The Freedom to F%$k Up: Thoughts on Dr. Hart’s “Drug Use for Grown-ups”
“I don't want comfort. I want God, I want poetry, I want real danger, I want freedom, I want goodness. I want sin.”
- John from A Brave New World
America is no stranger to ideological and political indigestion, and our social/moral enzymes have failed to process the topic of drugs. Adding our infant recognition of equality (at least nominally), the legislative excrement is…well…interesting.
Even if we ignore the racial undertones of drug stigma, our views on drugs and their effects are still characterized by ambivalence. Largely because, as Covid exposed, we access variable information, form different perceptions of risk, and develop different ideals to circumscribe freedom in light of perceived risk.
These aren’t easy topics. Philosopher Robert Nozick notes the uncomfortable knot that freedom and risk form:
”Since an enormous number of actions do increase risk to other, a society which prohibited such uncovered actions would ill fit a picture of a free society…….Yet how can people be allowed to impose risk on others whom they are not in a position to compensate should the need arise? Why should some have to bear the costs of others’ freedom?…….though the actions actually might involve no cost at all to anyone else.” from Anarchy, State, and Utopia (p78)
In his recent book “Drug Use for Grown-ups: Chasing Liberty in the Land of Fear”, Dr. Carl L. Hart, the Mamie Phipps Clark Professor of Psychology and Psychiatry at Columbia University, challenges the existing attitudes towards drug prohibition, with a strong focus on the branding and politicization of drugs (eg: the war on drugs) as well as the role pharmacological illiteracy and scientific stigma plays in our perpetual abuse and misrepresentations of specific drugs.
The book succeeds in exposing some of our unfounded assumptions surrounding drugs, and even how decriminalizing may help remedy inequalities and other risk around the application of the law. But it falls short of offering a rigorous argument addressing the risk/reward of certain drugs being made legal and accessible (there are such arguments). Drugs such as heroine, crack/cocaine, and bath salts are defended as being sensationalized and scapegoated, but Dr. Hart fails to outline the potential benefits or a vision for integrating these conventionally “risky” drugs into society.
Self-awareness of our inconsistencies has slowly gained traction though. A recent review article in the New England Journal of Medicine noted the lack of extreme toxicity and impairments of cannabis opposed to alcohol. Alcohol is a great example of accepted externalities and our incongruous relationship to recreational substances. A blood alcohol volume of .08% leads to 250-300% increase in risk of motor vehicle crashes vs. ~30-40% for cannabis in driving simulators + on road test (1). Yet the “more dangerous” substance is a national favorite while the other? Schedule I substance.
An outline from Dr. Hart may absent because we aren’t cohesive and self-assured enough as a society to tolerate systematic integration. As journalist Michael Pollen and pharma-pundit Hamilton Morris have alluded to, the medical model may provide “rigorous” clear medical benefits for some substances, but this research’s potential failure would risk throwing out the baby (phenomenological freedom?) out with the bathwater. Alternatively, indigenous and plant-medicine traditions have ritualized substances as sacraments, but authentically grafting these rituals onto our societal predilections for consumption and excess seems unrealistic. These are just two examples of paradigms for integration but there are countless, let’s say “orphaned”, psychonautical contexts.
Dr. Hart offers one caveat, saying that the book and drugs are for “grown-ups” that are able to function without concerns of serious addiction. Yet, this is a impractical disclaimer, since “a priori” paths to discern and mitigate long-term societal susceptibility to addiction and other externalities aren’t well-defined/executed. He says the statistics for addiction are overblown, and he’s probably right. But, even though “gateway” drug-use statistics are far from showing rigorous causality, are we to believe that removing barriers to entry and improving accessibility of more potent substances is going to be miscible with the prevailing culture of unconscientious consumption?
“There is a scale of virtues, and it is necessary, if one would mount the higher steps, to begin with the lowest; and the first virtue a man must acquire if he wishes to acquire the others, is that which the ancients called [greek] or [greek] — i.e., self-control or moderation” - Leo Tolstoy, The First Steps
Addiction, like many of America’s problems, comes from a deep, complex sickness. And complex problems generally require holistic solutions. So best case, investing in mental ointments may buoy morale, galvanize psyches, and empower systemic changes and improved personal capacity for moderation (a la pscilocybin-addiction research?), but worst case, does this psychosocial chemistry lead to escapism and passivity? I don’t think there is a clear answer here.
Co-opting Tolstoy’s point, I also fear the broader discounting of the tuning that abstinence, meditation, fasting, and exercise brings. These methods are some of the most sure fire ways to recalibrate your brain (re-sensitization, dishabituation, PFC modulation of reward pathways, etc). (4)(5)(6)(9) Though, amidst deep suffering/depression, orthodox self-help tools are not known to feel feasible or appealing. Thus, psychiatric interventions may be a form of catalysis. And as some of the mammalian studies of “enriched environments” support, sequencing interventions with proper support infrastructure is likely wise to help displace/minimize relapse and abuse. (2)(3)(7)(8)
Herein lies part of my concern with psychedelics. They are largely coming from niche, long standing, reverent contexts and being plunged into a culture that doesn’t have a great relationship with or knowledge of its sickness. Though some drugs may no doubt be a tool in assuaging our symptoms, are we clear about our expectations and implementation? Do we say, “we know”, but deep down, “we hope”…. hope that we’ve found another prospective panacea?
As we put the benefits back in perspective, we shouldn’t crop the ugly. Though creepy paternalistic legislation isn’t the answer, an honest look into the mirror is. If legislation was the fix, we probably should have more laws against alcohol, trans fats, and high calorie/hyper-palatable/low-nutrient fast food, that are costing our country millions in healthcare cost and ruining the quality of life of many people. We don’t, and so perhaps our asymmetric heavy handiness is overdue for re-evaluation.
Articles Referenced:
David A. Gorelick, M.D., Ph.D., N Engl J Med 2023; 389:2267-2275
DOI: 10.1056/NEJMra2212152Yates JR, Bardo MT, Beckmann JS. Environmental enrichment and drug value: a behavioral economic analysis in male rats. Addict Biol. 2019 Jan;24(1):65-75. doi: 10.1111/adb.12581. Epub 2017 Nov 27. PMID: 29178664; PMCID: PMC6265118.
Chauvet, C., Lardeux, V., Goldberg, S. et al. Environmental Enrichment Reduces Cocaine Seeking and Reinstatement Induced by Cues and Stress but Not by Cocaine. Neuropsychopharmacol 34, 2767–2778 (2009). https://doi.org/10.1038/npp.2009.127
Costa KG, Cabral DA, Hohl R, Fontes EB. Rewiring the Addicted Brain Through a Psychobiological Model of Physical Exercise. Front Psychiatry. 2019 Aug 27;10:600. doi: 10.3389/fpsyt.2019.00600. PMID: 31507468; PMCID: PMC6718472
Ünal M, Öztürk O, Öztürk G, Fidanci İ, Atayoğlu AT, Sönmez CI, Taş E, Gürsu O, Selcuk MY. Effect of Fasting on Smoking Addiction: A Multicentered Primary Care Research. J Addict Nurs. 2022 Oct-Dec 01;33(4):E60-E66. doi: 10.1097/JAN.0000000000000414. PMID: 34593700.
Garavan H, Brennan KL, Hester R, Whelan R. The neurobiology of successful abstinence. Curr Opin Neurobiol. 2013 Aug;23(4):668-74. doi: 10.1016/j.conb.2013.01.029. Epub 2013 Mar 16. PMID: 23510740; PMCID: PMC3706547.
Solinas, Marcello, et al. “Environmental enrichment-inspired pharmacological tools for the treatment of addiction.” Current Opinion in Pharmacology, vol. 56, Feb. 2021, pp. 22–28, https://doi.org/10.1016/j.coph.2020.09.001.
Rodríguez-Ortega E, Cubero I. Environmental Enrichment Modulates Drug Addiction and Binge-Like Consumption of Highly Rewarding Substances: A Role for Anxiety and Compulsivity Brain Systems? Front Behav Neurosci. 2018 Nov 29;12:295. doi: 10.3389/fnbeh.2018.00295. PMID: 30555310; PMCID: PMC6281824.
Di Sclafani V, Tolou-Shams M, Price LJ, Fein G. Neuropsychological performance of individuals dependent on crack-cocaine, or crack-cocaine and alcohol, at 6 weeks and 6 months of abstinence. Drug Alcohol Depend. 2002 Apr 1;66(2):161-71. doi: 10.1016/s0376-8716(01)00197-1. PMID: 11906803; PMCID: PMC2857526.