Article by Dorsa Rafiei & Stephanie Tran
Graphic design by Abeeshan Selvabaskaran
Earlier this year, Dr. Carl Hart, a neuroscientist and professor at Columbia University, released a book entitled Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear,1 arguing for people’s freedom to alter their consciousness with drugs. The book’s provocative topic certainly ruffled some feathers in both the general public and academic communities. Meanwhile, the book received glowing reviews from publications such as NPR and the New York Times, to name a few.
In Drug Use for Grown-Ups, Hart points out the way society has demonized drugs as well as users—particularly black and brown drug users—leading to policies that have contributed to social injustices, such as the disproportionate incarceration and harsher sentencing of black and brown people compared to white people for non-violent drug offences.2 An important step in providing a solution to this problem, Hart argues, is the decriminalization and legalization of all drugs, which allows for regulation and quality control of substances. However, we believe Hart’s argument becomes dangerous when he provocatively muses about his recreational use of heroin and states that he is a better person because of drugs, claiming that if he can use drugs safely, so could other “grown-ups.” Therefore, readers should be cautioned for the book’s lack of acknowledgement of variable social and biological predispositions for addiction, innate discrepancies of drug properties, and limitations of current scientific evidence.
The target demographic of Drug Use for Grown-Ups are, well, “grown-ups”. Hart defines a grown-up as a healthy adult who is “autonomous, responsible and well-functioning” and fulfills their social, parental, and occupational responsibilities.1 But how do we distinguish between the grown-ups that can use drugs responsibly versus the grown-ups that cannot? Hart argues that many drug users (like himself) do not meet the criterion for impaired functioning and thus do not have a substance use disorder (SUD) or an addiction. In fact, Hart’s argument dismisses the role of genetic predisposition and the environment, two common risk factors for mental illness and addiction.3 So, while a “well-functioning” adult can choose to responsibly use recreational drugs, environmental or situational factors (e.g., acute stress or trauma) may trigger increased use, dependence or even abuse, which can in turn impact, as Hart would suggest, “responsible use”. Ultimately, as Dr. William Haning, editor-in-chief of the American Society of Addiction Medicine, so eloquently puts, the fulcrum is “our inability to satisfactorily predict who will develop the illness state once they have first been exposed to the substance. It’s difficult enough to determine even the prevalence of substance use disorders, despite our having descriptive criteria.”4
In addition to user variability, there are innate differences in drug properties that cannot be overlooked. Hart resents the more accepting attitude of the public toward some drugs, such as psilocybin, versus the negative attitude toward “harder” drugs, such as heroin: “I had grown increasingly annoyed with the mental gymnastics that some psychedelic users perform in order to distance themselves from other drug users.”1 While psilocybin is a powerful psychoactive substance, it is physiologically safer than heroin.5 Psilocybin overdoses may include vomiting, paranoia, psychosis, and seizures and are rarely life-threatening. On the other hand, heroin can cause respiratory depression and overdose, which can be lethal. Although Hart’s intentions are to increase unity among drug users by emphasizing the positive effects of drug use, he fails to adequately address the different neurophysiological effects of drugs.
An overwhelming emphasis in Drug Use for Grown-Ups is on the positive effects of drugs which fails to highlight disparities in the social and biological predispositions of different “grown-ups”. Hart cites his own studies that investigated cannabis, cocaine, and methamphetamine, to name a few. However, the majority of these studies consisted of small sample sizes (< 10 participants) and looked at acute short-term effects (< 2 weeks).7,8 Hart draws on evidence suggesting that the majority of drug users do not become addicted and are able to function normally. However, the number that do become addicted is no small number. In 2017 alone, the global estimate of opioid overdose deaths was 109 500, of which 43% were in the USA.9 Even in new heroin users, approximately 30% of people become dependent within the first year.10 According to Hart, “the opioid problem is not really about opioids” but rather a problem of “ignorance.”1 He argues that fatal opioid overdoses have been largely overstated, citing that the majority of overdoses are a result of contaminated opioid drugs or opioids combined with another downer (e.g., alcohol). Hart’s solution for ignorance is better educating the public about how to use drugs to increase desired effects and reduce adverse effects; however, this approach hasn’t worked with other drugs. For example, many “grown-ups” know they shouldn’t take a benzodiazepine with alcohol… but they do it anyway. People know they shouldn’t abuse alcohol, but alcohol-related incidents still make up a large proportion of emergency room visits.11 In fact, alcohol is the cause of 5.3% of deaths worldwide every year.12 Therefore, as we have seen with alcohol, education will not solve the issue of “ignorance” and the risk of addiction should not be overlooked to solely focus on the positive effect of drugs.
All in all, it is our opinion that illicit drugs should be decriminalized and legalized to allow for better therapeutics for people with SUDs, without the stigmatization and risk of incarceration—but there are dangers in Hart’s method of advocacy. He states that the book is “unapologetically not about addiction.” But to talk about drugs without considering the neuropsychopharmacological outcomes is simply irresponsible. Nevertheless, Hart’s radical opinions are an important part of the discussion to be had regarding reforming drug policies and de-stigmatization of drug use.