Today’s prevailing notion is that drugs are inherently addictive and those who use them regularly do so because of a personal failing or because of a drug’s addictive properties. In his most recent book, Drug Use for Grown Ups, Chasing Liberty in a Land of Fear, neuroscientist, researcher, and Columbia University professor Carl Hart courageously challenges our society’s core assumptions about drugs and people who use them. Hart argues that most drug users do not suffer from problematic substance use or addiction but instead use substances in the pursuit of pleasure and wellbeing.
As practitioners who specialize in treating people who negotiate substance use challenges, we celebrate and support his position. However, along with identifying the positive utility of recreational drug use, we believe it is likewise important to acknowledge the sometimes catastrophic, negative consequences of problematic substance use, and to speak to the full range of drug use experiences. We also believe that Harm Reduction, contrary to the critique Hart lays out in his book, retains its importance as a philosophy, a set of health-promoting strategies, and a social justice movement. As we see it, an actionable Harm Reduction approach will only support Hart’s work on drug policy reform.
Hart provocatively posits that the pursuit of pleasure, wellbeing and happiness is not so different from the ideals written in our nation’s founding document and, therefore, that people have a constitutional right to use drugs and that drugs should be legalized and regulated. Further, he suggests that drug criminalization goes against the ideals written in the nation’s founding document, which the government is instituted to protect. For Hart, recreational drug use, irrespective of the drug, exercises our basic constitutional right to “life, liberty, and the pursuit of happiness.”
Hart proposes a paradigm shift for recreational drug use that challenges our society to rethink why we collectively relate to drugs and drug users in the way that we do. He elucidates how our ingrained perceptions are the product of deeper social, economic, and racial inequalities, which serve to further reinforce the social stigma of drugs and people who use drugs.
Hart recognizes that drug use requires boundaries, as with alcohol, which has laws and regulations in place (like the legal blood alcohol threshold permitted to drive a vehicle and an age requirement to purchase it). Hart has important caveats for his argument for recreational drug use, however: it demands that the person who uses drugs is a “grown up” (a responsible individual who can balance personal and social obligations), which means that if an individual cannot use drugs responsibly, Hart does not recommend using them. Hart states that while mental health challenges may not inherently preclude someone from using drugs recreationally, such challenges pose potentially greater risks for drug use and necessitate careful consideration. Hart also introduces the importance of honest drug education on recreational drug use, which would facilitate the drug user’s health, happiness, and safety.
Hart is uniquely positioned to speak to the scientific effects of drug use; he is an internationally recognized neuroscientist, and like many of his colleagues, he too once believed that drugs were inherently dangerous, addictive, and responsible for a variety of social ailments. Growing up in the midst of the 1980’s War On Drugs, he believed in the alleged narrative that drug use drove the crime, unemployment, and social unrest that permeated marginalized communities, like the one in which he grew up. Based on his observations over the course of his research career, Hart came to challenge the research that supported the notion that addiction is a brain disease, uncovering flawed research study designs, an overgeneralization of study findings, and inappropriate interpretations of causality.
He also came to find that drugs are not as addictive as we think they are. Hart reports that 70 percent of drug users (of all types of drugs, including substances like cocaine, amphetamines, and heroin) do not meet criteria for a substance use disorder or addiction (two terms Hart uses interchangeably), as defined by the American Psychiatric Association’s Diagnostic and Standardized Manual. If drugs were inherently addictive, Hart argues, more people (if not everyone) who use drugs would grapple with addiction. Rather, he suggests that the occurrence of addiction-related issues is more strongly predicted by social and environmental factors such as poverty, lack of education, and joblessness.
Hart observed and experienced first-hand that substances could facilitate positive effects on people’s biology, psychology, and interpersonal lives. He himself uses drugs recreationally. He makes the daring choice to disclose his regular use of heroin and other drugs. Hart uses himself as an example of a responsible adult who can use drugs recreationally without becoming addicted, and he shares that opiates provide him with experiences of emotional wellbeing, physical relaxation, perspective taking, and interpersonal closeness with others. Moreover, he encourages other responsible drug users to “out” themselves, to challenge the current distorted narrative of the type of people who use drugs that dominates our social discourse.
The idea that drug use can be decoupled from addiction may be very difficult for many readers to consider, particularly those who have dealt with the negative, and sometimes catastrophic experiences associated with addiction. Hart’s book is not an attempt to dismiss these experiences with drug use. Rather, he offers a valuable, additional point of view that is not acknowledged in the common narrative that often demonizes drug users.
Hart likens drugs to cars or guns—activities and experiences that carry liberty-giving rewards that outweigh their inherent risk but, unlike drugs, are not categorically illegal. And, contrary to the common perception, drugs are less dangerous than these other legal activities; for example, in 2017, automobile accidents killed almost three times as many people as heroin overdoses.
Hart not only questions the inconsistency between analogous legal and illegal activities, he also challenges the inconsistencies in how we relate to some drugs compared to others. Hart reasonably challenges the premise of psychedelic exceptionalism—the idea that psychedelic drugs used for spiritual or therapeutic purposes are somehow superior to drugs used simply for the pursuit of pleasure—asserting that it is based on an illusory distinction that further supports the stigmatization and marginalization of certain drugs and the people who use them.
In short, we agree with Hart’s contention with psychedelic exceptionalism. Rather than further promote somewhat arbitrary distinctions between drugs, the recent advancements in psychedelic-assisted therapy can instead engender an alternative opinion of other kinds of drugs and their potential utility. Just as with psychedelics, vilified drugs such as heroin, cocaine, and methamphetamine, can likewise promote “health and happiness.” By the same token, any drug holds its own benefits and risks, influenced by the context of its use (i.e., the environmental context of drug use, or the “set,” and the individual’s mindset around use, or “setting”). In an apt summation of the inherent dialectic that every drug (including psychedelics) holds, the ancient Greeks called drugs “pharmakon,” to mean that drugs can be both a remedy and a poison.
Hart emphasizes how the language we use to talk about drugs and drug users shapes and reinforces our perceptions. One example is Hart’s belief that the term Harm Reduction reinforces the cultural assumption that there is an inevitable link between drug use and harm. He suggests that by putting “harm reduction” and “drugs” together, it creates an association that implies that drugs are harmful. In fact, Hart states that “harm reduction has to go.” This emphasis on the negative effects of drugs, he believes, obscures how recreational drug use could facilitate the pursuit of happiness let alone be justifiable for legalization.
For Hart, the term Harm Reduction doesn’t capture the variety and complexity of people’s reasons for using drugs, and that they are most often used for their positive features. Not only does Harm Reduction connect drugs with harm, but also it assumes that the person using drugs is helpless and in need of intervention, a premise that Hart rejects. He says that the term Harm Reduction has worn out its welcome and if we need a term at all, he offers “health and happiness strategies” as an alternative (a phrase inspired by listening to Al Green’s Love and Happiness).
While we strongly support Hart’s project to de-couple the discourse on drugs from any presumption that they are inevitably harmful, we believe that Harm Reduction still has an important role to play in supporting the “health and happiness” of drug users. Hart is attuned to the nuances and complexities of drugs and drug use experiences, but in this instance, he seems to use a literal definition of the term Harm Reduction that we believe misses its complexity. We agree with Hart that Harm Reduction is an imperfect term. He raises an important point about how language shapes the way we think and behave and that our language should capture the nuance of drugs and drug use. However, by focusing on the subtleties of language, Hart overlooks the vital role that Harm Reduction plays in the service of improving the health and well-being of drug users.
Hart writes that most people use drugs responsibly and in non-problematic ways. While this may be true, we caution that it may set up an implicit notion that faults the individuals who do suffer from addiction and problematic drug use, and have families who, too, experience the catastrophic consequences of drug use. We want to underscore that the drug users and the constellation of people around them, who may need and want help, are not simply irresponsible but instead negotiate addictive relationships with drugs for many complex personal and contextual reasons, often overlooked by most traditional substance-use treatment approaches.
What is important about the term Harm Reduction is that it signals what is wrong with current treatment approaches and provides an alternative. While many treatments use abstinence-only models that minimize the complexity of problematic drug use and often blame and punish drug users. Harm Reduction humanizes the drug user and empowers them to choose if and how they engage with substances, leaving room for using substances for the pursuit of well-being in much the same way that Hart is advocating.
Furthermore, Hart does not acknowledge the broader historical and social context of the Harm Reduction movement. From our point of view, Harm Reduction is not just about reducing potential harms that an individual might experience using drugs, it is also a social justice movement that advocates for the rights, dignity and self-determination of drug users and fights against what we believe are the greatest harms associated with drugs: the harms associated with the criminalization, stigmatization and social marginalization of drug users. Harm Reduction is also a socio-political movement that has a long history opposing the unequal burden of drug prohibition on drug-using “communities” and its activities are committed to altering the social, economic, racial, and political inequalities that riddle the way society approaches drugs and people who use them. He does not acknowledge that embedded in the central tenets of the Harm Reduction philosophy is the empowerment of drug users by providing them with compassion, support, and representation.
To avoid these kinds of misinterpretations of Harm Reduction, those in the movement could better educate the public about all that the term encompasses. Despite its imperfections, we oppose jettisoning the term Harm Reduction. In particular, the landmark 30-million-dollar funding for Harm Reduction programs and services that was recently awarded by the Biden administration, marks the first time the federal government has officially acknowledged Harm Reduction and marks a historical shift away from punitive approaches and towards Harm Reduction ideals. So, until the day comes that all drug users are treated with respect, equality, and collaboration, we need the term to catalyze alternative, compassionate approaches to support and care for drug users. We believe that Hart’s important advocacy for drug policy reform provides a complementary and crucial component of a successful Harm Reduction program in support of drug users’ right to life, liberty, and the pursuit of happiness.
Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear By Carl Hart 304 pp. Penguin Press. $28.