s now, so it seems kind of weird to define my entire life based on that one period. On the other hand, there was a lot of my early life that led up to that. And by saying I am in recovery, I also kind of remind myself that it would be a really bad idea to do coke or heroin. But in terms of what do I have to do to take care of myself, it's much more simple than it was during the first five years. So I think that it's a good reminder, but I'm also perfectly happy for many people to say you know what? I'm recovered. It's done. It's in the past. And I think that certainly there are people who grow out of it and they don't see it as an issue anymore. I mean, I still think that my brain, you know, changed wiring at that point. Is it completely different now? I'm not going to test it.

GROSS: Maia Szalavitz, thank you so much for talking with us.

SZALAVITZ: Thank you for having me.

GROSS: Maia Szalavitz is the author of the book "Unbroken Brain."
TERRY GROSS, HOST:

This is FRESH AIR. Ben H. Winters is a writer whose work has spanned different genres. His 2012 book, "The Last Policeman," won an Edgar Award from the Mystery Writers of America. And his 2013 book, "Countdown City," won the Philip K. Dick Award for distinguished science fiction. Winters's latest novel, "Underground Airlines," mashes together elements of the thriller with speculative history. Our book critic, Maureen Corrigan, says that however you classify "Underground Airlines," it's indisputably a winner. Here's her review.

MAUREEN CORRIGAN, BYLINE: One of the comforts of reading a work of so-called alternate or speculative history is being able to stop reading it. What I mean by that is - most novels that imagine the different ways the past could have played out imagine things going really, really wrong. Think, for instance, of Philip Roth's novel "The Plot Against America," in which Charles Lindbergh wins the 1940 election against Franklin Roosevelt and promptly signs a peace treaty with Germany and Japan.

An even grimmer variant on World War II history is Philip K. Dick's "The Man In The High Castle," where Germany and Japan win the war and divvy up the United States between them. And at the more sci-fi-ish end of the spectrum is Margaret Atwood's "The Handmaid's Tale," in which a Christian terrorist group takes over the U.S., suspends all constitutional rights and renders women completely subject to the rule of men.

As ingenious as these novels are, it's also a relief to leave their worlds and hightail it back to the broken but nonetheless better real world that we readers live in. An extraordinary new novel of alternate history, however, refuses to deliver that payoff of relief at the end. Instead, "Underground Airlines" by Ben H. Winters jolts readers to a heightened awareness, making us see just how much of the nightmare of what could have been is part of the all-too-familiar reality of what is.

"Underground Airlines" imagines that the Civil War never happened. Rather, Lincoln was assassinated before he took office. And in an act of compromise, some states were allowed to maintain slavery. Those slave states, known as the Hard Four, consist in the present day of Louisiana, Mississippi, Alabama and the reunited Carolinas. They're demarcated from the rest of the U.S. by heavily patrolled borders.

The other states in the Union have agreed that any slave or person bound to labor, as they're called, must be returned to the corporate plantation from which they've escaped. That's where Victor, the anti-hero of this noir-ish novel, comes in. Victor is a bounty hunter working for the U.S. Marshals Service. He's adept at infiltrating abolitionist groups and retrieving runaways because he's black himself. Or rather, as Victor precisely tells us, he's moderate charcoal with brass highlights, which is one of the 172 varietals of African-American skin tone delineated in the U.S. Marshals Service field guide.

When the novel opens, Victor is sitting in a diner in Indianapolis with a Catholic priest who's suspected of running a rescue cell of what's called the Underground Airlines. Victor is posing as a husband, a free man desperate to rescue his wife from enslavement in a strip mine in western Carolina. That's all just a ruse, of course.

The person Victor has been assigned to find is a runaway named Jackdaw, who's escaped to Indianapolis from a plantation in Alabama run by the Garments of the Greater South corporation. Victor's voice, melancholy and wry, leads us through the labyrinthine hunt for Jackdaw, as well as through the puzzle of his own identity and why he's working as a bounty hunter in the first place. Let's just say that Jackdaw isn't the only fugitive here on the run from the unbearable.

Like all great works of suspense - and this is one suspenseful tale filled with double crosses and dangerous expeditions down drainage tunnels and into plantations - "Underground Airlines" is hyperattentive to details. The world Winters conjures up is chillingly credible. It's a world, for instance, where the righteous pride themselves on eating food and buying clothes that have the so-called clean hands seal of approval, meaning they haven't been produced by slave labor.

It's a world where persons bound to labor are branded at the base of their throat with the tattoos of their corporate owners. Anti-slavery activists voluntarily sport similar tattoos in solidarity. And it's a world where every city in the North has its freed man town. In Victor's description, a neighborhood of ramshackle houses and crumbling high rises crammed to the gills with the poorest of the poor, living hard - the forgotten children of forgotten children.

In "Underground Airlines," author Ben H. Winters has imagined not only a disturbing but plausible alternate reality for the United States. But as a white author, he's also imagined himself into the body and consciousness of his black narrator, Victor. These days in particular, that's a controversial move. But the exceptional novel that results seems to me to be justification enough for such an act of creative crossing.

GROSS: Maureen Corrigan teaches literature at Georgetown University. She reviewed "Underground Airlines" by Ben H. Winters.
Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.