Editor’s Note: Today’s post comes from contributing editor Brooks Hudson, a PhD student in history at Southern Illinois University.
Dr. Carl Hart’s timely Drugs for Grown-ups: Chasing Liberty in the Land of Fear attempts to ignite a shift in our collective consciousness—much like the psychoactive substances he chronicles. Credentialed academics and other elites tend to deny using drugs, or, if they want to pass as authentic for political reasons, they might admit to a few youthful indiscretions (e.g., then-candidate Barack Obama’s “inhaling was the point” comment in 2007).
Defying this taboo, Hart, Chair of the Department of Psychology at Columbia University, owns up to his affection for an expansive medicine chest. He reveals dabbling in amphetamines, discloses his use of the unfairly-maligned drug heroin, and discusses sampling 1990s club drug—and soon-to-be FDA approved medication—MDMA, along with other more obscure compounds like 2C-B, which was popularized by virtuoso, chemist, and psychonaut Alexander Shulgin.
Hart’s self-doctoring is reminiscent of nineteenth-century medical ethics, embodied by such titans of the time as William Halstead and Sigmund Freud. His self-prescribing bridges the gap between his knowledge and his experience, which helps him better understand subjects visiting his Columbia University lab. Drugs also filtered into his other extracurricular activities, figuring into adventures with his wife and enhancing their relationship and strengthening their marriage.
Who Are Drug Users?
Hart considers himself the rule not the exception in terms of drug use. Drug users are not zombies, he emphasizes; they are not the flesh-eating monsters sometimes depicted on highway billboards accompanied by inane anti-drug slogans. Drug users are not unwashed psychos or crime aficionados who inexplicably love doing evil. No, most drug users are typical, normal, average Americans, gainfully employed and living undetected—maybe you or your neighbor. And that’s okay.
Generally speaking, Hart’s ideas are easy to understand, and he gives primacy to the crucial observation that most people’s experiences with drugs are positive. Drugs offer insight, increase euphoria, and provide pleasure. Drugs act as social lubricants, making social interactions easier to bear or more enjoyable; and drugs break down barriers, allowing some individuals to be more vulnerable than they otherwise would be. People use drugs to soften the edge after a stressful day working a job they hate, and, conversely, drugs can help those who love their jobs be more productive and work long evening hours.
It can be even more basic than that. When asked why he used heroin, William S. Burroughs, answering through the persona of his fictionalized alter ego William Lee wrote:
Everyone has reasons for using drugs. Hart does object, though, to what he calls “drug elitism,” a phenomenon whereby an individual claims their drug is “good” and should be allowed, but other people’s drugs are “bad” and should be restricted, even for responsible adults.
Focusing on the Negative
Hart’s overall perspective is quite refreshing. I might guess that 90 percent of books about drugs—regardless of field and whether healthcare or history—follow a tried-and-true formula. Authors seem compelled, for whatever reasons, to emphasize the negative aspects of drugs and drug use. So, a historian writing about the evolution of opioids in American society, will inevitably and predictably litter their text with words like “addiction,” “crisis,” or “epidemic”—ideas defined so loosely and elastically as to become almost meaningless.
This disproportionate focus on the negative, while understandable to a certain degree, is kind of odd upon further reflection. Anything worth doing in life involves risk. We cannot eliminate all opioid risks in the same way we cannot eliminate all risk from guns or cars. Smart policies, however, can reduce the harms associated with these activities.
Hart does not minimize the adverse effect of drugs. For skeptics already wondering about his take on the “opioid crisis”—a characterization he rejects, by the way—Hart agrees that opioids have risks. But driving a car has risks, he points out; and owning a gun has risks. Hart examines and charts the relative rate of fatalities caused by all opioids, by heroin, by guns, and by automobiles. Total opioid deaths in 2017 were 47,600 or 13.8 per 100,000, and total heroin deaths were 15,482 or 4.9 per 100,000. Total gun deaths, meanwhile, were, 39,773 or 11.7 per 100,000, and total automobile deaths were 40,000 or 11.8 per 100,000. Recognizing and balancing risk does not need to lead to proscription.
Hart elaborates that many opioid deaths are caused by ignorance, stemming from a lack of drug education. Rarely do people die from opioids alone. Instead, they die from mixing opioids with other drugs like benzodiazepines (e.g., Xanax, Valium), nerve pain medications and anticonvulsants (gabapentin), antihistamines (promethazine), alcohol, or other substances, all of which heighten a person’s risk of overdosing.
Drug prohibition certainly plays a role, too. People simply cannot know if the drugs they bought are laced with fentanyl or other contaminants, making basic things like adequate dosage difficult to discern. Theis unfortunate reality has contributed to the recent surge in overdose deaths—which are driven especially by fentanyl and its analogs.
At a minimum, Hart recommends the establishment of safe drug consumption rooms, where people can be monitored in anonymous environments, can receive accurate drug information, and can be revived in the event of an overdose. He argues that anonymous drug-testing sites are another successful policy that can improve harm reduction. At these safe locations, consumers bring a small amount of a drug to have it tested for purity and to thus receive accurate drug-quality information.
What About Addiction?
Hart emphasizes that 80 to 90 percent of all drug users never develop an “addiction” and do not need treatment or need to be arrested. For these drug consumers, incarceration would be much worse for their mental and physical health than smoking crack or shooting heroin—even more so in the midst of a pandemic.
If 80 to 90 percent of drug users do not become addicted, Hart argues, we should not blame drugs as the cause of addiction. This seems counterintuitive but is easy to understand in thinking about gambling addiction. Do casinos or decks of cards, for example, cause gambling addiction? No. The pathological relationship a person has to these objects causes addiction.
Drug addiction is not the norm, but there are predictable patterns for people who become addicted. In Hart’s own studies, patients undergo comprehensive assessments that last between four to six hours. These analyses, he argues, are essential for determining whether a person has a drug problem, or if their drug use is a symptom of other problems. People who are are “addicted to drugs,” he writes, often actually suffer from undiagnosed mental illness or physical ailments that become expressed in their pathological drug use. Growing up in poverty, experiencing homelessness, or surviving sexual or physical abuse are other common causes of serious drug problems.
We understand this phenomenon. During the coronavirus pandemic, for example, there have been significant spikes in suicide, depression, drug and alcohol use, and overdoses. The composition of drugs or alcohol have not changed, and their availability and access has remained about the same. But the environment has changed. The pandemic-related stress, isolation, financial pressures, etc., have been expressed in increased substance use.
Hart argues that one barrier to progress is the brain-disease model of addiction, which claims that distinct neurobiological markers differentiate non-addicted people from addicted people. He disputes this, for example, by noting differences between addiction and other brain diseases. Having studied Huntington’s disease and Parkinson’s disease, Hart observes that these brain diseases are progressive, irreversible, and fatal—something that is not true of addiction. Most people, he points out, recover from addiction (substance use disorder) without treatment.
Other research by Hart shows there are no biological correlates associated with drug addiction—that is, brain scans cannot reveal whether or not someone is addicted. This relatively common belief, he argues, results from scientific studies in which naïve animals ingest doses ten– or forty-times a typical human dose. Even in animals, though. the toxic effects are prevented by prior exposure that slowly builds to tolerate the substance.
A study Hart conducted on the executive cognitive function of methamphetamine users, for example, found that when compared to normative data the subjects fell within the expected range of human variability. The brain-disease model of addiction has a propensity, he writes, to interpret slight variations in cognitive differences as clinically significant abnormalities. Moreover, “the view of drug use and drug addiction as a brain disease serves to perpetuate unrealistic, costly, and discriminatory drug policy.”
Consequences of Drug Prohibition
Hart argues that people in authority often use drugs and drug addiction as a scapegoat to target people or activities they don’t like. Many measures in the 1988 Anti-Drug Abuse Act, for example, disproportionately impacted African Americans and Latinos. Among other things, the Act created the first mandatory minimum for simple possession of a small amount of crack cocaine, instituted the death penalty for traffickers, and established 100-to-1 sentencing disparities between crack and powder cocaine. Despite these harsh measures, the law did not achieve its goal of a “drug-free America by 1995.” But the disparities continue today with Blacks and Latinos comprising a majority of federal opioid arrests.
Drugs and drug use, Hart argues, are routinely still used to discredit and demonize members of marginalized communities. Perhaps counter-intuititively, he praises former Maine Governor Paul LePage for explicitly admitting that drug law enforcement targeted African Americans and that selective enforcement continues to be suffused with latent racist ideology:
Authorities also often justify extrajudicial police killings by suggesting the presence of drugs. After Chicago police shot Laquan McDonald sixteen times in 2014, for instance, they claimed that officers believed McDonald had PCP in his system—a rationale also used by Los Angeles police after the 1991 beating of Rodney King. Attorneys for the officers involved argued, that if McDonald had used PCP, he would have felt “omnipotent” and “superhuman.” This drugs-as-dark-magic discourse is a frequent occurrence—not an isolated incident.
There is a long history in the United States, in fact, of justifying police brutality against, particularly, African Americans by suggesting drugs granted certain users superhuman strength. An infamous 1914, New York Times article, for example, blared in a headline that “Negro Cocaine ‘Fiends’” were “A New Southern Menace” and alleged that the drug was “proof against bullets.” The rhetoric has changed slightly since 1914 to disguise overt racism, but much of the language and imagery remains similar.
It’s not only PCP or Cocaine. Hart emphasizes that many drugs, including cannabis, still get used for this rhetorical purpose. Recently, for example, in several high-profile deaths—including those of Sandra Bland, Trayvon Martin, and Keith Lamont Scott—authorities have used marijuana toxicology reports to question the character of the victims and to mitigate irresponsible and reckless behavior by police or others.
Coming Out of the Closet to Move Forward
How do we stop the atrocities, stop the mass incarceration, stop the erosion of civil liberties, and alleviate the suffering caused by the government’s absurd goal of a “drug-free America”? After initially favoring decriminalization, Hart now argues that the only solution is a regulated marketplace that permits adult use, ensures quality control, generates jobs and tax revenue, and—importantly—promotes the notion of freedom that Americans believe already exists. For Hart, the goal is for people to live more healthy, happy lives; lives that they—not the state or the drugs—control.
Hart argues that “respectable” users of drugs—like himself and people he has met—need to aid the movement, be open about their drug use, and “come out of the closet.” Many people might be reluctant to rally behind this idea and to publicly admit their drug use, but Hart encourages civil disobedience against drug laws. In the words of Dr. Martin Luther King, Jr., he concludes, “one has a moral responsibility to disobey unjust laws.”