DR. CARL HART
Neuroscientist, activist, and professor at Columbia University, Dr. Carl Hart on how drugs and genetics are not the cause of addiction, and why it's easier for society to ignore the true root causes of one of our largest health crises.
Tracy: You have a fascinating backstory. Can you talk a bit about choosing to go into neuroscience and why you specifically focus on drug use in your research?
Dr. Hart: One of the reasons I got into this field is because I grew up in the hood. It was a place that was very poor and primarily black within the United States—in Florida. As a youth, I carried a gun, I sold drugs, I used drugs and as I’m sure you know, that’s a dangerous endeavour particularly in the U.S. But eventually, I decided to get serious about my formal education and earned a Ph.D. in neuroscience, which changed my trajectory a bit [Laughter].
I went into neuroscience specifically because I wanted to fix the drug addiction problem that I saw in my community. I was told—and I fully believed—that the poverty and crime in my community was a direct result of drugs like crack-cocaine. But more than 25 years later I have still not found any evidence to support this.
Pertaining to my path, the skills that sustain people throughout life are usually obtained through the critical period of young adulthood. I spent most of my young adult years in classrooms and labs, learning how to think and how to write, which were skills that enabled me to support myself and my family financially, and as a result, I have a 'stake' in my sick society.
I often say: because of this, society and I both benefit. Many of my friends that I grew up with didn’t ever get this same chance because they didn’t get the support they needed during that critical period. Instead, they were under the supervision of a [criminal justice] system that doesn’t seem to understand or care about the importance of the black male role in society. The supporters of this system have an irrational focus on eliminating certain drugs and are preoccupied with those who violate drug laws, especially if they are black. So this selective enforcement of drug laws is used as a tool to marginalize black males and keep them in this vicious cycle of incarceration and isolation from mainstream society. Of course, there are many cases when legal action is appropriate, but the penalties shouldn’t be so severe that the penalized young person is unable to recover and integrate back into society.
If the drugs aren’t the problem, what do you suggest is the smarter route for society to take in terms of looking at the use of drugs?
Initially, I argued that we had to decriminalize all drugs as they have done in Portugal and the Czech Republic. Decriminalization is simply treating drugs like a traffic violation where someone may be fined, but they don’t go to jail for possession. That’s what I argued for when I wrote my first book High Price.
But after a couple of years of being out on the road, I discovered that I was arguing for the wrong thing. One of the basic things that concerns me as a scientist, as a parent, and as a concerned citizen, is the adulterant of drugs. Not the drugs themselves—I’m not afraid of crack cocaine or heroin, I know how to keep people safe with those drugs, but I am concerned about things that I don’t know about: what people are cutting these drugs with. And if that’s the concern, then I’ve got to argue for legal regulation in order to be consistent with this position of concern. So we need to legalize the market and we need to regulate the market, just like we do with other potentially dangerous or harmful behaviours like driving and extreme sports.
We also have to constantly evaluate the risk-to-benefit ratio of our approach. That is, we have to weigh the benefits with the negative effects to see which way we should go. If we implement a strategy, we have to see if we’re getting more positive effects than negative effects. If so, continue. But if the reverse is true and the negatives outweigh the positives, then we have to simply change, and we certainly can do that with drug policy. I know many people are very comfortable with the popular phrase “treatment, not jail”, or looking at it as a public health approach, not a law enforcement approach. But the treatment and public health approaches are equally as flawed. Many physicians, public health officials, and treatment providers are just as incompetent and ignorant about drugs as law enforcement officials are.
The fact is, the majority of people who use drugs don’t have a problem. 80% to 90% of people who use drugs are like myself—responsible, tax-paying members of society. Bill Clinton used marijuana, George Bush used marijuana and is widely suspected of having used cocaine, Barack Obama has used marijuana and freely admits to having used cocaine. These guys aren’t addicts, they’re not living on the street and they don’t look like those folks we can see on Hastings street or the Downtown Eastside here in Vancouver. And given that most high-functioning people don’t require treatment, then that means that drug users—all drug users—need to be treated humanely and most certainly not thrown in jail.
Explain more about the role of medical professionals and why you suggest they are equally as clueless about drugs and drug addiction.
Yes, so you have to think about the money and who’s funding what, and when you do so, you’ll learn that the National Institute on Drug Abuse in the U.S. funds about 90% of the world’s research—so that’s not just the U.S., that’s the entire world. So what really becomes important is looking at what their mission is: what do they do? Well, their mission is to focus on pathology, the bad things that happen related to drug use. So given that 80% of people who use drugs without pathology, and without addiction or these other problems, if that’s the case, and your major funding is focusing exclusively on pathology, well, you’ll have a skewed perspective. The information will be skewed toward the very small percentage of pathology instances.
So what’s being published in the scientific literature, and what’s being published in the texts books, or in the popular press, or in movies and TV shows? All these things perpetuate this unbalanced information about drugs, and it all starts with this biased focus from the major funding. So we have this unrealistic focus on eliminating certain drugs at all and any cost—particularly towards a specific group of people. In terms of science, the spotlight is on pathology, and so that’s where most of us are looking. To paraphrase something Upton Sinclair has said, it’s difficult to get a man to understand something when his salary depends on him not understanding it.
Very fitting. On top of funding, why else do you think people are failing to look outside of this narrow view? Money is powerfully persuasive, but there are a few additional reasons behind our reluctance to look further.
I’ve given this a considerable amount of thought. It continues to happen because it allows us in society to target people who we don’t like without explicitly saying so. It allows us to go after the undesired in our society. And we don’t have to say we’re going after them, we say we’re going after crack-cocaine users or heroin users, but we know who we’re talking about. It also allows us as a society to avoid dealing with the real problems that marginalized and poor people face: unemployment, substandard education, and poor mental health. All of these things we don’t have to deal with. It’s a lot easier simply to say we need to rid our society of narcotics. But most importantly it increases the budgets of the addiction industry participants. These are all the people who are benefitting from our current approach: law enforcement, treatment providers, physicians, politicians, the media, scientists, even some parents because then they don’t have to look at their own actions, and they don’t have to teach their kids about these kinds of things. So all of these people benefit from not having to have these conversations, but they’re really not benefitting because we’re all paying the price in the end.
Talking about addiction, what’s interesting to me about your work is that it forces people to get away from the idea that drugs or genetics are the cause. The research I've seen points to early childhood trauma, motivational salience, and conditioning. I'd like to hear your thoughts on these.
Trauma is a factor that as a society we refuse to look at, to our detriment, but there’s a lot of emphasis here in Vancouver because you have Dr. Gabor Mate. He’s right on some level in speaking about the evidence he’s seen when looking directly at these people and their histories. We know this is a huge contributing factor, and have for some years now, but it gets ignored. Now to be fair, the reasons they’re looking at early trauma in the form of neglect [and] abuse is because those things set people at a disadvantage in terms of their ability to deal with stress. And stress [high levels of cortisol], is one of the main reasons people engage in these behaviours compulsively—so it’s not the drugs. This can be drinking alcohol, it can be flirting when you shouldn’t, it can be gambling, it can be many, many things.
To understand this, lets first define addiction. Addiction is a behaviour that repeatedly disrupts someone’s psychosocial functioning. Your obligations, whether they be employment obligations, family obligations, or social obligations are repeatedly disrupted to pursue something else, even in the face of consequence. Now, there have been studies that have looked at people who are addicted, and if you look at their family histories and you do your typical psychiatry write up, you’ll find trauma in some form within these people. Trauma can manifest in a wide range of manners, all the way to someone who might be schizophrenic; it can be a root cause of mental illness and a wide range of psychiatric events. So depending on the degree and severity of the trauma and the form it takes, trauma may play a role in someone becoming addicted because people who were abused as children face a wide range of repercussions from the lingering systemic effects of that abuse.
There are a few other things to look at here as well, most obviously, if you were abused as a child what else was going on in that environment? What kind of modelling was going on? So you can have all kinds of pathologies as a result. Certainly, all of this is important to consider when we’re treating addiction as criminal behaviour. The best thing we can do is to carefully observe the behaviour and try to find out why the act of taking drugs is so disruptive to everything else in their life. It gets a lot more complicated from there, but we have to look at their triggers and the reasons behind the behaviour. Another thing that I think about is that when we take these drugs, alcohol included, the drug is acting on the same exact systems in every person, but different people are affected differently. So the question becomes, “What is it about those people?” What’s different about the ones that concern us, is not the drug use, it’s something else in their environment, from what they experienced as a child to what they're experiencing today.
Cues of stress are really important to look at because for one person if they’re yelled at by their boss or they’re racially profiled, sure it's stressful, but not the end of the world. Yet, for another person, if the same happens, their entire nervous system goes into overdrive. They can't think straight and cortisol levels skyrocket. The first person has a healthy limbic system, because they had a nurturing upbringing without police brutality etc., so that system can self-regulate. But for the second person, their entire central nervous system functions differently. Any cue that reminds their sensory system of the trauma (being harassed or abused) will set them into fight-or-flight mode. And if not soothed, they feel a great deal of physical pain into the longterm: headaches, immune system dysfunction, heart disease—the list goes on. So they seek something that will soothe that neurochemical overdrive and ease the pain of stress: a drink, a cigarette, processed foods, etc. (any substance that releases soothing endorphins). Once the nervous system is soothed back down, they can think straight again. This has all been known since the 60s, but so many people deny the evidence or don't even look at it in the first place.
With the tough love, “pull yourself up by the bootstraps” or “law & order” mentality, society tells these individuals to just get over it [racism or childhood abuse].
Once people get accustomed to these arguments and actually look at what's happening, their bootstrapping beliefs will fall apart because they'll see how unfounded in any evidence they are, not to mention how outdated they are. Until then it's a waste of my time and yours to try to convince them, not to mention a waste of the tens of thousands of hours of research that has been going into this for over 50 years. You have to look at the people’s lives who are using these drugs in a destructive way. The question remains, just as you've pointed out, why does that addictive behaviour happen for some people and not others? Well sometimes, with the act of using the drug, the effects of using that drug in that moment outweigh the negative effects of having your life disrupted by those triggers. People with a healthy background can deal with that, but people who [experienced racism] routinely feel a great deal of stress.
I think about young people who are celebrities or athletes, and when they die like Cory Monteith, a Canadian actor who died from a heroin overdose, you have to look at why. Well, some people who have these jobs with that kind of pressure of fitting into what the industry expects of you, that can be overwhelming for young people, and for sure it would be overwhelming if you don't have a solid sense of who you are. So for these people, if heroin is there as an option, they might choose to do it, and guess what? Heroin is a great anxiety reducer. So if they can’t deal with these stresses yet we offer no alternatives to reduce this stress, what do we expect? The point is that there are a variety of reasons, but if you want to figure out an addiction, you have to give a comprehensive assessment to the person that you’re trying to help. Now that’s a daunting task. It can be difficult; you need a skilled clinician, and you’ve got to be open to discovery and you've got to be able to look at some things that you might not like.
It's also important to bring up that a lot of people point to biological reasons—you’re born with this addiction. That's an easier answer to just halt everything with, but again, it’s not true. Where is the evidence that points to this? Well, there isn't any. So that argument immediately falls apart as well because it’s not even true. Initially, I was also looking for the addictive chemical makeup of these drugs themselves for the reason that horrible things were happening in my community, but there’s absolutely no genetic or biological evidence to support this theory. It’s simply not fact. The drugs are not what’s hooking people, and [people with substance use disorder] don't inherit addiction from the genes of their parents. Of course, it's easy to think that way because then we don't have to look at how society functions, or waste any resources or time on them. We can just ignore them, ignore our actions that may have contributed to their troubles, or throw them behind bars, and not look at society or the way that society functions. It's just not that easy—the easy answer that drugs are addictive so we don't have to look any further is false. I won’t take part in arguments for stupid people. I can’t do that. If I have to give people a simple explanation that it’s this lack of willpower or this drug’s chemical components that cause this behaviour, then I can’t do that. I can’t even get into a conversation with those people. But if you genuinely want to figure out what’s going on, then great, let’s have a conversation. But if you are biased enough to play the blame game, then you’re probably not that smart and I don’t choose to waste my time like that.
Dr. Hart wearing and “Insite Saves Lives” shirt. Insite is a government-funded harm reduction facility that offers a place for the safe consumption of drugs.
A strong example of the way we dismiss root causes is with our First Nations populations. If you look at what's happening, you'll realize they survived a genocide where children were torn away from their families—and therefore from the proper conditions required for their healthy development. Those who didn’t experience direct genocide grew up with years of racist policing and social settings. So when they face addiction issues later in life, people simply blame genetics or label them as lazy and lacking willpower.
The genetics thing is very simple. Just ask people to show you the data, because there is no data. When it comes to drug addiction there is nothing. They tried really hard with alcohol, but even the best data with alcohol is extremely weak. So that argument I don’t even have; that’s entirely settled for me once I ask them to show me the data. There are none. And I’ll admit we’ve been looking really hard for it. Again, I got into this thing looking for a biological explanation but I haven’t found it because it’s not there.
Now, when you think about the First Nations thing in this country, it’s not that complicated. It’s like you said, you have a genocide going on and all of this pathology heaped on this culture, because they lost their culture. They lost their language, their family traditions, everything. So it’s not surprising that they have all of this dysfunction. And not only that but it’s dysfunction generation after generation. So you don’t need to find a biological explanation in that, you need to stop the degradation and punishment of that group and look at what’s really going on. This is exactly the same thing that happens with black Americans in the United States following slavery. You have all of this dysfunction that continues to this day, and people say, what’s wrong with them? But it’s not that complicated. It becomes complicated because people want to make it complicated so that we don’t have to deal with the real issues.
So as long as we are conflating these issues and making them about being lazy or about genetics then we don’t have to help those people. We don't have to change the way our society functions or the way we raise our children because it's just them, not us. So when I think about trauma, I'll say again that I realize some people have figured out how to relieve themselves of the anxiety, the stress, and the pain that are related to that trauma. So some people wind up dealing with it through drinking alcohol, others get in bad relationships, others may deal with it by being reckless in sports—the list is endless. But all of these things, narcotics included, relieve some of that pain that they continue to experience whether they are consciously aware of why or not. Pursuing other things gives these individuals some form of relief. So these are the things that we can measure and see, and try to understand, and help to alter or confront their pain and stress. If we get into a discussion on what their anxiety looks like, or look at the underlying reasons why they feel that social discomfort, then we can say okay, let’s confront that, let’s treat that and not just focus on the drug or the behaviour itself.
So there are a few major contributors: childhood trauma as we've just discussed is number one. And from what I've seen, the second is the power of repeated behaviour. So habit as we call it lightly. Some people are compulsive with money, some with food, others with smoking or alcohol, etc. But how does repeating these behaviours come into play with addiction or compulsive behaviour.
That’s a great question. In order to answer this, we should get familiar with operant conditioning, reinforcement, and B.F. Skinner. You could say Skinner is the most famous psychologist we know today. The term reinforcement says that the more a behaviour is admitted, or expressed, the more robust it becomes, in part because that behaviour is reinforced. For example, if I turn on a light switch and it works, and when I continue to do so, and it continues to work, well then over time you’re going to just start doing it automatically—without thinking. Or if I turn on a car, and every time I turn it on, it starts, then I learn to expect that the car will turn on whenever I turn the key into the ignition. So that behaviour is reinforced by the turning of those keys; it becomes more robust. So do you ever stop and stand outside of your car and wonder how to turn it on? No, because that behaviour has been so powerfully reinforced you don't even have to think about it. So the same is true with most other activities. If the behaviour has been reinforced over and over and over it becomes more solidified, more robust, and more difficult to destroy or stop doing.
This also helps to describe learning. When learning occurs in the brain, the cells that are responsible get really good at what they do. They get faster and faster and more robust at the activity, so it becomes entrenched. This is so we don't have to work so hard at thinking out each of these day-to-day activities, we just naturally carry them out, leaving room to think about other things. So that relates to the work of B.F. Skinner. This applies to addiction because the more you carry out any activity that comes with any form of [reward], the more inclined you are to continue to carry out that activity, and the more difficult it is to unlearn that activity—especially when stress relief is involved. So the more you do something, the more rewarding it becomes, and the more you go to it when you face stress. Most people know this when they describe the first time they took a sip of alcohol or had their first cigarette. Their habit or addiction only took place after doing it over and over again, teaching the body to expect that relief, therefore conditioning and reinforcing the behaviour.
[Two books on conditioning and reinforcement are Thinking Fast and Slow by Daniel Kahneman and The Power of Habit by Charles Duhigg.]
Our time is up, but thank you for your words today Dr. Hart—let's hope the awareness continues to shift; you do great work moving the dialogue forward.
Thank you for the conversation, and keep doing what you do too, we need our young people to keep addressing these topics.
This hour-long conversation was recorded then transcribed for your reading pleasure. It has been edited and condensed for length and clarity.