Pubdate: Thu, 14 Jan 2021
Source: Wall Street Journal (US)
Copyright: 2021 Dow Jones & Company, Inc.
Author: Sally Satel


In a referendum in November, Oregon became the first state to
decriminalize the possession of small amounts of heroin, cocaine,
methamphetamine and LSD. The move was inspired by a 2001 law in
Portugal that removed incarceration as a penalty for drug possession.
To judge by "Drug Use for Grown-Ups," Carl Hart welcomed this news,
which came too late for him to mention in his provocative and
enlightening book. He opens with the announcement: "I am an
unapologetic drug user."

Mr. Hart, a professor of psychology and a neuroscientist at Columbia
University, asserts that "recreational drugs can be used safely to
enhance many vital human activities." He bases his claim on decades of
research on the behavioral and physiological effects of drugs in
humans, coupled with his personal use. Thanks to drugs, he says, "I am
a happier and better person." He asks that we think about drugs in a
more nuanced way, even at a time when opioid abuse is still headline
news. Thus his book represents a calculated risk-namely, that by
portraying drug use as so potentially rewarding for responsible users,
it may inadvertently seduce non-grown-ups into hazardous use.

Mr. Hart reports that his views about drugs have evolved over the
years. Growing up near Miami as a teen in the early 1980s, a city then
overrun with crack cocaine, he saw drugs as a raging menace. In
graduate school he began studying neuroscience. "If I could stop
people from taking drugs, especially by fixing their broken brains,"
he told himself, "I could fix the poverty and crime in my community."
In pursuit of this mission, he tried to prove the dangers of drug use.
But over time he concluded that the marijuana, cocaine and
methamphetamine that he gave (with the approval of various ethics
committees) to his subjects, themselves experienced drug users, was
not as harmful as he had expected. No matter the drug, his subjects
overwhelmingly said that they felt "more altruistic, empathetic,
euphoric, focused, grateful, and tranquil."

"Drug Use for Grown-Ups" has the soul of a manifesto. Mr. Hart wants
to show us that "government bans on recreational drugs violate the
spirit and promise of the nation's founding document." Putting it more
personally, he writes: "It is my birthright to use substances in my
pursuit of happiness." Though a regular user of heroin, Mr. Hart says
that he is "not an addict," adding: "I have never failed to meet my
obligations as a result of the drug or its effects." The same is true
for most other heroin users, he says, citing data showing that
addiction affects only 10% to 30% of those who regularly use heroin
and methamphetamine, among other drugs.

The alleged enslaving nature of drugs-you use it and you're hooked-is
one of many misperceptions that Mr. Hart tries to dispel. Each of his
chapters presents a tutorial on the pharmacology and physiological
effects of a particular class of drug, including opioids,
amphetamines, psychedelics, cocaine and cannabis.

Take methamphetamine. Contrary to the image of "meth" users as
frenzied people out of control, Mr. Hart shows that they can modulate
their use in response to incentives. In one experiment, he gave
regular users a sample of the drug and then offered them $1 if they
would stop smoking it. Most didn't, but when the reward was raised to
$5, almost all stopped and took the cash. Relatedly, Mr. Hart observed
that regular marijuana use had "virtually no disruptive effects on the
complex mental abilities," including "reasoning and abstraction."
Performance on a test of vigilance even improved. He shows that the
effects of a drug often depend on the dose, the mode of administration
(e.g., swallowed, inhaled, injected), even the user's expectations of
what the effect would be like.

Mr. Hart makes clear that he sanctions drug use by responsible people
only-those who can delay gratification, control their impulses and
regulate their emotions. For individuals who have a history of
addiction or mental illness, or who are currently in crisis, he warns
that the risk of a bad outcome makes drug use not worth it.

As persuasive as Mr. Hart can be, it is impossible to avoid certain
doubts or cautions. The vexing paradox is that the very individuals
who feel compelled to use intoxicants to excess are often those least
psychologically equipped to handle them. One has to keep in mind, too,
that Mr. Hart, in his experiments, administered pharmaceutically pure
drugs at controlled doses in a safe environment-conditions not to be
taken for granted in real life.

As a psychiatrist, I know that some people can be responsible users of
even the most feared drugs. But the pill mills of Appalachia and the
needle-strewn streets of San Francisco show how devastating unfettered
access to drugs can be. Mr. Hart promotes treatment and harm reduction
(e.g., clean needles, safe-injection rooms, testing for contaminants),
but he doesn't offer a detailed blueprint for keeping drugs away from
the people whose lives can be ruined.

He does discuss the difficult relation between drugs and
neighborhoods. "I once wholeheartedly believed that drugs destroyed
certain black communities," he recalls. But now he thinks that living
in destroyed communities primed people to use drugs. After all, when
struggling rural whites succumbed to prescription opioids, the problem
was largely understood as a response to living in hollowed-out towns
and running on merely the fumes of the American Dream.

On Feb. 1, Oregon will implement its new law. For its citizens and the
handful of states now considering a similar ballot initiative, "Drug
Use for Grown-Ups" is an excellent guide to what can go right with
such a move. The question is how to address the individuals who can't
handle the freedom the author envisions for them.

Dr. Satel is a visiting professor of psychiatry at Columbia
University's Vagelos College of Physicians and Surgeons and a resident
scholar at the American Enterprise Institute.