238. Dismantling Purity Culture: Abstinence, Drug Use, and Harm Reduction with Sheila Vakharia

[00:00:00] Dr. Nicole: Welcome to Modern Anarchy, the podcast, exploring sex, relationships, and liberation. I'm your host, Dr. Nicole.

On today's episode, we have Shelia join us for a conversation about our right to bodily autonomy. Together we talk about meeting people where they are at consciousness, raising around set and setting, and moving beyond abstinence only paradigms. Hello, dear listener and welcome back to Modern Anarchy. I am so delighted to have all of you.

Pleasure activists from around the world. Tuning in for another episode each Wednesday. I'm Dr. Nicole. I'm a sex and relationship psychotherapist providing psychedelic assisted psychotherapy, author of the Psychedelic Jealousy Guide and founder of the Pleasure Practice Supporting Individuals in crafting expansive sex lives and intimate relationships.

Dear listener, purity culture. Wow. You know, we have had so many conversations on the show, dear listener, about my upbringing from purity culture and the ways that that has impacted me and all of us in the puritanical society around our sexuality. And the conversation continues because the purity isn't just about sex.

It's also about our bodily autonomy and the things that we put inside our bodies, whether it's a dildo, a penis, or some drugs, right? There's a lot of thoughts about what drugs are pure and what drugs aren't. And as a provider of psychedelic assisted work and all that I do in the drug space, it's important that we have these conversations because there is so much political work to be done in terms of drug reform and emphasis on psychedelic exceptionalism, where psychedelics are the only.

Good drugs and everything else is bad, right? And I really wanna have these important conversations here about the purity culture of bodily autonomy. Again, whether it's with sex, drugs, and so many other topics that we'll explore together in this space. And I'm here for the harm reduction and the pleasure enhancement of our use with sexuality and drugs.

And these are the essential conversations to be raising our collective consciousness on these topics. So thank you for sharing these episodes with your friends. Thank you for all of you who are having conversations about purity culture and how we need to dismantle this. And dear listener, if you're wanting to work with me and psychedelic healing, all of my links to work with me and the pleasure practice are linked below.

And so. Thank you for being here. Thank you for tuning in and I'm excited to keep learning with you in this space.

Dear listener, if you are ready to liberate your pleasure, you can explore my offerings and free resources@modernanarchypodcast.com, linked in the show notes below, and I wanna say the biggest thank you to all my Patreon supporters, and we have a new Patreon member. Hello. Hello. Pia, you and all the other Patreon members are supporting the long-term sustainability of the show.

Keeping this content free and accessible to all people. So thank you. If you wanna join Pia and the Patreon community, then you can head on over to patreon.com/modern Anarchy podcast, also linked in the show notes below. And with that dear listener, please know that I'm sending you all my love, and let's tune in to your today's episode.

Dear Listener, there's a space already waiting for you where you are invited to let go of every old script about sex and relationships, and begin living a life rooted in your pleasure. Empowerment and deep alignment. I'm Dr. Nicole, and this is your invitation to the Pleasure Liberation Groups, a transformative, educational, and deeply immersive experience designed for visionary individuals like you.

Together we'll gather in community to explore desire, expand relational wisdom, and embody the lives we're here to lead. Each session is woven with practices, teachings, and the kind of connection that makes real transformation possible. And I'll be right there with you guiding the process with an embodied curriculum that supports both personal and collective liberation.

This is your invitation into the next chapter of your erotic evolution. Say yes to your pleasure and visit modern anarchy podcast.com/. Pleasure practice to apply.

And then the first question that I like to ask each guest is how would you introduce yourself to the listeners?

[00:05:44] Shelia: Well, hi everybody. Thanks so much for tuning in. My name is Sheila, my pronouns are she her. I live in Brooklyn and I'm the Deputy Director of the Department of Research and Academic Engagement at a national advocacy organization called the Drug Policy Alliance.

And as an organization, we're working to end the war on drugs, and I get to help make sure that the policy advocacy we do is grounded in the best available research and that we're promoting policies that we believe are gonna help improve people's lives.

[00:06:19] Dr. Nicole: Such a joy to have you in the space. Thank you for joining us today.

[00:06:22] Shelia: Yes. Thank you so much for having me. Yeah.

[00:06:26] Dr. Nicole: One of the first questions I'd love to start with is hearing more of your story. How did you get into this space? Where did the passion start and, and what's keeping it alive for you today?

[00:06:37] Shelia: So I think I've always had a heart in advocacy and activism, uh, since I was growing up.

I grew up in a very kind of conservative rural white community. And as a brown person who wasn't Christian, who was a little bit on the outside, I very much knew what my experiences were, like feeling like an outsider. And so I was always drawn to causes and concerns and issues with people who also felt like they were on the margin.

Mm-hmm. And so, like advocacy and activism have been a really important part of my life since as far back as I can remember. And. I always wanted to help people and I thought for a long time that that would be through counseling and therapy. And so I studied psychology in college thinking I was gonna be a therapist.

Um, and you know, unfortunately you can't do a lot of counseling with a bachelor's in psychology. And that's when I learned about a master's in social work as a degree where I could practice working with people and helping people, but particularly people who are marginalized and facing a lot of challenges and oppression.

And so to me it seemed like the perfect way to get into the field. And it was through my master's in social work that I had the opportunity to work at a drug and alcohol outpatient addiction treatment program. And I saw that working in the field and.

Drug use impacts people from all walks of life. And in working in drug and alcohol treatment, I could work with people of all ages, all races, all socioeconomic classes and all different kinds of experiences. And so that's what kind of got me into the field of drug and alcohol use. However, one of the challenges of working in that kind of setting was how constrained we were by the approaches that we took and the hard lines that we often drew in terms of who could stay in treatment and what their treatment goals could be.

And um, how we engaged with external parties that often referred our clients to treatment, like the criminal legal system. Mm-hmm. And I saw that even though I wanted to be a client centered person, I wasn't actually delivering client centered or client driven care, uh, because the goals were determined by outside entities.

Compliance was dictated by outside entities, and it wasn't that client centered at all. And that's when I. Started exploring other ways to continue working with people who use drugs, and that's when I pursued a job at a syringe service program because I learned that at programs like that, we could really meet people where they were at and help them decide what their goals were and help them deal with the challenges that they were facing without that external pressure or structure, that I think limited how helpful I could be in the previous setting.

Um, and so I did that work for several years and decided I wanted to have a bigger impact on the field of social work and got my PhD and wanted to be a professor to teach future social workers on how to be harm reductionist. Did that for a few years, and after doing that for a while, I realized, you know, having an impact on changing who's providing care is really important, but maybe it's also the policies that are the problem.

Sure. Yeah. And so actually seven years ago last week, which will be a little bit longer from for our listeners. Yeah. But I took a foray and took a step into working in policy advocacy again, to broaden my potential impact and improve, uh, the conditions of people beyond those that I would just meet in a clinical setting.

[00:10:17] Dr. Nicole: Yeah.

[00:10:17] Shelia: And, um, yeah, and, and feel like I was still having an impact. Yeah. Beautiful. What, so that's, that's a, a somewhat succinct story of how I got here.

[00:10:27] Dr. Nicole: Yes, yes. What a journey. I'm excited to unpack a little bit more of that. I'm, I'm curious if you could speak to some of the constraints, the expectations that you were experiencing when you first got into the field that weren't harm reduction, you know, philosophy for the people who have never experienced that or understand what sort of limitations were put on you as a healer in that space.

Could you speak a little bit to that, to paint more of the layout of the land?

[00:10:55] Shelia: Sure, sure. So I worked in an outpatient treatment facility. That means it's not one where people sleep on site or it's some sort of program where you're away from home. Mm-hmm. A lot of people commute to treatment from home or from some other place that they're staying.

And so. The treatment facility was what we call an abstinence only treatment facility, meaning that in order to continue to receive care, but also in order to dictate whether or not you had succeeded at treatment, we looked at your abstinence from drugs as the key criteria. So if you weren't interested in pursuing lifelong abstinence from the drug, that maybe was the concern that brought you into treatment, but also all other potential drugs as well.

Um, this was not gonna be the facility for you. And if you walked in the door of this treatment facility and were still struggling with complete abstinence, which we would identify through drug testing, routine, yearend drugs, testing, we might say that this wasn't the best facility for you and you weren't succeeding or, um, meeting your goals and we might terminate you from treatment or refer you to another type of treatment.

So. The treatment goals being decided in advance, but also the criteria for being eligible to remain a participant in treatment were decided by the organization. And so that was really challenging. But also, you know, at any given time, about a third of our clients were mandated into treatment, um, and their completion of treatment was, uh, required as the condition of something else.

So, for instance, if you were on parole or probation, uh, or involved in a drug court over a drug charge or some other related charge, and your drug use was identified as the core driver potentially for your so-called crime or criminal engagement. The theory was that if you completed an abstinence only treatment, perhaps that could show some sort of rehabilitation to reduce the likelihood of you committing a crime in the future.

And then they could, that could be used as a condition to, to determine. Succeeding at parole, succeeding at probation, or whether you need to be locked up again on probation. There were also people who had children who maybe their drug use, uh, impacted their ability to parent or was decided by someone else to have impacted their parent, uh, parenting, right?

And so being sent to treatment and saying, if you complete this absence only treatment, you can see your children more often or keep custody of your children, or, uh, regain custody of your children. We also saw people who were mandated to treatment as a condition of receiving public benefits like Medicaid, healthcare or, um, cash assistance or food stamp assistance.

So these are low income marginalized people who are on the poverty line or below who are being told, we don't want to give you food or healthcare until we. See that you wanna deal with your drug use first and deal with your drug use in this very clear way.

[00:14:11] Dr. Nicole: Yeah. Listeners can't see our facial reactions.

[00:14:13] Shelia: Know, I know. I'm seeing your face right now. I was gonna comment,

[00:14:17] Dr. Nicole: that's America, right? Like, that's so wild. Let alone the understanding of the systemic reasons that are contributing to that. Mm-hmm. Right? Yeah.

[00:14:31] Shelia: Yeah. And so here I was naively mm-hmm. As an intern going into a treatment facility thinking, okay, I'm really helping people, you know, who are struggling with their drug use.

They wanna get help and we're gonna help them. And I just came to see that all of these principles that I was taught about, good clinical care, meeting your client, where they're at. You know, collaborating with them on goals and believing in their self-determination, believing in their agency and autonomy, believing the best in them.

All of those things were playing out in, you know, in the treatment setting, like in completely contradictory ways and in ways that actually disempowering to clients, but also facilitated distrust and mistrust between me and my clients, and often set them up to so-called, I'm gonna put air quotes here, fail when perhaps those weren't their goals to begin with, or that were setting them to so-called fail when their timeline just needed to look a little different.

They were gonna have some ups and downs and needed someone to be there with them throughout, but unfortunately we couldn't be that accommodating to people after enough positive drug screens or after enough, for instance, you know, struggles maintaining abstinence.

[00:15:52] Dr. Nicole: Right. I that's so sad to hear. Right.

They still need the support, but because they weren't passing the strict criteria, they no longer get it. What a world in terms of treatment or even just the thought that like, it's not important enough to them. They're not trying hard enough for that. Um, saying that some clinicians say, uh, I'm not gonna try harder than my client is like the effort that my client is putting into this.

Right. That's at least, um, I feel like I've been very, uh, sheltered because I have been training in a harm reductionist space, so I've never been in this alternative, but my supervisor who's more familiar with this, had talked about that sort of, uh, problematic messaging of clinicians coming in saying, I'm not gonna try harder than my client who's clearly not maintaining abstinence, so ugh.

You know, and just kind of tossing them aside in that way.

[00:16:40] Shelia: Yeah. Yeah. And you know, when I worked at the facility, I was the intake person. I did intake assessments for people walking in the door saying. I'm being mandated to treatment or I want treatment. Um, and you know, we have to assess, you know, what are their needs, where they coming from?

Like do they need this level of care or more intensive level of care? Are they treatment appropriate or um, could they get services somewhere else? And then I was also running the aftercare groups for people who had phased down through treatment after being with us for several months. You know, reducing hours per day or days per week as they were transitioning and getting, you know, getting ready to treatment.

What was to me is that the people that I did intakes on rarely ever made it to aftercare. And you know, one of the things that I was told was exactly what you said. You know, that some people don't want it enough, that some people are gonna fail. You know, air quotes again, that, you know, some people need to sit, hit their so air quote.

Rock bottom. And, um, you know, not everyone's gonna make it. Not everyone wants it bad enough. Um, and, you know, my colleagues and the broader messaging that I was getting was, it was a client level problem, not like a systemic problem or a structural problem. Um, and that this is the nature, nature of a, you know, so-called nature of addiction.

This is the so-called nature of, of what treatment looks like in, in America. And to me that was a tough pill to swallow. Yeah. You know, coming in from the outside, um, again, it almost made it seem like all of these things that I, and like, you know, so-called platitudes that I was taught. My clinical almost didn't apply to people who use drugs or had addictions.

It was like client centered. Sure. For a child who's living with ADHD and struggling with schoolwork, and if you're a school social worker, you wanna meet that kid where they're at, you know, they're struggling developmentally. Like let's talk about, you know, the accommodations you can advocate for in the classroom.

Or you know, say you're doing marriage and family counseling and you know, you're working with two spouses who are really struggling with each other and you wanna hear each spouse and each of them has valid complaints and concerns. Or, you know, you're working at a psych ward or a psych unit and this person living with schizophrenia is gonna, you know, have challenges differentiating between what they think they're hearing and what they're actually hearing and like how do you work with them and all of this compassion and client centeredness and all these values that we're seen as like, yes, those should be the undergirding everything about your work.

Almost like you throw it out the window when it comes to addiction. Like they were exempt. You know, they are by nature manipulative. They cannot be trusted. They dunno what they want, they dunno what's best for them. They're hedonistic. They only think about this moment. You have to, you actually have to take on a more paternalistic role 'cause they don't know what's good for them.

Mm-hmm. Um. Yeah, yeah,

[00:19:38] Dr. Nicole: yeah. I'm hearing the disease model, you know, there's something so wrong with them. Right. That it's a different category. Yeah. And I'm also just hearing a lot of the different ways that the field of psychology often puts this individualistic focus, right? The D sm, these different things that like, yeah, this is the individual and their problem and their issue, rather than that larger systemic view that should be taken into account for all diagnoses, but especially drug use.

I think about Rat Park and the research there, right? Mm-hmm. Yeah. I talk about that all the time on the podcast, and just a deeper understanding to what's going on relationally, you know, systemically and both personally in each person's life, that has contributed to a unique circumstance here. Rather than just saying, oh, they, they don't want it bad enough.

This is just who they are in their bones, right? All that sort of problematic messaging.

[00:20:31] Shelia: Yeah. And that it's not just. Right. Yeah. The DSM creates sickness, but it's also badness. Badness. Right. And I think the drug use has always kind of walked that line. You know, historically, in many societies, not only in America, but other societies, there's always been norms around acceptable and unacceptable types of substances or psychoactive use.

And, you know, there's been parameters around what is acceptable, what isn't. And oftentimes, in many cultures, people who can't ascribe or, you know, do not ascribe to those very narrow ideas of what is acceptable use, are shunned and stigmatized. And in many cases, seen as they're, you know, I'm saying bad.

Right. And in a, in a country like the United States, when you think about the unfolding of our policies and laws around psychoactive drugs and mood altering drugs. We drew clear lines around who becomes a patient to be able to get certain drugs and who is bad and should be punished for using certain drugs.

And I talk about this a lot in chapter two of my book, um, around like, how is it that certain people got medical access and certain people who got their drugs on the street or used, you know, drugs that were criminalized or not regulated mm-hmm. Were then seen as criminals. And I think that that fundamental tension of like badness, criminality with certain kinds of drug use has then, you know, been complicated by how we talk about certain patterns of drug use as diseased or ill, right.

Or disordered. And you know, people who use drugs and people who use illicit drugs and people who have illicit drug use disorders. Walk this of being both bad and sick. Mm-hmm. Absolutely. That we don't really see when it comes to other kinds of diagnoses or other, actually forms of criminality, like other so-called forms of criminality that people get arrested for.

Right? Drug possession being one of them with others, you know, people who engage in violent behaviors or people who've, who've, um, you know, stolen things or whatever. We don't necessarily pathologize that the same way. And drug use is very interesting in that it's both part of our criminal code, but it's also both, uh, you know, part of our medical system.

And, um, has it improved the material conditions for people who use substances? Has it, uh, led to improved health? Has it led to improved so-called public safety? You know, this bizarre confluence of punishment and. So-called treatment With this one size fits all approach, are we better? Are we healthier? Are we safer?

By all metrics, I would say no.

[00:23:25] Dr. Nicole: Mm. Right, right. This wanna hold space for that reality. Right. With your positionality of where you're at and what you see and like, and that right there, I think that's, uh, when you had first talked about abstinence only, I wanted to make sure we got to a, like, got to a space in the conversation where we could talk about the absurdity of that.

At least a bare minimum at a what are we abstaining from all drugs? Are we pulling like a full no coffee, no any, where are we drawing this line of what is considered abstinence? Right. Uh, prescribed drug where, and then just having that sort of like, deconstruction conversation about what exactly you're talking about.

The war on drugs, the war on people of color, all the different mm-hmm. Narratives that we have had, particularly in America about which drugs are bad and which drugs are, uh, medicines. Mm-hmm. Which drugs, you know. So I'd love to hear more of this deconstruction and just like pull it all apart for us.

[00:24:24] Shelia: Yeah, I mean, I think in traditional treatment, you know, the idea of abstinence is typically from illicit drugs, period, full stop.

You know, drugs that are controlled and are associated with penalties that you can be arrested for and incarcerated for. But yeah, alcohol is one of those drugs that's also included, despite it being a legal drug. However, um, you know, tobacco and nicotine products are in this interesting gray area because one of the things that we know is that people living with mental illness, people living with substance use disorders, people oftentimes who live in high stress situations, including oftentimes low income people, and people who haven't completed a high school education, are the populations who have some of the highest rates of nicotine and tobacco use.

Because, let's be honest, nicotine is a magical, wonderful drug in a lot of ways. Uh, boost mood. It can help mitigate kind of, for some people, even though we understand that it can increase anxiety, the act of smoking or puffing or vaping actually reminds you to breathe,

[00:25:35] Dr. Nicole: right?

[00:25:36] Shelia: And for a lot of people smoking a cigarette is a way that they take the edge off.

We know that for people on pretty heavy duty psych meds, that oftentimes, uh, a little bit of nicotine can help offset some of the, like, lethargic feelings or, you know, it can help suppress appetite, especially with certain meds that make you eat a lot or you know, you to weight gain. We know that for a lot of medications, constipation, especially when it comes to drugs, legal and illegal opioids, constipation is a reality and nicotine really helps your GI system get moving.

There are so many qualities and traits to nicotine, uh, that are actually quite. And people living lives that are complicated and challenging. Uh, unfortunately the most common delivery system is through a carcinogenic product, you know, through combustible tobacco. You know, and so one of the things that I remember, like, sorry, I'll just shift gears a little bit.

Sure. Because you know, when you're often at a rehab or a treatment facility, you know, like people go out and take smoke breaks. Um, and you know, if you go to Alcoholics Anonymous or Narcotics Anonymous meetings, people often congregate before and after meetings, smoking cigarettes outside. And, uh, while many of us understand that tobacco consumption can come with severe health effects, uh, you know, one in six deaths to this day can be tied to smoking, secondhand smoke or past, uh, smoke, you know, cigarette smoking, but.

You know, for a lot of time it was kind of exempt from the drug abstinence narrative. However, in recent years with more crackdowns on vaping and smoking in hospital systems, or within a certain radius of, of, of major buildings where people congregate, we're now seeing the playing out of tobacco prohibition or like anti-smoking narratives actually affecting the ability of people who have really serious drug and alcohol problems from getting the help that they need at treatment facilities.

Um, these anti-smoking or anti vaping policies and inpatient units in, in, in residential programs are often sadly a reason why people are terminated from care or leave ama, even though they actually need help with that abscess or they need, um, you know, to be on IV treatment with, for an infection they just got.

So it's complicated. We're in a moment where. Anti-smoking rhetoric and you know, clearly a public health intention is starting to harm people who use other drugs, which could kill them tomorrow. Right. You know, that next bag of dope that you buy, that's likely a highly potent batch of fentanyl could kill you.

And while yes, we should be talking about your tobacco consumption, is expecting you to cut off yourself from a drug that's helping you cope, that isn't gonna kill you tomorrow. Something that we're gonna terminate you from treatment for that you know, could lead you back out onto the streets shooting a bag that could take your life.

That is an interesting, I know I took us in a slightly different direction, but that's, that is a thing that's really been concerning me lately. And I, and I'm not the only one, you know, there are a lot of people in treatment facilities and harm reductionists who are flagging the alarm that these so-called like well-intentioned anti-smoking policies that are popping up.

Across the country, are they inadvertently, again, creating another threshold that is so high to keep people in treatment that people are facing treatment, termination for their tobacco consumption.

[00:29:21] Dr. Nicole: Right, right. Missing out on the help that they need. Uh, you had talked about meeting people where they are at.

What are we missing here? I have some thoughts, but I'd love to hear about the direction you'd love to take us in and this world that you're seeing.

[00:29:39] Shelia: Yeah, so there's this annual survey called the National Survey on Drug Use and Health. It's been conducted and federally funded since the seventies. It's funded by the Substance Abuse and Mental Health Services Administration, also known as samhsa.

[00:29:55] Dr. Nicole: Mm-hmm.

[00:29:55] Shelia: And it's a household survey that, you know, they literally stratify every state, create regional kind. And geographic, they cut lines across the country and try to figure out like how do we capture every demographic of person living in the United States and make sure we're representing each state accurately, but also, you know, rural and urban people of all races, you know, making it a nationally representative sample.

And what they do is they go door to door and they wanna get a sense like, what are the mental health challenges that people, the everyday American or resident is facing? And like also what's their everyday, um, experience of substance use? And have they been ever connected to treatment in the past? And, you know, what are, what's going on?

It's called like an epidemiological study. Mm-hmm. And so an interesting thing that comes from the national survey on drug use and health every year is that when they knock on these doors, they talk to anyone in the home over the age of 12 and they ask them about their lifetime, past year, past month, drug use experiences and.

Then depending on the kinds of responses, they often go through the diagnostic criteria from the DSM to see did any of these people meet criteria for an addiction substance use disorder? And one of the things that they find is roughly about 15% of Americans or respondents on this survey meet criteria for any sort of substance use disorder in the past year.

And that fluctuates a little bit. This includes alcohol and illicit drugs and prescription medications. And so then they asked these very specific subset of people who met the diagnostic criteria, you know, did you think you needed treatment in the past year? Did you seek it out? And did you get it? And did you complete it?

And when they ask these follow-up questions, what they find is that roughly 90% of people who met criteria for a substance use disorder did not receive treatment in the past year. And then they asked the follow-up questions, you know, did you think you needed it? And the majority would say no. Of those who said, yeah, I think I did need treatment.

And then they asked them like, well, why didn't you get it? The most common response is because I wasn't ready to stop using drugs.

When has a reputation that even the everyday person knows that walking in the door of a treatment facility means signing up for an abstinence-based program, and that's the reason why people who, the everyday person who knows that they might be struggling or might be concerned about their relationship with drugs is so deterred from walking in the door because they already know that that's not what they wanna pursue.

That's a problem.

[00:32:46] Dr. Nicole: Mm-hmm. Absolutely. I mean, as a Go ahead. Yeah, no, go ahead. I just, you know, as a sex educator, I think about abstinence only education. I mean, the parallels, I start to feel them, they're so, I mean, it's all about bodily autonomy, right? So the crossovers between the two start to become very apparent for me.

[00:33:05] Shelia: Yeah, yeah, yeah, yeah. And so that information should have been taken to heart a bit more by treatment facilities, policymakers. Experts, saying, why is it that the majority of the so-called indicated population who were trying to serve through the system, doesn't want what we're offering? And what instead ended up happening was, again, it's just used to perpetuate this broader narrative that, again, so-called, you know, and I'm using air quotes here, a word that I hate.

Don't want help. They don't want treatment. They don't wanna stop using drugs. They dunno what's good for them, right? Mm-hmm. And so instead of using the information from the survey to say maybe there's some other way, especially, you know, in light of an unprecedented overdose crisis or we've lost over a million people to drug overdose in the past 25 years, where we lost over 105,000 people last year and have lost over a hundred thousand people three years in a row.

Instead of saying maybe our treatment system isn't fit for purpose, maybe there are people who could be getting help, but that this system is not giving them what they would want. We just instead doubled down and said, oh, isn't it just tragic? Look at these people. They just don't, they, what's good for them?

They what? We offer the benevolent helpers. We're here, we're just waiting for them.

[00:34:40] Dr. Nicole: Mm-hmm.

[00:34:41] Shelia: Why aren't they coming?

[00:34:44] Dr. Nicole: Right. So the need to be able to create individual plans for each person in terms of what health and a relationship that feels beneficial to them for each substance, right? Rather than this abstinence only for everybody.

I assume that's what you're speaking to is, and just really slow down and be with each person. And that's certainly what I think about as a therapist, right? Like what is your relationship? What is going to be helpful for you, right? Mm-hmm. And so getting down into that individual level rather than this blanket answer that everyone needs to meet.

And if they don't, we're not gonna help them anymore,

[00:35:20] Shelia: right? Because you look at, you know, other so-called mental disorders or diagnoses, depression. We say we have some medications. Would you like to try them? Would you like to do individual counseling? Would you like to do group counseling? Would you like marriage counseling or family counseling?

Maybe exercise. Maybe a new hobby, maybe leave that job, maybe try and make new friends and you know, you're not a failure. If after six weeks you're still feeling sad. Yeah. And we wanna experiment on all the different ways that you can build up the strategies that work for you. Because for some people, the chemical aspect is real.

For some people the social element is real, the relational. For some people it's the isolation that's feeding into this. Why don't we get at the root of your individual experience of depression and where it might be coming from, what might be contributing to it, exacerbating it. Let's experiment and play with a variety of things that we've heard and seen that work for people.

And let's figure out what your plan should look like.

[00:36:36] Dr. Nicole: Yeah. Mm-hmm. Yeah. So part of the problem is the lack of education for therapists and all healers, right? In this, I'm not sure what you were taught in my school. I was lucky to have one class on drug use, and then it was also from someone who had a more harm reductionist lens.

So I was able to get a little bit of that. But that's not always the layout of the land that a lot of people are taught. It's often right, you hear, uh, drug use, okay, let's get them on a plan. Let's create this rather than, oh, what is going on in your life? That deepening of, uh, the roots like you're speaking to, rather than dealing with a symp uh, symptom, trying to get to the upstream thing that's causing that.

But I feel like a lot of healers get into this. Space where they immediately hear that, okay, how do we get to abstinence? How do we get to this? How do we get to that? Rather than actually going a little bit upstream to, oh, there's these relational things, oh, there's this, there's these other pieces. So I'm curious what you would recommend to other healers who feel like they just don't know where to take clients or, or people in their community when they hear this sort of content.

[00:37:44] Shelia: Yeah, I mean, it just reminded me of something that I wanted to bring up. So I'm gonna, I'm gonna get to your question, but Sure. It reminds me of a really key harm reduction principle. Mm-hmm. Which is don't take away what you can't replace. Yeah. And so much of how we approach drug and alcohol treatment is we take away drugs before we know what we're taking that away.

And before we've actually helped them build the coping strategies to potentially. That role or meet those needs or, um, yeah, like help, uh, help them live their day-to-day lives in a different kind of way. And I think that's a fundamental failure of how we look at drug use more broadly. We look at it as a, we still at some level see it as this like hedonistic self pleasure, reckless, the kind of selfish, uh, joy seeking rather than people use substances to alter how they feel.

And oftentimes people use substances too for maybe the first time take control of how they feel to autonomously be able to change how I'm feeling in this moment. And while yes, there are behaviors and thoughts and practices that can also change my. Like this, consuming this substance is the way that I'm doing that right now.

And that's the way I'm taking charge of my mental health. Mm-hmm. I'm taking charge of my bodily autonomy. It's how I'm deciding how to change and like take charge of my emotions. And what happens for some people is that it comes with a trade off. Right? And sometimes those trade-offs are worth it because how I'm feeling and how I need to not be feeling that right now is my top priority.

Um, and so I'm willing to deal with the tradeoffs. I'm willing to deal with perhaps some of the negative consequences and the challenges because they're gonna be a little bit longer term. But right now, how I'm feeling needs to stop or needs to be enhanced or needs to be changed. And if we can't truly get at that with people, you know, like, tell me about when you use, tell me about when you Right.

Crave, tell me about. In your body that needs to change. And like what happens during that first moment when you take that puff or do that line or do that shot. And it's almost scary for a lot of clinicians to have those conversations because they're almost taught that, like talking about drug use is gonna make them go out and use right away.

And while sure, maybe it might for some people, but maybe they were gonna use anyway, right? If you can't get to the core of understanding what is going on in my mind, when I'm seeking, when I'm using, when I know it's time, like I need to, I need to use right now. And how do I know it's working for me when and after those first puffs, after those first few drinks?

Or if I can't get there, then how can I expect you to just cut it off? Because like life is gonna happen. Yeah. When you walk out these doors, these feelings are gonna come back. You're gonna see that person. You're gonna be in that situation. You're gonna be alone, you're gonna be bored. I'm just expecting you to just somehow all of a sudden, because we've agreed you can't piss test positive anymore.

Right, right, right. That all of a sudden you're gonna walk out the door and know how to deal.

[00:41:24] Dr. Nicole: Right. Right, right. Exactly. Yeah. That's one of the first questions I, or one of the first pieces I feel like I was taught in my trading with harm reduction was to ask, how was it working for you? Right. Yeah. What are the benefits of your heroin use?

How is this benefiting you? People don't, people do things in, in a desire to benefit themselves. Right. I think when we think about other sorts of lenses like, um, abusive relationships and domestic abuse, there's a little bit more understanding of, okay, even though this overall is causing harm in their life, there's a sense of love and connection that this person is having, and so we're gonna have some understanding for that.

Yeah. Space for that and what that's doing for them in their unique context. Right. Which sometimes sort of somehow gets to be forgotten completely with drugs, right? I think because of this moral issue and all these other pieces that are on it, where in other circumstances we have a little bit more patience and understanding for the benefits that these things are giving to people.

And so taking that lens to ask, I, I, I find it kind of funny to think that it's gonna perpetuate use, the person's already use or this is already in their, ah, you know, it's already in their head just to ask why it's help. It's already there. And just the benefits of having, I just. When I think about healing, I think about connection and the fact that so many people feel like they can't talk to other people about their use because of the shame, because of all, you don't understand what kind of power of healing is there.

Just to have a space where the kids, oh, I can talk about this and why this is actually beneficial. Oh, and how then that creates a whole different world where they're no longer alone, they're rapport, the trust, the, the ability that has to actually create a lot of change and movement for someone can be radical just to talk about why this is feeling good to them.

[00:43:14] Shelia: Yeah. Yeah. And instead, you know, in traditional absence only settings, we often wanna know all about the negatives. What did you lose? Who did you hurt? How did you hurt yourself? You know, what could you have had that you don't? And it's very much like, again, so focused on the negatives. When oftentimes the positives are far more compelling and interesting and actually, um, gonna send people back, you know?

And, uh, yeah. You know, like, I think the analogy to like interpersonal violence is I think a really important one. Um, because, you know, we also took the same approach with survivors because we tell her, if he did all these things to you, why are you staying with him? Because the logical thing is don't stay with anyone who hurts you.

Right. And that like, very moralistic idea without truly acknowledging. And I'm gonna be like, I'm gonna use the gender binary for a second and talk about, you know, very like, heteronormative things. Just for a second though. But like this idea that, you know, a woman should be ever sacrificing, ever, ever compromising, ever loving unconditionally in service of her husband.

And we've raised little girls. Telling them that the whole point of everything is to like find a nice man, marry him and like become a wife, become a mother, become all these things. And then, you know, the traditional narrative was, you know, these women chose badly and for a long time we still didn't make it easy for them to leave men.

And now you look at like, historically, you know, generations of, of women who had nowhere to turn and oftentimes, you know, staying historically, but even today was an economic question. You know, when women couldn't even have their own bank accounts, when they couldn't have their own credit cards when they weren't working.

Or they'd been outta the workforce for a long time or hadn't gotten degrees or, or training. Um, you know, the economics of staying are quite rational and real. This in many cases is the father of my children. Um, but also you don't understand like when he's, sorry, it's so good, right? When he's, sorry, you know, the honeymoon.

Yep. You know, those, those moments, moments where, where all of a sudden now you come home and, and the home is clean and there's flowers and you know, the intimacy and the connection all comes back and, you know, you just wanna avoid the next time. And so those cycles, like we don't have a lot of compassion for people, for victims, right?

In general, in our bootstrap, you are the manage, you know, you manage your own destiny, you create your own destiny. You choose like all of these narratives. Now, also make it really hard for us to have compassion for people who don't make those always so-called logical decisions. Who find them, you know, who continue to stay in so-called bad situations.

How much should I be helping you for your so-called bad choices? You know, this goes back to the, you know, the narratives even about poor people and low income people. Are they at fault for being poor? We hold up these millionaires and billionaires as being, you know, models of what a hard work ethic can get you working, hard sacrificing and whatever.

Yeah. It's, it's all connected.

[00:46:42] Dr. Nicole: Oh yeah. Absolutely. I love having that discussion about, yeah, this example of domestic violence and all the cultural context that has been laden and that choice to leave, right? The complexities of all that holding that we can see that right now and hold that sort of understanding and then to think, could you imagine a clinician coming to that woman and saying, ah, she doesn't want it bad enough.

You don't want it bad enough, I'm not gonna help you more, no more treatment for you. Goodbye. Right? Like you would, yeah, we would say this is massively unethical. You are not seeing the larger, broader social context that are playing into that. And yet with drug use, we're like.

[00:47:26] Shelia: They don't want it. And if they wanna kill themselves, let them, if they need to hit their rock bottom, they have to, you know?

Could you imagine the narrative in the, the narratives, you know, in treatment facilities where it's like, look to your left, look to your right. One of you's not gonna make it. You know, the inevitable consequences of, um, letting your addiction wreak havoc is death or jail.

[00:47:53] Dr. Nicole: Mm-hmm. Absolutely. And that's, I think it is just so important to be able to see how in other contexts that logic no longer follows.

And I think that helps people to kind of illuminate the unique experience that drug is, and the narratives around moral disease model that start to come out, when you look at it in that logic, in other contexts, you say, well, that's absurd. We wouldn't be saying that. What is going on specifically in our culture about the narratives, about drugs that are particularly creating this sort of empathy fatigue, you know, these moralistic uh, thoughts for healers that are, are really getting in the way of, of showing up in a way that's actually client-centered, that's actually gonna make that change.

Mm-hmm. Mm-hmm. And I think too, I mean, just. When we're talking about bodily autonomy, I think you had said earlier that people get upset about this or, uh, you know, bothered by this concept of hedonistic pleasure, but isn't, I'd love to talk about that more, right? Like how pleasure, right, exactly.

[00:48:54] Shelia: We have such a complicated relationship as a culture with pleasure.

Yeah. I'm here for this discussion. Right. I think it's all connected. Yes. It's all connected. Right.

[00:49:07] Dr. Nicole: Yes, because we do drugs in theory for pleasure, right? I would say that when you are in your saddest state of possibilities and you're processing horrible atrocities, I'm thinking of so many of my different clients, and then they desire to use alcohol to get to a state where you stop feeling that's.

Pleasure, right? Like to not feel this pain anymore or to have that psychedelic trip, or to be outside in the cold and need to use meth so that you feel warm again, the pleasure, right? Mm-hmm. We have such a problem with the concept of pleasure, which again, it just mirrors so deeply for me when I think about, um, sex education, right?

Abstinence only. Abstinence only. And then we've gotten to a model, ideally in some places not all, where we at least at minimum get a harm reduction lens. Like, okay, these are STIs. This is how you use a condom, right? But then we still don't get that full discussion of, and it's supposed to feel good, and here's how we can use this to feel good, right?

I feel like harm reduction, um, similarly, you know, it's easy error. We're still struggling, right? We're, it's easier to get, um, more discussion of harm reduction, but what's that full continuum from harm reduction to pleasure enhancement and the pleasure side seems to be pretty taboo to talk about. Mm-hmm.

[00:50:31] Shelia: Mm-hmm. Yeah. There are so many parallels, right? Like, I feel like when it comes to, and I talk about this in the first chapter of my book, right? That we're so busy telling kids not to use drugs, that they're wholly unprepared, right? If in theory the first day they drink alcohol is at their 21st, first day, how do we make sure that they don't, you know, black out?

Yeah. Because we do as a culture, understand that if after the age of 21 you're legally allowed to consume alcohol, you know, after the age of 18 you're legally allowed to consume a tobacco product. Um, and on your wedding night, if that's the first night you have sex, 'cause you're supposed to now start having babies.

Right. Right. Um, and like the other thing is, is that it also assumes that you're never gonna get touched before.

[00:51:23] Dr. Nicole: Right.

[00:51:23] Shelia: And you know, one of the things that scares me so much about these conversations about taking sex ed outta schools is that so many children and young people are initiated into sexuality long before.

[00:51:36] Dr. Nicole: Oh yeah.

[00:51:36] Shelia: Um, they're old enough to consent and they don't know what's okay and they dunno what's not okay. They know it's an adult, they know it's supposedly maybe a trusted figure. Maybe they know it's their older sibling or cousin or family member. And when we don't teach people, the world teaches them.

Right. And oftentimes the world teaches them in ways that are setting them up to be hurt, that put them in danger, that are damaging to them physically and psychologically, um, and that that's gonna have ramifications for the rest of their lives.

[00:52:14] Dr. Nicole: Yeah, absolutely. Yeah. It was really eye-opening for me to record with Dr.

Rachel Smith, who does a lot of purity culture recovery groups, which is where I come from, and how I got to the space of being an educator of coming from purity culture to here. Um, and she had talked about finding research that had shown people who, some people who have gone through purity culture show the same symptoms as people who have experienced childhood sexual abuse, right?

This world of never being educated, never being prepared, and also the unique experience of grooming that that often creates for folks who are unprepared. And it was such a heart breaking conversation, but it's also such a reality and I'm thinking, yeah, a lot of crossovers, again, it's all about. Bodily autonomy, right?

The bodily autonomy to have pleasure with other people, the bodily autonomy to have pleasure with substances, right? And so in the same world where you're not taught about what safe, you know, use looks like for various drugs, then instead, you know, you're being educated from media. It shows that night of all the people partying, drinking alcohol, getting drunk, having this great experience is like, it's like the porn, right?

We'd never see the consent conversations. We never see how to have a safe experience. And so then, yeah, you're, you're 21, you're at college, here you go, right? It's just a complete lack of preparation, I think, because of, yeah, that fear. If I talk to my child about drugs, they're gonna do it. If I talk to my child about sex, they're gonna start doing it right?

Forgetting the reality that eventually. They'll be presented with it at some point. It's often sooner than you think, right? Mm-hmm. And so the benefit of being able to have those conversations and actually talk both about the, the risks and the pleasure, right? To be able to have that balance, not just a fear mongering.

Never, never do it. To actually get into that nuance balance of both, I think is where you see people thrive.

[00:54:03] Shelia: Yeah. Yeah, yeah. Because we don't, we're so afraid gonna hurt them. We don't how much we're actually our young people, uh, conversations. We're helping them understand what harm can look like, understanding what.

Not acceptable. Understanding what your boundaries are. Understanding that you should control what happens in your body, and you should always have a say what you put in there, whether someone touches it, what happens in your personal space. All of these things are so important.

[00:54:43] Dr. Nicole: Yeah. I wish I had control over how much plastics I've ingested over the years.

What did that have been or shit? That research about the, uh, tampons just came out. Did you see that one? Oh, I know. With the toxic metals. Yeah. I was like, cool. That would've been good to know. All, all those years, you know, pro bono birth control shit,

[00:55:01] Shelia: I just, I just saw meme on Instagram that was like, you know, it had a picture of like an, an older like grandparent or something and it was like, you know.

Their biggest concern, you know, like they were exposed to like arsenic. Yeah. Right. And then like, it was like the parents being like exposed to lead and then now like the young person being like, well, I've been consuming microplastic. Let's see what happens.

[00:55:22] Dr. Nicole: Totally. Totally right. Yes. There's so many different worlds where consent, I mean, yeah, you could have a consent conversation about all this sort of stuff for, for decades, and I hope I will in this space, right.

Of, oh, that none of this is lining up all across the board. And so to get into this sort of deeper conversation about what does bodily autonomy mean, right in all senses of the word for us here with these things, because I think. An informed consent conversation about risks. Oh, I would just love to talk about the risks of alcohol.

Right. I, I just find the absurdity of, of the, the legal ness, I mean, again, the war on drugs, the war on people of color, the narratives, all these different things, but for alcohol to be legal, which, you know, there was the prohibition years where we said this wasn't illegal and mm-hmm. And, uh, this wasn't legal and this was a moral problem.

But currently in our, our contemporary context, uh, alcohol is legal. Yet when you look at the charts of, of harm, right? Mm-hmm. Drugs that can cause harm, uh, both to yourself and to others. Mm-hmm. Alcohol is often the highest on that list of risk. Oh, can we talk about that just for a little bit?

[00:56:37] Shelia: That's like the informed consent I think we need, yeah.

I mean, like, at the very least, we should be having harm reduction conversations about alcohol. More than anything, it's the drug that is most commonly used in this country.

[00:56:50] Dr. Nicole: Yeah.

[00:56:51] Shelia: Uh, causes, you know, so many health issues and it's a driver of accidental death. It's, you know, a driver for, you know, various forms of morbidity and mortality.

And it's the drug that we just expect people to figure out how to stay safe with as it's fully legal. And like, this is where, you know, and I talk about this in my book, that harm reduction in public education and public health education should look like talking about the real risks of any drug, but also like the real strategies that we know that can help you stay safe with these drugs.

And like, you know, indicators and, and, and things that we should be mindful of that maybe we should pay attention to, to like reevaluate. Like maybe, um, you know, maybe getting a hangover a couple times in a month is something you should think about, like what was happening that month. Um, and while like a hangover isn't the end of the world for everyone, it can be the difference between getting a promotion or losing your job or missing that pickup for your kid, or, you know, missing a really important exam at school.

And like, how do we help people also long before they meet diagnostic criteria for a substance use disorder, catch themselves in these moments and like, reflect and say, huh, maybe how do I avoid that from happening again? How do I prevent that in the future? Maybe I need to reevaluate my patterns, frequencies amounts and who I'm with and where I find myself when I'm drinking.

That causes these moments for me. But absolutely. You know, I think the National Institute of Alcoholism and Alcohol Abuse, the Iaaa, you know, has developed some really interesting resources recently around like responsible drinking. And I would love, like for if, if you don't understand harm reduction when it comes to needles, at the very least, like we should be talking about harm reduction when it comes to alcohol, to start alternating water with, with alcohol.

Counting your drinks, knowing what's happening to your, you know, your blood alcohol content, knowing what kind of, um, you know, impairment you might be at. Who are you with, who are you keeping an eye out on? How are you getting home tonight? Have you eaten?

[00:59:00] Dr. Nicole: Yeah, exactly. I remember reading some research from the American Heart Association that had come out and said there was no safe amount of alcohol for that.

Mm-hmm. Yeah. No amount. Mm-hmm. No amount is safe. And that was such a, a, a game changer for me in a lot of ways to read about that research. Right. There was so much, oh, a glass of wine is healthy. Right. A you know, all this other sort of to Oh no, there's no amount that is actually safe for your heart. Right.

Sure. I think narratives, how do we get educated on both the risks, uh, socially, the risks of, um, your life, your job, but also yeah, that physical risk. That every sip of alcohol has, right? And how does that shape our collective consciousness to this drug? I've seen some pieces talking about how even just in like rave and music culture, there's um, significantly less purchasing of alcohol at these events going down.

And I'm wondering if, you know, the collective rise towards other substances is kind of contributing to that, especially even in Illinois where cannabis is legal. I've seen some ads that say like, Hey, use cannabis no hangover tomorrow. Right? These worlds where people are seeing other sorts of substances that can have less of an impact of, uh, a hangover that messes up your whole next day.

I think there's a lot of, um, shifting going on in terms of what sort of drugs are being more used in our culture currently.

[01:00:20] Shelia: Yeah. That brings up several things for me, right? First of all, I don't think that we as a society know how to talk about risk and harm in any sort of way that is like accurate.

Like I believe our health literacy as a nation is incredibly poor. We don't understand that like MSG isn't gonna kill you. It's about like how much MSG you're consuming. We don't understand, uh, again, that yes, you can say that like alcohol is legal, but we can also at the same breath say that like, alcohol comes with risk.

We wanna legalize marijuana. And in some ways marijuana is associated with fewer harms that perhaps come with alcohol. But marijuana still comes with its own risks. We don't see risk occurring on a continuum. We're very much a black and white society. Right? Right. For instance, even, you know, at the beginning of this overdose crisis, the ways that prescription opioids were being marketed by big pharma as being safe and so-called addiction proof formulations of opioids, when truly like, just because it's a medicine doesn't mean it's safe either, right?

All medicines come with risks, all medicines, even those that are prescribed and the ones that are gonna keep you alive can come with a risk. Even too much water, right, can be a risk, right? And I don't think that we as a society really, really know how to talk about risk and relative risk and gradients of risk and toler our how We all may have different tolerances for risk, right?

Because I'll never say that any one drug is so-called safer than another. It's just they have different risk profiles. Which risks can you tolerate? Which risks can you not tolerate? What comfortable with, whatcha not comfortable with? And are there strategies that we can teach you to reduce the risk as much as possible?

For instance, not mixing, not taking too much, starting slow, being around people who you feel safe and comfortable with. You know, being mindful of the time of day that you're consuming all of those kinds of things.

[01:02:27] Dr. Nicole: Right, exactly. Which often, you know, I think of therapists and healers as the first space to have that conversation, ideally.

Right. Someone that they could talk to about that. You could spend a whole session just unpacking that, right. This substance, what do you, where do you think it'll benefit? Where do you think there might be some risk to it? Right? And just having someone be able to have the space where they could unpack all of that would be radical because, yeah.

So much of our society is this black and white and in many ways, right? The good, good person, the bad person, right? The good drug. The bad drug, right? Psychedelic exceptionalism, right? Like mm-hmm. All of that is right there. Versus a nuanced understanding of each drug, each person, and then each situation, which is constantly gonna change a drug that maybe was super helpful for you in a some chapter of your life could be bringing up so much anxiety and distress to your life at a later time.

It's constantly gonna be moving. And so where. Do we have the space to have these sorts of conversations with someone who's educated on it, right?

[01:03:31] Shelia: Mm-hmm. Because education will then dictate whether you truly consent, right?

[01:03:37] Dr. Nicole: Mm-hmm.

[01:03:37] Shelia: You know, taking it back to your, your comment as well, it's like if people truly do not have all available information on hand, and if it's not presented to them in a way that's digestible, easy to understand and feels applicable to their life, and can like dictate a choice that they can actually make, do they even have choices that they can make with that information?

Then can we really talk about consent? You know, unfortunately, people who are currently using drugs from the underground market who wanna alleviate opioid withdrawal, who do find that opioids help them with their general mental health and their functioning, who find pleasure in using street opioids and illicit opioids.

Are they consenting to an unpredictable, highly adulterated supply when truly our society has not created any other option through to them. Mm-hmm. To be able to, uh, you know, actually consent to a known dosage, a known potency, a known quality of a substance. Our policies have dictated what kind of choices they can even consent to.

[01:04:37] Dr. Nicole: Right, right. And then the complexities of how patterning when you have an um. Not consistent space. Right. It's kinda like gambling, right? When you don't know what you're gonna get. Right. The, the joy that is then connected to that. So when you don't know what the dose is, when you don't know what it's gonna be, the sort of like patterning that that can create for that substance that is always different each time versus, I'd just be curious what a world would look like of being able to have access to these drugs in very controlled, dosed out, pure settings.

How that would create a very different relationship to it rather than this gambling poll of like, is this gonna be this high or where is it gonna be? Right. That sort of mm-hmm. Unpredictable nature often creates even more craving for it compared to a, oh, I know what I'm getting. I'm able to get this safely in that world.

I, I see a very different world of what our relationship could be if we had spaces, you know, I think yeah. Access to clean needles, right. But full spaces to be able to get these things in ways that were safer.

[01:05:38] Shelia: Yeah. And I mean, we've seen models, you know, since the. Nineties, you know, in Switzerland they've had heroin assisted treatment.

They actually had clinics. Um, and also there was the British model where, you know, doctors could knowingly prescribe heroin to people who are using street heroin and, you know, in various models being able to either, you know, inject on site or, you know, have, take home doses. But we've had models like that for decades because we understood that for many people, you know, the ongoing use of heroin was to manage and mitigate physiological opioid withdrawal symptoms, which are incredibly distressing and uncomfortable and take a toll on your body.

And people don't wanna have to deal with that. And, um, you know, here we are at this moment where during the COVID-19, you know, initial shutdowns, the Health Authority of Canada gave doctors the ability to prescribe known quantities and qualities of. Medic, medic as alternatives to street drugs to patients.

Mm-hmm. They called it safe supply or Safer supply. And, you know, a number of doctors across Canada started prescribing, um, opioids to their patients because they were like, we need you to beyond lockdown, be at home, be safe. We also know that the supply is gonna get really unpredictable and could get really disrupted on the streets, and we want you to be home and stay safe and not catch COVID.

Um, and so they were prescribing these various opioids, but also various stimulant drugs to patients that they were already serving. And what they saw was that people just got engaged and got plugged in, took him as, as prescribed, took them when they needed them. And for many people, getting that regulated access, let them decide how often do I wanna really use?

Mm-hmm. How much do I really wanna use? Is this the kind of life I want? Because now I can actually, like, I'm not about copying drugs every couple of hours, right? So now I'm able to pursue that job at that, you know, at that store that I work at. Or maybe it's time for me to start now committing to my I regimen or my Hepatitis medication regimen.

Or it's time for me to go back to school because now my mind is cleared up because I can dose myself. A few times a day, I'm not getting into withdrawal, but my mind is clear and I actually can get that degree that I always wanted. Right. Or start picking up my kids from school because I'm, that would be when I would start feeling sick and I would start copying and I wasn't there to pick up my kid from school.

[01:08:13] Dr. Nicole: Mm-hmm. Absolutely. Right. What a different world, what a different world when you see that out on a larger scale. Um, and I think about just even, yeah, the ways that we use these, these drugs that are often like so condemned in hospitals, but under different names, right? Yeah. Morphine heroin, right? Like all these, oh, it's okay to get it here, right?

Yet all, you know, so, ugh, the narratives. But I, I think about the fact that you talked about heroin. Heroin assisted treatment. And I remember that just brought me back to a moment in my training where I had done a presentation on psychedelic assisted psychotherapy in my class. And then I started, they started talking and basically my classmates were kind of bringing up concepts of psychedelic exceptionalism.

So then I brought up, oh, I mean, there's other paradigms where we use heroin assisted treatment. And everyone laughed at me in the whole room and the, the professor didn't stand up for me. I was doing a presentation, just looked at me ex expecting to kind of like address this situation. So I think that even in the, the treatment of, of therapy and healing spaces, me bringing that up created such a response from all the future clinicians of that's absolutely absurd.

And then I was kind of sitting in that of how do I. How do I even begin to break down some of these paradigms for them to see a different way? Yeah. These are our future clinicians in the room with me. Yeah.

[01:09:35] Shelia: I mean, we currently provide Wellbutrin assisted therapy. Right? Right. We provide, you know, um, Ritalin assisted treatment, which is essentially, you know, an amphetamine.

Right. We, we provide benzodiazepine assisted treatment. Mm-hmm.

[01:09:51] Dr. Nicole: So, yeah. Yeah. I think, again, it's the narrative when I say heroin mm-hmm. There is a whole slew of what that means and what kind of drug that is and who uses that and what for, right. And so that's what we're up against is like when we name these words and we name these drugs, the collection of all of the narratives where, oh yeah, well, oh, that's fine.

Like all these other drugs. Right. Drugs. And often morphine fine. Right? Like if it has a different name, it has a whole different slew of connections to it. Yeah. And so just the ways in which we need to have way more nuanced conversation about the narratives that we have been actively sold about these drugs.

[01:10:36] Shelia: Yeah, absolutely. I mean, whenever I give a talk on the history of the drug war, and I talk about this in my chapter two of my book is like, you know where the name heroin came from? No, let's talk about it. Well, at the turn of the 20th century in the United States, we did not. Criminalize, uh, morphine or morphine derivative drugs.

Um, we also didn't regulate or criminalize cocaine derived drugs. Um, cannabis tinctures, alcohol based tinctures, and Bayer Pharmaceuticals wanted to get into this market of helping to address pain, and they created a formulation of a morphine derived drug, diacetyl hydromorphine. And they marketed it and they named it heroin.

That was the name of the product that they created. And part of the reason why they made that name was because they said it made you heroic and strong. Mm wow. And, you know, at the turn of the 20th century, you could get a vial of heroin to use for your day-to-day aches and pain. Um. You know, this is before we really understand physiological dependence.

It's before, it's also before we developed anti-inflammatory medications and we understood also like what led to tuberculosis. We didn't have treatments so like, you know, opioids can suppress coughing. We also didn't, you know, understand how to treat GI issues, but we knew that opioids suppress the immune, uh, the GI system.

And then, you know, if you're, if you're having diarrhea, an opioid could stop that diarrhea. Mm-hmm. So, you know, back then we didn't under, we didn't have treatments for these conditions to get at the root of their conditions. Sure. And so like, yeah, opioids were kind of a cure-all and they were being marketed for a variety of things, you know, also like females so-called hysteria, you know?

Yeah. Right. And, and speaking of, go ahead. Yeah, no, no. So like, again, like that's also, I think a really important part of our history is like that these lines between drug medicine. And, you know, legal substances or readily available substances have always been blurry, have never been precise, have always been subject to change.

Those lines are constantly being drawn and redrawn. Just because the the lines look this way in this moment doesn't mean that they were always drawn that way. And it doesn't mean that they aren't changing. I mean, look at the way that we've been changing how the lines are around marijuana. Right. You know, it was a criminalized substance.

It was widely available that it became a criminalized substance. Then the medicinal potential started being opened up. Mm-hmm. People started to see it medicinally and then eventually we were like, maybe people could just also dip and dabble in this recreationally on their own terms, their own in ways that they could manage and stay relatively safe with.

And so we've been living through a moment and psychedelics are going through that same trajectory in a lot of ways where people are opening up to these potentials and if we can do that with these drugs, we don't have to stop. We don't have to, and I talk about this in the last chapter of my book, is that I hope that we're moving beyond drug exceptionalism.

Right. And that, you know, we don't just let, we don't stop at psychedelics. Right. And that we don't stop at marijuana. Right. But that we see that some of these general principles of harm and risk can be ones that we can use to make different decisions around how we wanna regulate and allow access to other drugs as well.

[01:14:02] Dr. Nicole: Mm-hmm.

[01:14:03] Shelia: Because let's be honest, and I'll say this, psychedelics are scary too. Oh yeah.

[01:14:09] Dr. Nicole: Oh yeah.

[01:14:09] Shelia: You know, you can do a line of cocaine and still know who you're Yes. Understand where you're, yes. And after it's worn off, like your perception of reality is still the same. The same, yeah, totally. But like, you know, you do.

Yeah. Yeah. And you may fundamentally question your entire existence. Reality. Yes, you do LSD and you might find yourself in a head space for hours. That is residually affect your perceptions and things for a while. Like you may fundamentally have some positive insights, but you may also have some really scary oh and challenging insights that may haunt you.

Right. You know, like, I think it's really important for us, like, but I'm not saying that that should be a reason for us to not talk about psychedelic policy reform, but like, heroin isn't gonna change your self concept after it wears off. Right. But mushrooms might.

[01:15:03] Dr. Nicole: Right, exactly. Exactly. Other than the self-concept.

If I'm a heroin user, which has a lot with it, right. But you're right, yeah. Paradigm. But it's,

[01:15:11] Shelia: it's not gonna alter like, you know, your perception of the world or like No. What you believe the world, the rules are that guide the universe. You know what I mean? I know. Or like that I'm separate being from other people and like, you know, losing myself in these kinds of moments like.

In talking about risk is really important because like psychedelic affects your mind perceptions and not just when you're under the influence and they can have long lasting impacts that can be transformative, but also challenging. So again, like I think that, you know, having broader conversations about risk and risk tolerance and like harm mm-hmm.

Are super, super important for people when they make decisions about drugs.

[01:15:54] Dr. Nicole: Yeah. Yeah, absolutely. Which makes me think about the set and setting, right? That's the big kicker of that experience and, and dosing of course, but particularly the set and setting of a psychedelic and what happens when you apply that sort of paradigm to all drugs, right?

What is the set of the person mm-hmm. And the reality and the setting, the systemic things that are going on that are contributing to that. We understand that sort of, um, uh, I think most of us in this space understand how that makes or breaks the psychedelic experience. What does it mean to apply that out broader?

Right. And yeah, I think that just in this time it's, it's hard because, you know, and our finiteness of humanness when we, uh, you know, live to maybe a hundred plus in an ideal, you know, depending on how you look at it world, um, we forget historically. Just the different messages that have been going on, right.

About different drugs and substances. So we're seeing this little bit of change now, but we come into this world feeling like, oh, this has always been this way. This has always been wrong. This has always been that. And so the benefits of being able to look back historically, right? And I'm sure you see it in your positionality, but for people who don't know about the history of drugs, to look back and see that it wasn't always this way.

There wasn't always these narratives. Our, our big guy Freud was doing lots of cocaine, right? Like all these different ways, or, you know, as a sex educator, when you were talking about hysteria, I was thinking about the ways that, uh, back in the day, you could, you would go to the doctor vibrators were created as a medical treatment first, and then you would go to your doctor for hysteria and have an experience with a vibrator where you would have an orgasm and it was to heal you, right?

Let alone the space we're at now where there's so much shame around that sort of thing. So just, I think a healthy dose of. Questioning where you can just wonder, taking at face value what we have now, but also continuing to question who is this benefiting? What are the narratives I'm being sold? Where is the research?

Right? And having that level of healthy skepticism where you're at constantly, I think is a really important thing to remember as we're advocating and moving through these spaces.

[01:18:06] Shelia: Absolutely, absolutely. And I think that the more we open people up to these conversations, the more minds we can change. Um, you know, I talk extensively about the drug set setting chat.

Uh, I actually have an entire chapter on the drug set setting model because I think it's gained a reputation as being a psychedelic model. Right, right. But it explains our relationships with all substances and that, you know, thinking about the ways that our policies can change our settings. Right. If you're not fearing getting arrested, will you use more?

You know, like we talk about, you know, people who, you know, why, why do we need overdose prevention centers? Overdose prevention centers, also known as supervised injection facilities, or safer consumption sites. Places where people can bring their pre drugs and use them on site. We have two here in New York City where people can bring and inject drugs or smoke drugs on site.

Why do we need sites like this? Because when people don't have a place to inject drugs, oftentimes they'll do them in public places. But doing drugs in a public space and knowing that it's criminalized can lead you to rush. Yep. Do too much. Yep. Use in an unsafe situation because you don't wanna get arrested.

So like, again, like when we think about drug set and setting, you know, how does the criminalization, the, the criminal status of a drug affect your experience of the potency quality? Composition of your drug. Yeah. But also affect your, um, risk of being criminalized, punished and arrested. And when you're a person of color, very specifically a black person, an indigenous person, um, and a non-white person of color, um, you are at disproportionate risk for even your occasional drug use to likely make you the target of criminalization.

Whereas unfortunately, the vast majority of drug users who are white never even think about criminalization when they think about their drug use. And they never imagine the consequences of what that is. And they def facto live in a world of decriminalization. And especially if you come from a family with resources, even if you were to face criminalization, you could be buffered and insulated from those harms, getting a good defense, getting, you know, a non carceral sentence or getting, you know, your record expunged.

You know, all of those kinds of things. Us to zoom out about how can we create a policy landscape where the settings in which we're using drugs are safer. Yeah.

[01:20:38] Dr. Nicole: Yeah, absolutely. And that's how we save lives. It's how we save our community, right? That's how we step into more pleasure collectively, right?

Yeah. It's a very different feature. I have, um, a post-it note that I'm looking to, to the left of the screen that says the set and setting of sex, right? I've been trying to apply that metaphor, that paradigm to a lot of different things, right? Mm-hmm. Of what is the individual. 'cause I feel like maybe this is what I didn't get in my school and training, you know, you take a class on systems in the larger, broader context, or you take a class on psychodynamic and they talk about the relational context, and these are broken into different categories of therapy or CBT that you could specialize into, where it's like, ah, I think we need the set and setting of all of them, my friends, um, as a deeper paradigm to understand, uh, lots of different things, whether it's drugs, whether it's sexuality, all these other things.

What's. The set of yourself and your experiences, your past, your history, as well as the broader setting as impacting all of these things. And so that, that paradigm I see running through all of my work, particularly in sex and relationships, right? And so I think that that's a, like an amped metaphor for understanding a lot of different things, is that we have to get out of this western individualistic concept of the self and the isolation, the diseases in this person, and into a broader context of the self in relationship.

I think that will kind of bring more movement to the space. And so when I think about that too, of the self in relationship, what changes people is being in community, right? For me, training at a site that is a harm reductionist site, that's where I had this perspective where in years past I would've been, I was absolutely not would've, I was absolutely the person that was judging people who use drugs, right?

Because I grew up in a very conservative culture and this is what I was taught, right? And so, mm-hmm. I. Um, the inspiration and the direction being continuing to find communities, resources, content where you can educate yourself, educate other people in your community, and having those conversations so that we can kind of raise the collective consciousness to a broader understanding of even at minimum what we talked about, the risks, right.

And nuanced conversation about risks and pleasure. I think that's kind of the future movement. Hopefully we can go towards Yeah.

[01:22:54] Shelia: Yeah. And you know, like when it comes to drug use, like it's still a deeply personal experience, but when it comes to sex, it's like the other person is part of your setting.

Mm-hmm. The other person or the other people are part of your setting experience. And what's okay in one situation with one person may not be okay in another situation with another person. Right. Um, and like, what does that mean for consent? And just because you've consented to it before doesn't mean you have to consent to it now in this setting, in this situation, right.

Absolutely. I loved about my social work training, even though I feel like in a lot of ways it did not set me up for the realities of working in drug and alcohol use was, um, that we were very much trained with the biopsychosocial model Sure, yeah. Of looking at human behavior in the social environment.

And I do appreciate that because my training, I got my bachelor's in clinical and social psychology, which was deeply individualistic to some extent social and cultural, but really thinking about yeah, the, the broader society, the broader culture, the policy landscape, the stigma, all of these kinds of things, all of these dynamics that can play out, um, I think is super, super important.

Yeah. It's easy to situate problems in people. Yep. When so much of what we're is we're ing, we're the embodiment. Social and structural environments as well. Mm-hmm.

[01:24:27] Dr. Nicole: Absolutely. I often think that's some of the benefits of a social work degree compared to a clinical psychology degree is a little bit of that, that that focus on that rather than the individual.

Our school or the school that I went to said that I practiced from that paradigm then through in spirituality is another one of the four pillars.

[01:24:43] Shelia: Yes. Cultural, yeah, cultural, spiritual, like my, my program actually TA like tagged on cultural and spiritual as well.

[01:24:50] Dr. Nicole: Yeah. And, but I think particularly a social work degree often emphasizes that way more than a clinical psychology degree.

And so to be able to like hold that nuance, I think that's hopefully where we can keep moving. And so it's why it's such a joy to be able to have conversations with people like you, to kind of hold that cultural context in your positionality and everything that you see. And to be able to speak to that and change the narratives around it, I think is really, really powerful.

And so I'm, I'm thankful for you coming into the space today and Yes, thank you. Yeah, it was so good. And before we move towards our closing question, I always like to check in and see if there's anything else that you wanna share to the listeners. Otherwise I can guide us towards a closing question and then I also Yeah, no, I think that's good.

Great. Cool. Alright. So then the last question that I ask every guest on the show is, what is one thing that you wish other people knew was more normal? Drugs.

[01:25:51] Shelia: Yeah. And that's even the things that you don't think of as, so drugs are drugs. Caffeine is a drug, thank alcohol is a drug. Nicotine is a drug. And depending on who you talk to, sugar is a drug too.

Right? Right. And if everyone's doing drugs, it's to an extent a normal activity. And if we can kind of like lift the veil on that, absolutely. We can have so many more productive conversations about safety, health, pleasure, joy, autonomy.

[01:26:28] Dr. Nicole: Yeah. I've had a lot of, a lot of funny conversations just with people.

Oh, I'm about to do some drugs. Like, I'm gonna take some caffeine right now at 8:00 PM I'm gonna be late. Yeah, right. Everyone, they're like, what Nicole? I'm like, I'm trying to get you guys to see this paradigm that I'm living in. Like, I see these all the same, they're all have different ratios. Right. But they're all drugs.

Ugh. I hope that,

[01:26:49] Shelia: I mean, yeah, people, people died of caffeine consumption. Was that a Panera bread Really? Uh, lemonade or there was like, um, holy shit. I think Panera, like a year or two ago, a couple years ago, came out with like a very caffeinated iced cold drink and people were chugging it because it was tasty and sweet and whatever, and people had heart attacks from consuming too much caffeine.

Mm-hmm. And, you know, caf like, how do we mitigate caffeine related harms? One of them is that it can affect your sleep. You know, how, how early do you wanna stop using caffeine? That is a harm reduction strategy. Right? What time do you not use caffeine Past? Yep.

[01:27:33] Dr. Nicole: Exactly. I think about that halflife and how it's gonna affect your sleep.

Yeah. Mm-hmm. Exactly. I hope therapists and healers can at least ask that question too, when you ask about drug use. Yeah. How much caffeine are you have that anxious client over there? No one ever asked me back in the day when I was so anxious. How much caffeine are you drinking? I was drinking huge cups of coffee.

Wild. Right? When you think about that was never a part of the drug conversation.

[01:27:57] Shelia: Yeah. Also, you know, like you, um, the more I'm learning too, is like when you wake up in the morning, you've, you've got all these wakefulness. Neurotransmitter is kind of circulating in your system and, you know, delaying your first cup for at least an hour or so after you wake up can also really help you like naturally reset for a day.

And it can also affect your morning, like cortisol levels. Sure. Um, but like, you know, all of these kinds of things, like we can't even have these conversations because we're just like, oh, caffeine, it's safe, it's normal, it's everywhere. Anyone can have it. The tasty drinks at my local franchise are yummy and sweet and syrupy, and sure there's caffeine in there, but like, it's my tasty treat.

Like, but you know, you should also think about like, are you gonna be able to sleep tonight? Right. Did you consume more than you can handle? Because if it was a hot cup of coffee, you would've sipped it slowly. But it's an iced, frothy, creamy, sweet drink. And I'm chugging it because it's hot outside.

[01:28:58] Dr. Nicole: Right.

Exactly. Exactly. This is the conversation that needs to be had. I hope that people can take that sort of, you know, this is a starter point to a deeper discussion, a deeper conversation about all these pieces that need to be unpacked. And so I'm curious, where can people find you and all of your work, that way they can continue this.

'cause there's so much more to unpack than we just barely touched the surface in this conversation.

[01:29:25] Shelia: Yeah. Um, well I think the most important thing to send you all to is my book that came out in February, 2024. It's called the Harm Reduction Gap, um, and Gap. It's available anywhere you buy books online. And I think it's a really great primer to harm reduction, but also this broader system in which drugs are.

Medicines or readily and legally available. Um, I talk about the drug set setting model. I talk about drug prevention education. I talk about the current treatment system. I talk about drug exceptionalism. If you're looking to dig deeper into any of these broader concepts that we talked about today, I think the book might give you some more broader context.

[01:30:10] Dr. Nicole: Absolutely. Yeah. Thank you for plugging that. I'm so thankful to have had you on the show today and to. I've made this special conversation with you, so thank you for joining me.

[01:30:19] Shelia: Thank you for having me.

[01:30:22] Dr. Nicole: If you enjoy today's episode, then leave us a five star review wherever you listen to your podcast, and head on over to modern anarchy podcast.com to get resources and learn more about all the things we talked about on today's episode.

I wanna thank you for tuning in and I will see you all next week.