A neuroscientist who specializes in addiction unravels the myths of the opioid 'epidemic'

Laws are not natural. They are made by society. As such, they reward certain behavior and punish others. The law is not "neutral" or "blind." It is made by the powerful, often to the disadvantage of the less powerful. America's drug laws serve as a powerful example of how justice that is supposed to be dispensed equally becomes a form of social control.

This article was originally published at Salon

For example, the long-running "War on Drugs" punishes the poor more than the rich. Black and brown people are racially profiled, subjected to "stop and frisk" procedures, and experience routine violations of their civil and human rights. White people -- who in many places are actually more likely to possess illegal drugs -- are treated much more benignly. Through lobbying, donations and other interest-group behavior, pharmaceutical, tobacco and alcohol manufacturers make sure their products are protected under the law. Politicians understand that the War on Drugs -- although it has been a massive policy failure -- remains a powerful political tool they can use to raise money and win elections.

What would a rational and humane drug policy look like in America? Is there really an opioid crisis in red-state or suburban America? What does it actually mean to be "addicted" to drugs? Where did the arbitrary distinctions between "legal" and "illegal" drugs come from? Who is winning and who is losing in America's war on drugs? What social damage has been done by the many myths of the drug war?

In an effort to answer these questions I recently spoke with Dr. Carl Hart, one of America's leading advocates for the legalization of drugs and their responsible use. He is the chair of the psychology department of at Columbia University, and is Ziff Professor of Psychology in the departments of psychology and psychiatry.

Hart has a reputation as a "myth buster" of the many public misconceptions surrounding drugs and drug use. He is the author of the award winning book “High Price: A Neuroscientist’s Journey of Self-Discovery That Challenges Everything You Know About Drugs and Society” and has been a featured guest on MSNBC, CNN, NPR and HBO's "Real Time with Bill Maher." Hart's essays have also appeared in the New York Times, Scientific American, and the Nation.

This conversation has been edited for clarity and length.

There is so much conflation going on when we talk about opioids. When we think about just opioids in general, for example, very few people who are addicted to opioids were actually prescribed them. Another example: Even with heroin, less than a quarter of the people who use it are actually addicted to the drug. The vast majority of people who use these drugs are not addicted. But too many people conflate "addiction" with overdose. In fact, people who are addicted are less likely to overdose from the drug, in part because they have a higher tolerance.

I love to participate in public education. But so many reporters and others who are trying to write on these "opioid addiction" stories have not done the basic research.

How do we define "epidemic," and is there a drug epidemic in this country? What do we actually know?

In epidemiological terms an epidemic is something that is rapidly rising and spreading. Opioid use is not rapidly widening. It’s not spreading. Something like heroin is always being used by a relatively low number of people. There have always been more cannabis smokers, cocaine users, Ecstasy users or the like.

Then we think about prescription opioids. The general narrative is to say those numbers have really increased. But in reality they have not. Then we have to add in the fact that they are legally available to people who use them appropriately and there are other people who take them for not legal reasons. Again, there is no epidemic of opioid use.

From black people, marijuana and "reefer madness" back in the 1950s and 1940s, to Chinese immigrants and "opium dens" where white women would be kidnapped and put in sex slavery in the late 19th and early 20th centuries, to crack in the 1980s and opioids today, there is a consistent moral panic around drugs in America. How does this influence our conversations about drug policy?

I wish everybody would ask the question you asked. In these conversations, we should ask, What are the issues? What are people concerned about? If they say, “Well, we’re concerned about all these deaths,” then say, “All right, that’s something to be concerned about: deaths.” Then we look at the evidence and say, “Why are people dying?” Well, a small percentage of them are dying from using opioids exclusively. However, the vast majority of them are dying from other reasons, such as combining opioids with alcohol or benzodiazepine or another sedative that then accounts for a large percentage of the deaths.

Another important percentage of the deaths occurs as a result of people getting a drug like fentanyl when they thought they had something like heroin. Fentanyl is more potent than heroin and unsuspecting people can take too much of it and die. You separate what the real issues are. When you know what the real issues are, you can then attack them real issues with some logic and reason. If people are not doing that, they are just interested in stirring up the flames of hysteria.

If they say, “Well, I’m really worried about addiction to this drug,” you then respond, “OK, the majority of the people using this drug are not addicts.” That means we have to shift the blame away from the drug itself and try to focus on what’s going on with those people, whoever they are, the addicts. Those writers, journalists, activists, politicians or whoever they may be are keeping our focus on the drug. If they do this, we know those people are not sincere and are not really interested in solving the problem they claim to want to solve.

How do we define an addiction versus a habit?

In medicine it is simple. We use the DSM, the "Diagnostic and Statistical Manual of Mental Disorders." There’s a list of symptoms. People have to display a certain number of those symptoms in order to meet the criteria for addiction. This includes having had several unsuccessful attempts to cut down or stop their drug use. They put themselves in harm’s way when they’re using the substance. It disrupts their ability to meet their obligations like work, family obligations, social obligations, all of these things. Their drug use is causing them a tremendous amount of distress. If people endorse these symptoms, then it’s clear we are then talking about addiction correctly.

We’re not talking about somebody who uses the substance every day, goes to work and they’re fine and able to live normally with their substance use. We can think about people who have a glass of wine at dinner every day, for example, who are fine. They’re not distressed. They handle their business. They’re not an addict. The same is true with somebody who might use heroin every evening and go to work and do their thing. They’re not an addict. That’s how we define it.

The idea of an "addict" conjures up images of certain bodies and types of people. This is of course racialized and gendered. White people who are addicted to opioids and other pain killers are now being depicted in a sympathetic light. They get empathy, while black and brown "addicts" get prison. The hypocrisy surrounding white privilege and economic class is disgusting.

I definitely understand that frustration. I point out the racial discrimination that happens in law enforcement specifically around drugs. People of all colors use drugs.

Yes, it is true that the media has a different level of sympathy depending upon the race and also the sex or gender of the person involved. It’s a fine line that we have to walk because it’s important to identify all of the things that we share in common too. I like to get high, somebody else may like to get high. But we live in a world where it is very true that people like Donald Trump and too many uninformed reporters contribute to the divisiveness that we see in the United States. It worries me. I want to live in a world where we’re all struggling together and we all recognize that we have the same struggles as human beings.

"Drug addict" is a term usually applied to a select group of people by the news media and in the American popular imagination. White suburban women after World War II were medicating themselves with amphetamines, but they were called "Mother's Little Helpers." White suburban and professional men were drinking alcohol to excess. America's elites abuse drugs, both illegal and otherwise, but they are not being put in prison.

The housewives with their "little helpers" and all the related drugs happened previously? That is still happening today. First of all, we have all these public judgments about a housewife who uses amphetamines. Why are we judgmental about it? Is she getting her job done? Is she happier? Great. That happens today with wealthy people. But when poor people do it they are judged harshly.

It happens in my university at various social functions. We have things like alcohol to enhance sociability. It’s happening all around us. Some parties that one may go to, there may be some cocaine. There are some opioids. There’s something else. But there are wealthier people so there is no judgment. The problem becomes when we start judging people about the choices they make to moderate their moods. What is wrong with people making that choice?

I’m a libertarian in this regard. If you’re an adult who can make decisions, so what? As long as you’re not hurting anybody. For a lot of people, that’s a provocative and problematic claim. This leads to the question of what a humane drug policy would look like?

Thirty-seven thousand Americans die every year from automobile accidents. But as a society we try to make sure that drivers have the appropriate training. We try and have speed limits. There are seat belts. All of these harm reduction strategies? That’s what a rational drug policy would look like. The state regulates the quality. One needs to be of a certain age and possess certain skills to purchase a car. That’s what a rational drug control policy would look like. It’s not that complicated. It only becomes complicated for Americans who are mentally shackled.

The "crack epidemic" dominated American politics in the 1980s and early 1990s. There was a whole popular culture subgenre around black urban crime with films such as "New Jack City." There were the stories about "crack babies." But all of a sudden crime rates dropped to historic lows in the United States. How did this happen?

I wrote about this in my book "High Price." The thing that’s amazing is that the crack story is so perfect that it refuses to die. When "High Price" came out in 2013, I was critical of the movie "New Jack City" and how it perpetuated the crack cocaine epidemic narrative. Then I got an email from the writer of "New Jack City," the white writer. He wasn't too happy with my criticism. We met. We had lunch and had a great conversation and he told me how it all went down.

He originally wrote the screenplay for "Godfather III." They didn’t like it because of the emphasis on the black protagonist. He sold the script and it became "New Jack City." They had another writer help them rework it and all this drama and exaggeration was added. Stuff that wasn't real, that was make-believe.

Now let’s look at the facts. People talked about crack being responsible for unprecedented rates of unemployment, all manner of mayhem and social problems.

The highest rates of unemployment in the United States were in 1992. Crack did not appear in the newspaper until around 1985. Then it really didn’t appear in the major cities until 1986. Unemployment rates were never as high. Then we talk about this unprecedented amount of murder and violence. Well, 1980 had one of the biggest peaks in murder. The powdered cocaine trade had something to do with that -- crack was not around at that time.

It’s true that when crack hit there were new drug markets. Whenever there are new drug markets, people will fight over territories. Some of that certainly did happen. Crack was not special in any way. Many observers were not considering that Ronald Reagan had become president and had decimated a number of the programs that were aimed at helping poor folks, folks who were disadvantaged. Factories were closing too. All these socially deleterious things were happening at the same time.

It was also becoming popular for politicians to talk about being tough on crime. The Clintons were talking about this. Lots of hip-hop artists, including my favorites such as Public Enemy, were also bought into this crack war narrative. Everyone bought into it. It was easy for politicians to just follow suit and that’s exactly what happened. Crack wasn’t that special. In fact crack is around today, and the use of crack is about the same. All of this nonsense about the power of crack -- if it was so powerful and did all those things, it would still be happening. Crack never went anywhere.

What is the short story about America’s drug control policy? Why are some drugs categorized a certain way and others are not -- even if they are also very addictive and dangerous?

The tobacco industry made sure that their drug was exempt from all laws that regulated drugs. They got that early in their history. Then, whenever a drug is used by a small number of the population, as you point out -- especially if that population that’s using it or perceived to use it is some type of racial or ethnic minority -- then incredible stories can be conjured up. Elites and others can make up incredible stories about the behavior of those people when they use those drugs, and it looks like you’re not going after those people. Which in reality you are.

That’s what is happening with things like heroin and crack cocaine. Not many people use these drugs, and when many people don’t use these drugs, you can just make up these stories.  The public will believe anything. That’s why a show like "Breaking Bad" was so popular, because the information about methamphetamine in that show was mostly nonsense.

People don’t know because they've never tried methamphetamine. We were all glued to the TV because we believed that nonsense. It wasn’t true. Considering "New Jack City" again, most of the people who smoked crack didn’t behave like the addicts in the film. We could see one person in our community who smoked crack, and they were doing badly or were homeless, for example. But we are not focusing on the factors that led to their homelessness. Maybe they are mentally ill? Maybe they were unemployed for a long time?

We can just say it was the crack alone which, frankly, is a stupid, simple answer. This is why we need people who use drugs to come out of the closet. I love Prince. Prince was an opioid user for years, doing his business and being one of the best and most prolific artists we’ve ever had. Nobody would think of him as being like a heroin user. What they didn’t know was that Prince was an opioid user and most likely a heroin user too. I think about Philip Seymour Hoffman. That guy was an excellent artist. One of the best actors that was around. A heroin user for many years, but he handled his business like most heroin users.

We don’t think about that because these people stay in the closet and instead we are able to vilify the ones who are out of the closet, because the ones who are out of the closet are having so many problems they need help. That’s the minority -- the aberration and not the norm. But American society doesn’t know that. As a result, some drugs get mislabeled and other drugs don’t. Like marijuana today -- we can’t vilify marijuana because a lot of people are out of the closet about their marijuana use, from the person who is the CEO to the person who is the criminal in the neighborhood.

In this moment there is another dominant narrative in which pharmaceutical companies are targeting certain communities and supposedly “dumping" opioids. What is actually happening?

I find that hard to believe. It’s so hard to get opioids, and it has always been difficult to get pain medicine, particularly for black folks. When people are talking about pharmaceutical companies dumping these meds, the major thing these companies are guilty of is that they undersold the extent to which people might become dependent or are addicted on these drugs.

In terms of dumping these meds, that’s an exaggeration. Pharmaceutical companies undersell the side effects for many of their drugs. That’s what they do. It’s not that different with opioids.

It’s not like there was some evil plot to go out there and target poor white folks. In fact, they were more liberal with the white folks being able to get prescriptions, and more conservative with black folks. Perhaps this even protected some people from developing a dependence, but then again we also have to require that people be adults.

It is your body. If you start to recognize some negative effect of something that you doctor prescribed, it’s your responsibility to say, “Hold up. I’m not doing this.” It’s ultimately your responsibility as an adult. There is this notion that these companies are going to protect us. I don’t understand where such an idea came from.

What does responsible drug use look like? How do you counter the obvious objection that "illegal drugs" are dangerous and their users cost the American people a great deal of money?  

Returning to the car example: There are accidents. We have these problems related to cars, and we deal with it. We could arrest everyone, for example, who drives over the speed limit. That would cost our society a lot of money and a great deal of trouble. We would lose a lot of productivity. We don’t do that, but we do it with drugs. It would be a lot more efficient to worry, for example, about people dying from drugs. Let's make sure that people who choose to use have high-quality drugs. Make sure that there are no adulterants in their drugs. Then you save people's lives.

If you really were concerned about people, those would be the laws and rules enacted. But the lovely thing about drugs and drug policy is that it always provides a way for the country to increase the budgets of American law enforcement. That’s why drugs are illegal. Drugs also give politicians a reward for their constituents ,such as the police.

They can also reward physicians or treatment providers by making sure we have money for the treatment of illegal drug users. Politicians make these speeches. The newspapers and media also get to write these great stories about these awful drugs. Everybody is winning except the people who use drugs or have a risk of dying from drugs. Many people are winning from the current approach. That’s why we have the current approach. It pays off for people. It is not because it keeps people safe.

We have bars. People go into bars. They go home, they take care of their families. That’s responsible drug use. The vast majority of people do it responsibly. That’s responsible drug use. The same is true with cocaine. The same is true with heroin. The same is true with MDMA. The same is true with some other psychoactive substances. That’s how we all use drugs.