Editorial Comment 1/19/2021: Drug Use for Grown-Ups

“I discovered that the predominant effects produced by the drugs discussed in this book are positive,” Carl L. Hart writes in his new book. “It didn’t matter whether the drug in question was cannabis, cocaine, heroin, methamphetamine or psilocybin.”

Being printed in the New York Times at least makes an article susceptible to commentary and criticism by the readership, even while not strictly meeting peer review standards.  A discussion of drug usage by psychology professor Carl Hart is reviewed in the New York Times at this link, and is largely self-referential:   https://www.nytimes.com/2021/01/12/books/review/drug-use-for-grown-ups-carl-l-hart.html  Focusing principally on heroin use, Hart makes a case for mood-altering drugs as useful, pleasurable, and generally safe over time providing “…a gradual rejection of the overly simplistic idea that drugs are inherently evil, the destroyers of people and neighborhoods.”

The problem of course is that the same drugs can be both.  No one in medicine disputes the utility of morphine in the management of pain, whether in myocardial infarction or in cancer (although there is controversy over its benefit in reducing the pre-load in congestive heart failure), and we all will concede its euphorigenic properties.   Those of us caring for those with substance use disorders, with addiction, are sensitive to the risks; but Hart’s argument approaches reductio ad absurdum, extending a contention to an extreme. Most Americans have consumed beverage alcohol without developing an alcohol use disorder, I understand; the consequences for those who do become alcoholic, however, are commonly severe, pervasive, and extend beyond the drinker her/himself. I don’t think a discussion of drug policy, apparently the author’s larger aim, can be completely divorced from consideration of risks.  It seems that it might be more useful to move this discussion from the arena of criminal penalties into that of safety.

So, what is the fulcrum in this discussion on which pivots the argument between “normal” or safe usage of substance, and addiction, or dangerous use? It is our inability to satisfactorily predict who will develop the illness state once they have first been exposed to the substance.  It’s difficult enough to determine even the prevalence of substance use disorders, despite our having descriptive criteria.  Investigators such as Marc Schuckit have brought us much closer to this objective, at least with alcohol; we can hope for parallel advances in predictability for the other substance use disorders.

- Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM