A Really Good Day

by Ayelet Waldman

  Because we believe that the refusal to be honest will eventually hurt our children, my husband and I have adopted a harm-reduction strategy when it comes to issues like drug use. Harm reduction is defined as a set of practical strategies and ideas aimed at reducing negative consequences.*2 The basic tenets of harm reduction when it comes to drugs are that drug use is a fact of contemporary life, that drugs can be dangerous, and that it is possible to minimize the harm. Harm reduction is not incompatible with disapproving of drug use, but it is incompatible with denying that drug use exists.*3

  The truth about drug use is so much more complicated than we want to believe. It’s certainly more complicated than our drug education programs allow. Take, for example, Project D.A.R.E. (Drug Abuse Resistance Education), the most popular drug education program. For twenty-five years, D.A.R.E. persisted in miseducating children that all drugs, from marijuana to methamphetamine, were similarly dangerous; all drugs would destroy their brains and lives. Numerous reputable studies proved that the “facts” D.A.R.E. was pushing were both inaccurate and ineffective. Research showed that children who participated in D.A.R.E. programs actually experimented with drugs at higher rates. This makes sense. A seven-year-old hears that the demon weed will sizzle his brain and thinks, I’ll never do drugs! A cynical fourteen-year-old hears the same message, notices that her cousin the pothead just graduated magna cum laude from Harvard, and dismisses not just the misinformation about marijuana, but everything else the D.A.R.E. program has to offer. It was only in 2009, with its funding sources at risk, that D.A.R.E. finally adopted a science-based approach, focusing on honesty, safety, and responsibility.

  Recognizing the context in which teenagers live is critical to helping them make good choices. And the context in which our children live is one in which drugs are a constant presence. According to a 2014 study funded by the National Institute on Drug Abuse (NIDA), more than half of high school seniors report having tried illegal drugs.*4 And these are self-reports! The figure might even be larger, because people tend, if anything, to under-report illegal activity.*5 Forty percent admit to having used an illegal drug in the previous year, and 25 percent in the previous month. The rates of alcohol use are even more striking. Fully 68 percent of seniors say they have tried alcohol. Given these numbers, a parental policy exclusively focused on abstinence is not only deluded but dangerous.

  Most people are familiar with Mothers Against Drunk Driving’s “Contract for Life,” in which the child agrees not to drive drunk but to call for a ride, and the parent agrees to provide the ride without judgment or consequence. This is a classic harm-reduction model. None of us wants our children to abuse alcohol or drugs, but even less do we want them to fear our wrath so much that they take a ride that ends up killing them. Studies show that the flexibility in thinking that allows your teens to learn is what also causes them to be more likely to engage in an unknown risk (drunk driving, possibly dying) than a known risk (being yelled at by Mom). It’s as though the very thing that makes them smarter must first make them stupid. My husband and I feel that the best way to combat this stupidity is with information.

  Giving kids accurate information about drugs is particularly critical right now, because we are currently experiencing a dramatic increase in opioid use. This is hardly surprising, given the massive amount of advertising dollars pharmaceutical companies have invested in these drugs. More than a decade of intensive marketing and overprescription of painkillers like Oxycontin, Percocet, and Vicodin has led to skyrocketing use and abuse rates.

  It’s important to recognize that these drugs aren’t in and of themselves evil. They are invaluable for treating acute pain. The morphine I was given immediately after my Caesarean sections helped alleviate what otherwise would have been intolerable agony. Moreover, opioids, if taken under proper conditions and without adulteration, aren’t particularly physically harmful. If you take opioids in appropriate doses and don’t mix them with alcohol, you will not die. When opioids are given for limited periods of time to deal only with acute pain, such as the pain of surgery or the pain of dying of a disease like cancer, addiction is generally not an issue. To the dying, addiction is irrelevant, and for those dealing with acute pain, once the pain resolves, so generally does the need for the drug.*6 Only rarely does a patient become addicted after just a few days of opioid use.

  It is when these drugs are prescribed over the long term for chronic pain that problems occur. There is a growing consensus that there is little evidence that opiods are reliably useful in dealing with chronic pain.*7 Patients report that the drugs become increasingly ineffective over time.*8 Moreover, with prolonged use, the risk of addiction rises.

  The CDC believes that the best way to stem the tide of opioid abuse is to reduce the number of “unnecessary prescriptions” by physicians. Though on first blush this seems sensible, it ignores the fact that the rise in heroin use is not so much a result of the overprescription of opioids but of overprescription followed by prohibition. When patients are no longer able to receive prescriptions for the opioids on which they have become dependent, when pills are reformulated to make them more difficult to abuse, or when pills become prohibitively expensive, patients start searching for alternatives to stave off withdrawal. That’s when they discover heroin, a cheaper and more potent way to get the same kind of high. According to the CDC, the numbers of people who report using heroin has doubled in the last decade.*9 Heroin is, next to tobacco, the most addictive drug we know of. According to the National Institute on Drug Abuse, nearly one-quarter of the people who use heroin end up becoming dependent.*10

  This has led to a dramatic increase in overdose and death.*11 In particular, the fatal heroin overdose rate, which was stable throughout the early years of this century, has gone through the roof. Heroin is produced and distributed by criminals operating outside of any regulatory system and, unlike prescription opioids, is not regulated for potency and purity. Fatal overdose is thus far more likely. Recently, for example, heroin dealers have begun lacing their product with easily obtainable fentanyl, a highly addictive synthetic morphine alternative that is thirty to fifty times as potent as pure heroin. The results have been catastrophic.

  My older kids go to college on the East Coast, and we spend part of the year in New England, which is ground zero for the heroin epidemic. In the increasingly likely event that one of my kids witnesses an overdose, I want them to know that they must immediately dial 911. I don’t want them to follow the fatal course of action of so many other frightened teens, desperately immersing an overdosing friend in a tub full of ice water, or dumping the person in a hospital parking lot, to expire in a pool of his or her own vomit.*12

  I have recently changed the message I give my kids when it comes to stimulant drugs such as methamphetamine. My kids tease me that my three phobias are rats, sharks, and methamphetamine. As disgusted as I am by rats (even the cute ones my eldest keeps as pets), as confident as I am that I will be chomped in half by a Great White if I so much as paddle in the ocean, the street drug known as “crank,” “ice,” or “crystal” has, for years, really scared the shit out of me. When I was a federal public defender, I had a client with cardiomegaly and congestive heart failure caused, according to his cardiologist, by repeated exposure to methamphetamine. I used to tell my kids that methamphetamine is so toxic that it would kill them, and so addictive that a single experience with the drug could lead to dependence. It was only while researching this book that I realized I’d been inadvertently lying to them.

  We’re going to take this next part slow, because it’s going to contradict everything you think you know about meth. It certainly contradicted everything I thought I knew. What I learned was so hard for me to believe that I had to read and reread the studies several times. I asked Dr. Carl Hart, a Columbia University neuropsychopharmacologist and the country’s pre-eminent researcher on methamphetamine,*13 the same questions so many times that eventually he got sick of repeating himself and stopped answer
ing my e-mails.

  Here goes:

  Stimulant drugs like methamphetamine are dangerous. According to the Drug Policy Alliance, “Increased or prolonged use of methamphetamine can cause sleeplessness, loss of appetite, increased blood pressure, paranoia, psychosis, aggression, disordered thinking, extreme mood swings and sometimes hallucinations.”*14 There is some evidence that it causes long-term cognitive harm. A 2010 study found that methamphetamine users performed worse than nonusers on tasks associated with daily functioning (dealing with finances, communicating, managing medications and transportation).*15

  However (and here’s where you’re going to start hearing things that will surprise you), the extent of this impairment seems to be less dramatic than we’ve been led to believe. According to Dr. Hart, though long-term effects have been observed, cognitive functioning of meth users generally falls within the normal range.*16 We hear a lot about the deleterious effects of the drugs, Dr. Hart says, because researchers studying drugs like methamphetamine or crack cocaine tend to view any and all differences, no matter how small, as clinically significant. This, he says, is a reflection of bias, not of fact. Researchers see effects from drug use because they anticipate seeing effects from drug use.

  And what about those negative behavioral effects of stimulant use? The crimes and violent outbursts? These do occur, though Dr. Hart insists that the dangers associated with stimulants are over-reported in the media. The evidence shows that antisocial behavior associated with methamphetamine is less common than we think, and more likely to be a function of circumstances such as poverty, trauma, and the presence of a criminal marketplace than of drug-fueled rages.*17

  The most damaging physical effects of stimulant use appear to be tied to their effects on sleep. According to Dr. Hart, “Low to moderate doses of amphetamine can improve mood, enhance performance, and delay the need for sleep. Repeated administration of large doses of the drug can severely disrupt sleep and lead to psychological disturbances, including paranoia.”*18 It’s sleep deprivation, not crack or meth, that makes some people crazy.

  What about meth mouth? We all know what that looks like, we’ve seen the photographs! The pretty white girl with blond hair and blue eyes, turning before our eyes into a haggard crone with a mouthful of snaggly brown stumps. Methamphetamine restricts salivary flow, leading to xerostomia—dry mouth—which, if left untreated, can cause tooth decay. But so do all stimulants, including Adderall! Adderall and other stimulants are among the hundred most prescribed drugs in the United States, and yet we don’t have an epidemic of “Add mouth.” One of my kids has ADHD and has a prescription for Vyvanse, an amphetamine that works just like Adderall. Not only can this child finally sit still through a test, but he has gloriously sparkling teeth, a function of his profound commitment to dental hygiene—the best, according to his dentist, of any teenager she’s ever treated. According to Dr. Hart, “The physical changes that occurred in the dramatic depictions of individuals before and after their methamphetamine use are more likely related to poor sleep habits, poor dental hygiene, poor nutrition and dietary practices.”*19 As hard as it is to believe, “meth mouth” is a myth, a function of media sensationalism.*20 Some even theorize that the hype around meth mouth is actually an expression of horror at the loss of white privilege, a warning that if whites are not careful they will descend into “white trash.”*21

  The addiction rates of stimulants are high, but not as high as those of heroin or nicotine, and most people who take methamphetamine will never become problematic users. Research*22 shows that the number of users of methamphetamine who go on to develop an addiction to the drug is 17 percent.*23 Yes, you read that right. Only 17 percent of people who use methamphetamine end up addicted to the drug. But here’s the thing. A rate of addiction of 17 percent is high. It only sounds low because the drug warriors and their media mouthpieces have led us to believe in the “one and done” myth. We’ve been told that a single dose of methamphetamine, a single puff of a crack pipe, a single injection of heroin, is enough to make an addict. But that’s simply not true in the vast majority of cases. Had we not been exposed to an aggressive campaign of misinformation that led us to expect something like a 99 percent addiction rate, we would be able to recognize that it is a very big deal if nearly a fifth of methamphetamine users and nearly a quarter of heroin users become addicted. Instead, we see those numbers and are confused.

  From now on, when I talk to my kids about methamphetamine, I’m going to stop doing a Google image search for “meth mouth.” Instead, I’m going to be candid with them about the drug’s high potential for abuse (“If you and nine friends try meth together, one or even two of you could end up addicted”) and about its negative effects. I’m also going to tell them what I always tell them about drugs: one of the worst “side effects” of drug use is arrest. If you are arrested for using drugs, our system can come down on you like a ton of bricks. Though of course my children share a quality that makes it unlikely that they will be arrested: they’re white. When they’re walking down the street, they will probably not be stopped and forced to turn out their pockets. Their black friends, however, face a very real risk of this.

  In addition to providing my kids with accurate information and having in place a system of consequence-free party pickups (made especially easy now with the advent of Uber and Lyft), our family harm-reduction policy has, since the incident at Wesleyan University when the group of students nearly died taking a drug they thought was Molly, included stocking a cupboard with drug testing kits, so if the kids try Molly or another club drug they can be sure they aren’t inadvertently taking poison. We also stock their bathroom cupboard with condoms, though recently one of our daughters has taken over this role, becoming a member of Berkeley High School’s “Condom Club,” distributing condoms to her friends. She’s a little Johnny Appleseed, but with johnnies.

  All this frank talk about risks and rewards can make a parent uncomfortable, even afraid. Abandoning the question of whether my kids use drugs, and focusing instead on minimizing the chances of their being hurt by drugs, feels sometimes like abdicating responsibility. But it isn’t. It’s actually a hell of a lot of work. You can’t just say, “Don’t smoke pot!” You have to go out and do the research. You have to explain to your kids that some studies have shown that marijuana can affect the developing brain in negative ways, so they should put off smoking pot for as long as possible.*24 You have to explain to them that alcohol is even worse for their brains than marijuana.*25 All this can be exhausting. So here’s an alternative: print out a copy of Safety First: A Reality-Based Approach to Teens and Drugs, a thoughtful, research-based harm-reduction guide for teens, parents, and educators, written by Marsha Rosenbaum, Ph.D., and published by the Drug Policy Alliance.*26

  A harm-reduction approach to parenting need not be permissive. My kids know how I feel about the risks and rewards of drug use. They know that there are drugs that I hope they will put off using until they are older (marijuana and alcohol), drugs I hope they will use only when they are older and under very circumscribed conditions (MDMA, psychedelics), and drugs that I hope they never use (methamphetamine, cocaine, heroin).

  But what about this experiment of mine? Although having a harm-reduction policy means that I don’t lie to my kids about drugs, it doesn’t require me to discuss anything I don’t feel comfortable sharing. I get to decide what I tell them about my own life. Though I have to admit that it feels dishonest, I’m not ready to be open with them about this. For now, I’m going to stick with “taking a walk.”

  * * *

  *1  This is an actual excuse I once gave my mother after, I believe, the first time I smoked pot.

  *2  The best-known example of a drug-related harm-reduction policy is a needle exchange program, in which drug users are provided with clean needles so they do not share dirty ones and thus expose themselves and others to potentially fatal diseases. According to the World Health Organization, needle exchange programs “substant
ially and cost effectively reduce the spread of HIV among intravenous drug users and do so without evidence of exacerbating injecting drug use at either the individual or societal level.” Dr. Alex Wodak and Allie Cooney, “Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users.”

  *3  If you listen closely, you can hear the sound of my children’s play dates and prom dates shriveling up and blowing away.

  *4  Sara Bellum, “Real Teens Ask: How Many Teens Use Drugs?”

  *5  Teenagers are really good liars. Especially to their parents.

  *6  Wilson Compton and Nora Volkow, “Major Increases in Opioid Analgesic Abuse in the United States: Concerns and Strategies.”

  *7  Charles F. von Gunten, “The Pendulum Swings for Opioid Prescribing.”

  *8  Pauline Anderson, “Scant Evidence for Long-Term Opioid Therapy in Chronic Pain.”

  *9  Rose A. Rudd et al., “Increases in Drug and Opioid Overdose Deaths—United States, 2000–2014.”

  *10  “DrugFacts: Heroin,” accessed June 27, 2016, at https://www.drugabuse.gov/​publi cations/drugfacts/heroin.

  *11  According to the National Institute on Drug Abuse, between 2001 and 2014 there was a sixfold increase in the number of deaths from heroin overdose; deaths from overdose of prescription drugs tripled (“Overdose Death Rates” at drugabuse.gov).

  *12  This was the fate of a twenty-four-year-old from Wilmington, Delaware, named Greg Humes, whose tragic death has inspired many parents to turn to harm reduction instead of insisting on an abstinence-only approach to drug education.

  *13  In 1998, Dr. Hart became the first African American tenured professor of science in the history of Columbia University. In 1998. I’m typing that twice because otherwise you’d probably think it was a misprint.

  *14  “Methamphetamine Facts,” accessed April 20, 2016, at http://www.drugpolicy.org/​drug-facts/​methamphetamine-facts.