No Easy Fix: On Carl L. Hart’s “Drug Use for Grown-Ups”

November 16, 2021   •   By Maria Cichosz

Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear

Carl L. Hart

ADVOCATING FOR SENSIBLE drug policy can be like reasoning with a toddler. It might prompt a thinking person to write something like Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear, Columbia University psychologist Carl L. Hart’s latest stand in the War on Drugs. Drawing on a mix of personal anecdotes and research, Hart argues that arresting drug users does more harm than good. He dismantles the racist underpinnings of arguments that drug use causes poverty and crime, showcases the benefits of harm reduction approaches (though he prefers the term “health and happiness” strategies), and convincingly takes on the influential but problematic neuroscientific model of addiction as a brain disease. Most harms associated with drugs are, he claims, caused by ignorance and prohibition. He recommends drugs be regulated and legally available. Recreational drug access is more than just good drug policy: much like the decision to own a car or gun, it is an unalienable right to “Life, Liberty and the pursuit of Happiness.” Prohibition, in other words, violates the promise of the nation’s founding document. “Stop behaving like children,” Hart exhorts. “Time to grow up.”

It’s surprising, then, to learn that the children in Hart’s key analogy are not politicians and policy-makers refusing to consider the evidence, but rather drug users themselves: those whose irresponsible use interferes with being “autonomous, responsible, well-functioning, healthy adults.” Hart’s book is not intended for them; it’s for drug-using “grown-ups” who “meet their parental, occupational, and social responsibilities,” “get ample sleep, eat nutritiously,” “pay their bills and taxes on time[,] take care of their families,” volunteer locally and globally, subscribe to enriching monthly periodicals, meditate, and own a Peloton (not all these activities are on Hart’s list of grown-up traits, but they might as well be). Drug Use for Grown-Ups is “unapologetically not about addiction.”

Hart’s argument hinges on creating a new archetype of the typical drug user: educated, healthy, and self-controlled enough to enjoy drugs primarily for that most taboo of purposes — pleasure. In this way, he aims to shift the terms of debate over drug regulation from negative social consequences to the exercise of a fundamental right. This is at once profoundly problematic and profoundly familiar: it evokes an expedient legal framework with strong precedents in the libertarian strand of United States politics. Circumventing the need for handwringing about addiction or complex systemic issues, it attributes all responsibility for the consequences of drug use to the individual.

Most importantly, the strategy works. Framing users as responsible middle-class professionals free of messy social complications like poverty, homelessness, or illness is remarkably effective. Consider marijuana activists who have represented the average user as a white-collar worker or stiletto stoner destressing after a long day at the office. Now all but five states have legislative provisions for some form of legal, decriminalized, or medical cannabis. It’s no coincidence the movement’s major advocacy group uses the acronym NORML (National Organization for the Reform of Marijuana Laws). In 2016, advocates for kratom, a psychoactive botanical, were successful in preventing the Drug Enforcement Administration from scheduling the substance, a historically unprecedented effort attributable largely to the American Kratom Association’s savvy legal team’s representation of the average kratom user as a responsible citizen, consuming the plant to manage pain while maintaining a rich and productive life. Both the AKA and NORML call those they represent “consumers,” foregrounding a framework of individual choice. Hart broadens their strategy to include all drugs. Liberty, as Hart puts it, means responsibility, and responsible citizens should have the freedom to consume what they wish.

The much-maligned addict is simultaneously cast as the poster child of prohibitionist “Just Say No” horror stories and as an inconvenient fact to be slipped under the rug of progressive legalization arguments. Hart is partial to the latter strategy, repeatedly emphasizing that addiction is not the norm: “only” 10 to 30 percent of the 30 million Americans who use drugs become addicted. For him, addicts constitute marginal, sensationalized cases beyond the scope of his discussion. (For the sake of comparison, a favorite rhetorical strategy of Hart’s, consider that COVID-19 mortality rates of “only” 1.6 percent were considered significant enough to shut down the country.)

A figure of extremes, the drug addict embodies our deepest fears about deviancy, agency, and self-control. To put it crudely, the addict is bad PR. “We need to think about drugs and behave in a more nuanced manner,” Hart maintains, though his own argument doesn’t exactly excel in subtlety. “We need to cut the bullshit and stop pretending drugs inevitably — and only — lead to undesired outcomes.”

Most egregious in this alleged cutting of the bullshit is Hart’s strategic dismissal of the “so-called” opioid epidemic, which “has made it damn near impossible for rational adults to acknowledge publicly their recreational opioid use.” He suggests we get clear-eyed on the “whole lot of money made on publicizing the crisis.” Here, he takes the media to task while inexplicably dismissing the role of “big pharma,” which appears in quotes in his text, as if Purdue Pharma’s responsibility for systemically pushing an addictive prescription through years of deceptive marketing is a fringe conspiracy theory rather than a rigorously documented fact. The billions of dollars in profit reaped by the Sackler family are curiously absent from Hart’s analysis.

Hart may think he can purge addiction from the room, but its absence haunts his argument. He cautions against cherry-picking evidence, and yet, in a discussion of problems with opioid death reporting, he cites a minor caveat in a study that otherwise shows that even when the best quality data is used, such deaths have increased exponentially over the past 38 years. He could easily have chosen to cite a more recent study showing that, if anything, opioid involvement in unclassified drug overdoses is underestimated. He presents Sigmund Freud as a happy advocate of cocaine use while somehow neglecting to mention Freud’s later disavowal of the drug after prescribing it to his friend Ernst von Fleischl-Marxow for morphine addiction, resulting in the latter’s relapse and death. He cautions that “[t]oo often anecdote alone and misinterpretation of data drive the unrealistic and inaccurate drug stories presented to the public,” dismissing Trent Reznor’s “Hurt” (1995) as a nonauthoritative account of heroin use while centering his own anecdotal experience of taking small, controlled doses of extended-release morphine to prove that withdrawal is a mild “inconvenience that could be dealt with without failing to meet major obligations.” An experienced opioid user taking many times this daily dose intravenously would certainly experience withdrawal far more intensely. Hart is right that “beliefs alone are insufficient to guide drug-education efforts,” but falls short of this standard in presenting his case. Given the prevalence of misinformation about drugs, progressive policy advocates do have the responsibility to present data objectively, even when it suggests politically inconvenient truths.

Downplaying addiction as a significant aspect of drug experience trades one moral extreme (all drugs are evil and will kill you) for another (drugs create only happiness, not harm). Drugs are poor candidates for one-sided rhetoric. They are what the Greeks called a pharmakon: both poison and cure, bringing pleasure and pain. One does not negate the other. A strong, humane drug policy would account for both. Hart repeatedly emphasizes that drugs are just chemicals, “inert substances” that do not have “magical qualities,” but these chemicals in fact circulate in complex social contexts that overdetermine who is able to use them and what the effects of that use will be. Any drug policy worth its salt must contend with these complexities.

The framework of individual liberty, choice, and responsibility is thus woefully inadequate for capturing the wide range of reasons people choose to use drugs. Consider the adaptive model of addiction, which understands drug use as a rational response to an individual’s social, psychological, or economic circumstances. Beyond pleasure and happiness, people use drugs to serve a variety of vital functions: gaining control over their aggression or otherwise undesirable behavior, reducing family tensions, dealing with chronic unemployment, making demanding or exploitative work conditions bearable, self-medicating physical pain or emotional trauma, alleviating insecurity, increasing productivity, navigating systemic oppression, and so on. This is why students, long-haul truck drivers, and homeless entrepreneurs use amphetamines; it is also why opioids and benzodiazepines have become a form of self-therapy in an economically precarious society where affordable mental health care is not widely available. Hart himself admits he uses opioids “to lessen the anguish” caused by racism and the pressures of his profession. Beyond the pursuit of happiness, drugs are clearly also a way to cope with living in a damaged world, representing an individual response to otherwise overwhelming conditions. The decision to use drugs in this way is not irrational or irresponsible, but neither is it solely the result of abstracted free consumer choice.

Yet in Hart’s choice-based model of drug use, the decision to use drugs maladaptively can only be framed as the result of “ignorance” — if users were informed about potential harms, they would make different decisions. He maintains, for instance, that drug-checking services and education would empower individuals to avoid drugs contaminated with fentanyl, a condescending perspective given that no one is more educated about drug contamination than habitual opioid users, some of whom actively seek fentanyl-laced heroin for the stronger high it provides, while others are not in a position to turn it down in a market where so many street drugs are adulterated. Similarly, he explains that people choose to inject heroin “despite knowledge of the risks and alternatives” because “the injecting drug-user identity captures the persona they’d like to project.” Let’s be real — no one injects heroin to seem more “down.” They do it because it is the most efficient way to get high if you have a tolerance.

Drug users with rhetorically inconvenient addictions are not children but adults navigating complex social conditions. Hart holds himself up as a model, writing that his drug use had never been as “disruptive or as problematic” as his position as a department head at Columbia University. It has instead, he contends, “been largely protective against the negative health consequences of negotiating pathology-producing environments.” He doesn’t consider all the ways in which his economic and professional privileges have allowed him to use drugs in this self-protective way.

The price of positioning respectable users as mascots for free consumption is writ large in the failures of marijuana legalization. The movement’s reliance on the rhetoric of respectability has resulted in lucrative business licenses and a cornucopia of pot goodies for white professionals. By contrast, the overturning of past drug convictions for disproportionately policed and incarcerated racialized users has been slow and uneven at best. These disparate outcomes are a direct result of the kind of rhetoric that legalization arguments depend upon: responsible, middle-class, “adult” drug users are implicitly white, and respectability is a form of colorblindness. This form of rhetoric doesn’t use racial terms openly, but codes them into veiled language carrying the same racist biases responsible for African Americans being six times as likely to be arrested for possession as whites. Hart is justly critical of biases that result in “one drug policy for white users and another for black users,” like media empathy for white middle-class crack users perceived as using the drug as a tool for managing professional stress, but he seems untroubled by how his argument for respectable drug use participates in this very logic.

Carl L. Hart’s Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear is good drug policy based on bad rhetoric. Leveraging respectability infantilizes non-ideal drug users, who are implicitly poor, of color, struggling with physical or mental health, living in precarity, possibly addicted, and likely to be harmed by blanket drug policies. It renders their needs subservient to those of recreational middle-class users. Fair and equal drug policy would mean including all users, not just those with college degrees, good jobs, and the privilege to disclose their use with impunity. Policies built around harm reduction can be just as beneficial to recreational users as to addicts. Both types of use can be more productively conceptualized as extremes on a spectrum, with all kinds of people using drugs for all kinds of reasons that vary throughout their lives. A multifaceted understanding of drug use would be messy, and hard — a task for the grown-ups in the room.

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Maria Cichosz is a novelist and scholar of literature, art, theory, drug cultures, and the history of ideas. She earned her PhD in Modern Thought & Literature from Stanford University. She teaches writing at the University of Toronto. She is a Books Editor for The Social History of Alcohol and Drugs journal and the author of a novel, Cam & Beau (2020).