Carl Hart is a neuroscientist and Ziff Professor of Psychology at Columbia University—he was the first tenured African-American professor of sciences at Columbia. His research focuses on the “behavioral and neuropharmacological effects of psychoactive drugs in humans.” Hart’s new book, Drug Use For Grown-Ups, is a bold and engaging effort to counter what he sees as generations of misinformation and moral grandstanding about drug use. Today’s “sensationalistic media coverage of the opioid crisis continues a long, awful tradition of exploiting ignorance and fear to vilify certain members of our society,” Hart writes. The media is not the only problem. Scientists, he states, “have frequently overinterpreted and distorted” drugs’ effects on the brain.
Hart reports that more than 70 percent of drug users—whether they use alcohol, cocaine, prescription medications, or heroin—do not meet the health criteria for drug addiction. In Drug Use for Grown-Ups, Hart strives to “present a more realistic image of the typical drug user: a responsible professional who happens to use drugs in his pursuit of happiness.” With genial candor, Hart presents himself as a model drug user. “I am now entering my fifth year as a regular heroin user,” he writes. “I do not have a drug-use problem. Never have. Each day, I meet my parental, personal, and professional responsibilities. I pay my taxes, serve as a volunteer in my community on a regular basis, and contribute to the global community as an informed and engaged citizen. I am better for my drug use.”
Nautilus caught up with Hart to discuss his drug use and his sharp points about science and society. He was as casually bold in conversation as he is in Drug Use for Grown-Ups.
You say “most drug-use scenarios cause little or no harm and that some responsible drug-use scenarios are actually beneficial for human health and functioning.” How so?
Let’s just talk about alcohol first. When you’re at a wedding reception, alcohol serves as a social lubricant. People are more gregarious. They talk, they interact. The same is true with cocaine at parties, heroin among friends, or opium among friends, NDMA among lovers. It enhances empathy, openness, and forgiveness, all of these pro-social attributes.
Drug research, you write, is full of bad science. If you had to name one example, what would it be?
The notion that drug addiction is a brain disease. That encapsulates all that’s wrong with today’s science in this area. There is absolutely no data in humans to show that drug addiction is a brain disease. Yet the narrative, the dogma, the dominant perspective is that it does. Even though nobody will dispute that, there’s absolutely no data in humans to support that statement.
Yet opioids do change the brain biologically, do they not?
Yes, opioids bind to a class of receptors called endogenous opioids, which you find in endorphins, for example. Opioids bind to these receptors—just like natural chemicals do—which results in a response. In some cases, because of decreased sensitivities and certain types of pain, they may enhance a sense of euphoria. So it’s really just facilitating what’s already in the body naturally, a system that helps in our survival. Think of fructose or glucose. We add sugar to our tea, our coffee, whatever we have, we add more and more because we like it, it tastes good, and it enhances pleasure. It can give you energy. It can make life more interesting. Humans do not live on logic alone. And so sometimes we do these things, and that’s OK.
People become addicted because they once had a middle-class-paying job that made them someone in their community.
How have scientists “overinterpreted and distorted” the effects of drugs on the brain?
Take brain imaging. People often show one image of someone’s brain. Let’s say this person is addicted to methamphetamine, according to DSM criteria, versus the brain of someone who’s not addicted. If you see some difference, some researchers have a propensity to make more out of the differences than are there. There’s a wide range of brain structural sizes, such that when we think about one person’s size of their nucleus accumbens, it may be smaller or larger than somebody else’s nucleus accumbens. But both of the nucleus accumbens, despite their sizes, are within the normal range of human variability. It’s like height. One guy might be 5’10”, another guy might be 6’2”. But we don’t say the guy who’s 5’10” is height deficient. We just say that he’s in a normal range, and he’s not as tall as the other guy. We wouldn’t say one is deficient versus the other. In neuroscience, one of the things that has happened, particularly when it comes to drugs, people have over-interpreted the differences to mean pathology, when, in fact, both of the brain structures are within the normal range of human variability. The overinterpretation is to interpret it as being pathological.
You say the opioid crisis has been sensationalized, and write, “People are not dying because of opioids; they are dying because of ignorance.” What do you mean?
Some people don’t know not to mix specific sedatives with opioids. For example, they don’t know not to mix large amounts of alcohol or large amounts of antihistamines. Specific combinations can lead to respiratory depression, which can lead to death. Another point of ignorance involves people who buy street drugs and don’t necessarily know if the drugs contain contaminants. That’s the kind of ignorance I’m talking about.
So it’s the mix of drugs that is the problem, not opioids like heroin themselves?
Yes, the majority of opioid deaths occur as a result of combining opioids with multiple sedatives. But there are certain opioids that do concern us if taken alone and the person isn’t aware that they have this particular opioid. Those are fentanyl and the fentanyl analogs. These drugs are a lot more potent than something like heroin, meaning they require less of it to produce the effect. Most of the public aren’t seeking fentanyl or its analogs, but people are tainting things like heroin and oxycodone pills with fentanyl or an analog.
One way to deal with this tainting, this contamination, is to have free drug-checking facilities, where people can submit samples of their drug and get a chemical readout of what is contained in the substance. That way they’ll know whether to take the substance or how much of it to take. The public also needs to know that most people who use these drugs are not addicts. If you understand that, then you know that for the people who do become addicted, we have to look beyond the drug and look at the person’s environment, their life. Do they have co-occurring psychiatric illnesses? Do they have pain that is not treated? All of these kinds of issues become important.
At what point does biological change in the brain lead to physical addiction?
Physical addiction occurs as a result of opioids—or any other drug, alcohol too—being in the body for consecutive weeks or periods, in particularly high doses. And then the body tries to compensate. For example, with opioids, one of the things that happens is that your gut, your gastrointestinal system, slows down the receptors. Your body is trying to compensate by speeding up the gastrointestinal tract. So when the drug abruptly leaves after several weeks of constant administration of the opioid, now the body is unprepared for the drug not being there and it overcompensates. It really ramps up the motility of the gastrointestinal tract, which causes diarrhea, among other things.
It can give you energy. It can make life more interesting. Humans do not live on logic alone.
Why do some people get addicted and not others?
The amount of drugs they take, the period at which they take it. Some people can take opioids for extended periods of time. As long as they keep the doses fairly low and they don’t take multiple doses a day, they probably won’t experience physical dependence. It’s just like with alcohol. Most people drink alcohol on a regular basis, but they don’t become physically dependent. Whereas others drink every day in large amounts, and they will become physically dependent.
Why can’t people overcome addiction?
One of the major reasons people can’t overcome it is because we’re not very good at treating addiction in this country. Just think about why people become addicted. A large number become addicted because of co-occurring psychiatric illnesses, because of pain issues, because they once had a middle-class-paying job that made them someone in their home, someone in their community. Those jobs are gone. Then there’s no healthcare or there’s poor education. If your treatment is not addressing these issues, people are not going to overcome it. But if we have treatments that are holistic, and they’re looking at the individual, and not so much the drug, then we’re good. But if we’re just talking about the drug, then we’re already behind the eight ball, then we will lose that battle.
Your definition of addiction follows the DSM-5, which refers to a “substance use disorder” and values functioning over regular ingestion of a substance. How do you define “functioning”?
Functioning is determined by whether a user is happy in meeting their obligations, whatever they may be, whether they’re work-related, whether they’re family-related, or other social sorts of things. The person is not stressed out about their substance use. In fact, they’re cool with it. That’s functioning. The person’s happiness is more important. That supersedes any other thing.
You write that, contrary to the cultural myth, regular use of recreational drugs doesn’t damage the brain. What’s the frequency associated with recreational?
Yeah, I’m sorry. I couldn’t think of a better term. I don’t really like that term.
Try another one.
I don’t know a term. I simply mean people who take drugs, like alcohol users, somebody who may have a glass of wine or two every night for dinner, whereas somebody else may only drink on the weekend. It’s a wide range. And the same can be true with cocaine or heroin. That’s what I mean. People are functioning and don’t have these psychosocial disruptions. They’re meeting their obligations. They’re happy with their life.
The notion that drug addiction is a brain disease encapsulates all that’s wrong with today’s science in this area.
You write, “Despite the current false narrative, the addiction rate among people prescribed opioids for pain in the United States, for example, ranges from less than 1 percent to 8 percent.” Why do we have that false narrative?
It serves many purposes. It allows for the “war on drugs.” It allows for people to be moralistic; for treatment providers to have a raison d’etre. And what would the media have to write about?
In the context of the opioid crisis, might your arguments supporting opioid use be used by drug makers to defend themselves in court?
I don’t think they can because they’re being sued for minimizing the addiction potential of oxycodone preparations. It’s clear how they were supposed to inform the public, and it’s clear what they did. They were just not as forthright as they should have been. They were forthright with morphine, so why not be forthright with oxycodone?
Why do you use heroin?
That’s like saying, “Why do you use alcohol?” For the same reasons: a social lubricant, alter my consciousness. It’s a lot less toxic on my liver than alcohol and it’s really good at producing euphoria.
Where do you get the heroin?
It’s no one’s business. I would only say it’s always tested for quality.
You write that heroin has made you a better person. How?
It helps me to think about the impact of my behavior on other people, and then make the appropriate adjustments where I may have caused people harm, or anguish, or anxiety, stress. I try to rectify that. It’s a great solace in that way, it helps me to be patient with people—to be all the things that we hope our children will be. That’s what I’m trying to do. And it helps me to do that.
In your book, you describe the death of your dog, Kenya. You note that in those moments after the veterinarian arrived to put the dog down, you got caught up in what drugs were going to be used to put him down, and that enabled you to escape the very strong emotions you were feeling. I wondered if that has a broader significance in your experience with drugs?
It’s a hard thing to say. I’m a typical American male. I mean typical in the sense that we’ve been all lied to about hiding our emotions. They’re forcing us to not emote and forcing us not to express pain, and hurt, and all of those kinds of things. And so thinking about drugs, in my learning about drugs, has been a way to avoid dealing with the emotions that are there and that are appropriate for humans to express. And that’s what that scene with Kenya was. I was trying to illustrate that I’ve been screwed up like many American males by not facing my emotions, by not sharing my emotions, by pretending that I’m hard and emotionless. And that’s not healthy for a human.
You write that only “healthy, responsible adults” should use recreational drugs. Who should decide who is the healthy, responsible adult?
Excellent point. Certainly not me. I was really trying to make the point that I was writing the book for grown-ups. And I was trying to say that just because you’re 18 or 21, whatever, it doesn’t mean you’re grown-up. Part of being grown up is you have this freedom, but with freedom comes responsibility. And that’s the point I was trying to illustrate. I can’t decide. We think about somebody who’s driving an automobile. There are a lot of irresponsible people who drive automobiles, but we do our best to make sure they are a certain age, that we have speed limits, that people wear seatbelts, that they pass some competency exam. We have all of these things in place to try and help us, to serve as proxies. But we really don’t know. And I certainly don’t know who’s the grown-up. And I certainly don’t think that we should have some person sitting there deciding who’s a grown-up, because it gives us an opportunity to exclude other people. Lord knows I don’t want that.
Your birthright to use drugs is part of the pursuit of happiness, you write. But others might say, “It’s my birthright not to take vaccines, not to wear a COVID-19 mask, to storm the Capitol.” Has “my” pursuit of happiness become dangerously exclusive?
That’s great. That’s good. We have those birthrights as long as we don’t prevent others from pursuing their rights. When you’re infringing on other people’s rights, then you no longer have those rights. But as long as you’re not disrupting other people’s ability to pursue their rights, then, cool. If you’re not wearing a mask, when we have this highly communicable disease, then you’re potentially impacting the rights of other people. I think of my birthright as the basis of my liberty to control my body, and put what I want in my body as long as I’m not interfering with other people’s ability to do the same. I am allowed to pursue happiness as I see fit, as long as I’m not disrupting other people’s ability to do the same. And that’s part of the responsibility that’s required of anybody who is exercising these rights.