Monday, August 19, 2013

Challenging Everything You Know About Drugs and Society

Carl Hart is a professor in the departments of Psychology and Psychiatry at Columbia University. His research specialty has been illegal drugs, their effects on the human body, and the implications for society. He is co-author of a textbook on these subjects. 

Hart has also written a book for a general readership: High Price: A Neuroscientist’s Journey of Self-Discovery That Challenges Everything You Know About Drugs and Society. He provides this description of his motivation.

"The primary reason I wrote this book was to show the public how the emotional hysteria that stems from misinformation related to illegal drugs obfuscates the real problems faced by marginalized people. This also contributes to gross misuses of limited public resources."

Hart is also a black man who came to adulthood about the time of the surge in usage of crack cocaine. He grew up in a segregated area of Miami, the type of location that became ground zero in the "War on Drugs." Hart had left to join the Air Force before this surge actually hit, but he was able to observe the effects of cheap cocaine on his family, friends, and neighborhood. He could have written a book that focused solely on drug and drug effects on humans, but feared that such an approach could not deal adequately with the importance of a person’s individual circumstances in determining the difference between no drug use, recreational drug use, and drug addiction.

Hart tells his story about drugs and society from the perspective of his own life and experiences.

"To truly understand where I came from, you have to understand where I wound up—and how mistaken ideas about drugs, addiction, and race distort the way we see lives like mine and therefore, how society addresses these questions."

Hart’s autobiography provides valuable insights into what it is like to be a young black man in our society. He makes clear the historical tendency to link drug use and race, and to use that link to argue for strict drug laws and tough mandatory sentences even for mere possession. The result has been a situation where illegal drug use and sales are roughly equally common between the races, but arrests and incarceration fall far more heavily on blacks and Hispanics. This is too important a topic to treat casually. Consequently, the focus here will be on drugs and physical response with racial issues mostly left for a later date.

Hart focuses on cocaine. At some point drug producers concluded that marijuana was too bulky and not sufficiently profitable and switched to cocaine as their drug of choice. The characteristics of cocaine are summarized in Wikipedia.

"Cocaine increases alertness, feelings of well-being and euphoria, energy and motor activity, feelings of competence and sexuality. Athletic performance may be enhanced in sports where sustained attention and endurance is required. Anxiety, paranoia and restlessness can also occur, especially during the comedown. With excessive dosage, tremors, convulsions and increased body temperature are observed."

"Occasional cocaine use does not typically lead to severe or even minor physical or social problems."

Much the same could be said for alcohol use and cigarette smoking. Why has cocaine then been long viewed as a dangerous drug that must be declared illegal? Hart references a study by David Musto: The American Disease: Origins of Narcotic Control to arrive at this observation.

"....between 1898 and 1914 numerous articles appeared in the scientific literature and popular press exaggerating the association of heinous crimes and cocaine use by blacks.....As Musto has detailed, ‘experts’ testified before Congress that ‘most of the attacks upon white women of the South are the direct result of a cocaine-crazed Negro brain.’ As a result, it was not difficult to get passage of the Harrison Narcotics Tax Act of 1914, which effectively prohibited the drug."

It was understandable at the time that stories like this would emanate from the South where it was important to maintain the myth that blacks were inferior in as many ways as possible to whites. It is disturbing to realize that so many historians and others of influence in the North bought into this myth and propagated it.

Does the use of the drug actually produce "cocaine-crazed" brains? First some facts about the drug and its usage are required. For those who are not already conversant with the details:

"Powder cocaine is chemically known as cocaine hydrochloride....This form of cocaine can be eaten, snorted, or dissolved in water and injected. Cocaine hydrochloride cannot be smoked, however, because it decomposes under the heat required to vaporize it. Smoking requires chemically removing the hydrochloride portion, which does not contribute to cocaine’s effects anyway. The resulting compound is just the cocaine base (aka freebase or crack cocaine), which is smokable. The important point here is that powder and crack cocaine are qualitatively the same drug."

What is important to a drug user is that the effect be delivered reliably and quickly. Ingesting the drug is a slow and unreliable process. Snorting powder delivers an effect in a few minutes. The fastest approach to a high is by getting the drug into the blood stream via injection or by inhaling vapor into the lungs. Smoking also allowed for an efficient high while requiring only a small amount of the drug. The discovery of a simple and safe way to mass produce crack cocaine meant that the drug could be sold in small amounts and at low prices.

Powder continued to be the drug of wealthier whites, while crack provided a high cheap enough to become popular in the black community. This upsurge in usage led to an upsurge in scare stories about crimes and family dissolution similar to the "cocaine-crazed negro brain" tales from an earlier era. The War on Drugs was in place and pounced on this phenomenon and declared "black cocaine" to be more dangerous than "white cocaine." Much more severe penalties were associated with crack than with powder cocaine. This allowed, and even suggested, that law enforcement should focus on arresting and incarcerating blacks even though usage was just as common among whites. And that is exactly what happened.

Strict laws against the possession, usage, and sale of a drug seem reasonable if the drug is actually highly destructive in leading to addiction, criminal behavior, and social disruption. The point Hart makes is that this condition does not exist for cocaine—nor for many other drugs we criminalize.

A definition of addiction is needed. Hart uses the one described by psychiatrists in their catalogue of mental disorders.

"....a person’s drug use must interfere with important life functions like parenting, work, and intimate relationships. The use must continue despite ongoing negative consequences, take up a great deal of time and mental energy, and persist in the face of repeated attempts to stop and cut back."

Given this definition and actual data on drug dependence, such behavior is relatively rare.

"But more than 75 percent of drug users—whether they use alcohol, prescription medications, or illegal drugs—do not have this problem. Indeed, research shows repeatedly that such issues affect only 10-25 percent of those who try even the most stigmatized drugs, like heroin and crack."

Even the person who becomes a regular user of the drug continues to maintain the ability to choose to take the drug or not depending on the given circumstances. The image of the addict being driven mad with desire for his drug just doesn’t happen. Hart suggests that the desire for the drug is more closely analogous to the desire humans feel for sex and food—both being cravings difficult but possible to control.

Destructive use of a drug does not spring from an uncontrollable physical craving, although the craving is a factor.

Further enlightenment comes from animal studies. Hart describes an experiment where a collection of rats were divided so that one group lived in a shared space (referred to as Rat Park) where they could interact and socialize in whatever manner rats do. The others were placed in isolation in individual cages. All the rats had access to water doped with morphine at a level that should have produced a physical response.

"They found that while the isolated rats quickly took to morphine drinking, the Rat Pak rats did not. Indeed, even when the morphine solution was so sweet as to be overwhelmingly attractive to rats, the Rat Pak residents still drank much less of it than the solitary animals did. Under some circumstances, the isolated rats would drink twenty times more morphine than their social-living compatriots."

Similar results have been obtained with rats using cocaine and amphetamines rather than morphine. The conclusion seems to be that when natural rewards are available, they are generally preferred to the artificial, drug-induced reward.

"When natural rewards, such as social and sexual contact and pleasant living conditions—also known as alternative reinforcers—are available to healthy animals, they are typically preferred. There is now a plethora of evidence collected in animals and humans showing that the availability of non-drug alternative reinforcers decreases drug use across a range of conditions."

Humans and rats have needs. If those needs are not being met in their existing environment, both are more likely to turn to drugs as a source of satisfaction.

"....when people have appealing alternatives, they usually don’t choose to take drugs in a self-destructive fashion. But it does show that in the absence of social support or other meaningful rewards, cocaine can be very attractive indeed. The bottom line is that we have been repeatedly told that drugs like crack cocaine are so attractive that users will forego everything for them. Nonetheless, overwhelming empirical evidence indicates that this is simply not true."

The importance of social context for drug use cannot be overemphasized. People who live in an environment with social support and other alternative reinforcers are less likely to use drugs in a destructive fashion than those whose environment is more devoid of alternative reinforcers. One would then expect addiction to be higher in lower-income neighborhoods than in middle class or wealthier environments.

"....despite years of media-hyped predictions that crack’s expansion across classes was imminent, it never ‘ravaged’ the suburbs or took down significant percentages of middle- or upper-class youth. Though the real proportion who became addicted to crack in the inner city was low, it was definitely higher than it was among the middle classes, just as is true for other addictions, including alcohol."

Given the data Hart has assembled, the path we are following seems to make little sense. Recreational use of drugs seems to be as old as recorded human history. If recreational use is a viable lifestyle choice, why criminalize it? Why not leave controlled users alone and provide support for those in need of help. It is a lot cheaper to provide counseling to a few than to imprison many.

Hart recommends the approach taken by Portugal. In 2001 Portugal decriminalized all illegal drugs. Possession of drugs for recreational use is no longer a crime. Those found in possession of drugs are cited and required to appear before a board consisting of a social worker, a medical professional, and a mental health professional. If the person is deemed to not have a health problem due to drug use, he/she is fined and sent on their way. If a health issue exists, the person is referred to appropriate care givers. But even in this case treatment is not mandatory. Repeat offenders can be issued greater penalties, but are still not considered criminals.

"How has decriminalization been working out for the people of Portugal? Overall they have increased spending on prevention and treatment, and decreased spending for criminal prosecution and imprisonment. The number of drug-induced deaths has dropped, as have overall rates of drug use, especially among young people (15-24 years old)."

Compare that to our system with its severe penalties and immense prisoner population.

"A 3,500 percent increase in spending to fight drugs between 1970 and 2011 had no effect on daily use of marijuana, heroin, or any type of cocaine. And while crack has been seen as a largely black problem, whites are actually more likely to use the drug, according to national statistics."

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