Carl Hart’s case that addiction lives outside the molecule

Lex Fridman opens by naming the provocation. Carl Hart, department chair and professor of psychology at Columbia, has written *Drug Use for Grown-Ups* and, in private life, uses the drugs he studies, including heroin and cocaine. The first question is the one a listener would ask: what is taking heroin like, in the body and in the mind? Hart throws the question back. He also takes MDMA and cannabis. Asking what heroin does to body and mind is, he says, like asking what an orgasm feels like in the body and the mind, or any other event you really enjoy. Poetry is for that. He is not sure what people want from the answer.

Fridman tries a narrower cut: keep it to chemistry and biology, the differences among MDMA, psilocybin, and the rest, rather than the full human scene. Hart calls that the standing mistake. People act as if biology were the only determinant of drug effects, and that is not how it works. You need the environment. You need the cage, as researchers say. Without the cage you do not get the full extent of the effects. The same MDMA can give you an awful, paranoid time or, under the right conditions, one of the best moments you have ever had.

Hart has seen both ends with MDMA. It has enhanced a number of his relationships. It has also gone badly when he was with people he did not know and did not trust. Talking only about opioids and the brain’s endogenous opioid system, or about dopamine and other monoamines, will not get you closer to the experience people actually seek. Positive and negative outcomes, he says, are strongly defined by the environment. Fridman asks how big that word is. Does it mean the people in the room, or the whole arc of a life: parents, crushed or realized dreams, trauma, success?

All of those things matter, Hart says, with a split. Childhood trauma that has been worked through is not so important in the moment. Trauma that was never dealt with and gets triggered in the event is crucial. He puts himself on the table. He is 54, turning 55 that month. He has spent years figuring out who he is, is comfortable with himself, and knows how to set limits. He needs to work out, eat well, sleep well, and be with people he trusts. If those conditions are met, it is likely to be a good time. If he has not slept or trained or does not feel well, it will not be.

Responsibility is the other half of the preparation. He takes care of eating, sleeping, and outstanding obligations so that in the moment he is simply there. He is not thinking about an unpaid bill or something he forgot to do for his kid. If those things are not handled, they will color the experience, often for the worse. The practical aim of all that work is to drive present anxiety down. Anxiety, he will argue, is the big one. Many of the negative effects attributed to drugs come from situation-induced anxiety, not from anxiety the drug itself induced. Not knowing what you have, fearing a contaminant, is enough to change the night.

Fridman reads from the book’s findings section, the passage Hart knows will sound non-obvious. The predominant effects of the drugs in the book were positive. It did not matter whether the drug was cannabis, cocaine, heroin, methamphetamine, or psilocybin. Overwhelmingly, consumers reported feeling more altruistic, empathetic, euphoric, focused, grateful, and tranquil, with better social interaction, more purpose, and better sexual intimacy and performance. That constellation, Hart writes, challenged his original beliefs. He had been indoctrinated to be biased toward the negative effects. Two-plus decades of work gave him a more nuanced picture.

The public, Fridman says, has come around a little on psilocybin and cannabis. Cocaine, heroin, and methamphetamine still sound like agents that make a bad life worse or ruin a good one. How do you raise the odds of a positive effect? Hart repeats the checklist: handle responsibilities, eat, sleep, exercise, and know exactly what you have so you are not paranoid about an adulterant. Understand dose and potency. Lower anxiety about the substance itself. As for the media, he is not gentle. There is money in reporting the negative effects almost exclusively. A newspaper piece about an opioid crisis is easy to gin the public up with. You do not even have to say how to keep people safe, or why they are dying.

Overdoses in the United States, he says, happen largely because people get contaminated drugs, or because they combine sedatives without knowing that the mix enhances respiratory depression. Newspaper articles do not say this. They frighten the population. There is money in that. The same, he argues, is true of people who write television and movies. Most of what they write about drugs is bullshit. Comedians, whom he loves to watch, say stupid things about drugs and are believed. You can skip character development entirely: throw in that someone is a drug dealer, and the audience thinks it already knows the person.

Hart’s example is *The Sopranos*. Tony kills people for a living. The show asks the audience to feel sympathy for him when he besmirches his nephew Christopher for using a drug. A racist murderer becomes the person you feel for, because a drug user is supposed to be worse. Hart calls that crazy, and says the American public bought it. Fridman asks why there are so few stories of grown-ups using the full spectrum of drugs well. They have talked offline about Joe Rogan starting cannabis later in life and describing a productive, slightly paranoid edge. Hart thinks people are afraid of being belittled as addicts. Cannabis, he adds, is lightweight now. Starting later, with responsibility skills in place, is a good thing. You do not want the young and immature in any potentially harmful behavior, whether a partnership or a car.

Fridman’s real complaint is darkness. He has a crappy but workable map of what can go wrong in relationships and in a car. With heavy drugs he is in the dark. He drinks, and culture taught him what not to do. Weed and psilocybin are acquiring stories. LSD still arrives as a trade-off: you create something, then the drug destroys you, Robert Johnson selling his soul for guitar. Hart says that is bullshit we tell children. These are fairy tales in the same vein as Pinocchio’s nose. *Drug Use for Grown-Ups* is an argument that it is time to grow up. The same teaching that exists for alcohol can exist for MDMA, cocaine, and heroin. Potential dangers are real. He writes about them. The problem is that the education is coming from people who believe the Pinocchio story, which does not fit the evidence.

That evidence, he says, sits in the scientific literature. At Columbia they administer thousands of doses a year, on public grants. Would they be allowed to do that if the drugs were as dangerous as the folklore claims? The drugs in question are all approved for medical use somewhere in the world. The lab’s job is an empirical database: what the drugs do and do not do, the conditions for positive effects, the conditions that raise the odds of negative ones, and clues for treating people who are already in trouble.

What should a careful person actually watch for: addictiveness, the pain of withdrawal? Hart ranks physical dependence in a way that upends the usual ladder. Cocaine has very limited withdrawal symptoms; they are hard to see. Methamphetamine is similar. Heroin produces a withdrawal syndrome that is displeasing and unpleasant. Alcohol withdrawal can kill you. That is the most dangerous of the set. Benzodiazepines, he will say later, sit close to alcohol, so benzo withdrawal can kill you too. The questions are worth asking. The answers are not the ones television prefers.

The negative effect he worries about most with regular heroin, and that society almost never discusses, is constipation. Slowed gut motility is bad for general health. Contaminated street drugs and inexperienced mixing of heroin with other sedatives can kill. Constipation, he says, is huge, and unsexy. Amphetamines, for their part, disrupt sleep and food intake, both essential to staying alive. Those effects go undiscussed because they are not as sexy as the addiction narrative. Fridman admits the standard is hard to hold. He knows he should ask the same questions of alcohol, yet hearing that cocaine’s bedtime rule is like caffeine’s, and that heroin’s headline risk is constipation, still sounds absurd. Hart’s educational version is specific: cocaine is a stimulant, do not take it at bedtime, protect sleep, get up in the morning, and know that it can blunt appetite enough to hurt nutrition. You cannot throw people in the water and call it education.

Addiction, Hart says, has almost nothing to do with the drugs themselves. He makes the comment because the vast majority of users of any drug never become addicted. If that is true, you have to move beyond the drug to talk about the phenomenon. Addiction has much more to do with psychosocial environment than with the chemical. That is not sexy, so it does not travel. He is careful not to dump everything on the outside world. People with co-occurring mental illness, depression or anxiety, carry a vulnerability inside themselves that raises the odds. People with chronic unrealistic expectations heaped on them are more likely to have problems. So are the immature, who have not developed responsibility skills.

Then there are people who lost jobs, whose factories went away, who used to have standing in a community and now have none. If they indulge, they may be susceptible to a drug-related problem. All of those issues, he says, are far more important than the drug itself. Fridman offers an intuition: each drug has a biochemistry, and some pull you in harder when you need to escape. Hart interrupts. What evidence does he have for that belief? There is none. People say that, and that is precisely the problem. Fridman concedes he is operating from limited personal evidence. Hart’s reply is that a scientific database exists. In a math problem, you do not want someone saying they feel like the answer is this. Forget what you feel. What does the data say?

Fridman objects that some of the drugs are illegal, so the in-the-wild dataset is thinner than it should be. Hart says the database is substantial. People ignore it. When he uses the word addiction, he means the DSM-5 criteria of the American Psychiatric Association: disruptions in psychosocial functioning, and distress about those disruptions. Using heroin is not enough. He grants that the DSM evolves, that it still carries a once-an-addict-always-an-addict idea the evidence does not support, and that it is the shared language of science and medicine anyway. Simply using is not the diagnosis.

Should all drugs be legalized? The drugs people actually seek, Hart says, should be legally regulated and available to adults: cannabis, MDMA, cocaine, heroin, and some of the psychedelics. That is not a free-for-all. There would be age requirements and maybe other requirements. Do what we already do with alcohol. You can put enough alcohol in a bottle to kill someone; we do not. Regulate unit dose to enhance safety. Do not sell intravenous preparations. Keep routes to oral and, say, intranasal. Dose per unit and route of administration can minimize harm. We have the technology and the know-how. We choose not to use them.

Fridman wonders what safe exploration would look like for an adult like himself. Nobody, he says, ever sat him down with alcohol beyond not filling a bottle with a lethal dose. He learned by osmosis, word of mouth, and watching people do the wrong thing. Hart does not want that model copied. Education has to change. Cocaine is a stimulant: not at bedtime, protect hours of sleep, get up in the morning. Amphetamines at night are a bad idea for most people. Cocaine can disrupt food intake, less than amphetamines, enough to matter. Time the drug around the functions that keep a person alive. Throwing people in the wild, he says, is stupid.

Fridman then names a worry about freedom. If you tell people the effects are mostly positive and can be used well, will those who are already not doing well psychologically take it as a pass, and use instead of repairing themselves and their environment? Hart’s first answer is that those people already have alcohol. The larger answer is the Declaration of Independence: we are free to live as we want so long as we do not disrupt others from doing the same. What astonishes him is how hard Americans work to control other people’s behavior. The book is about that freedom, and freedom comes with a tremendous amount of responsibility. He is responsible to his neighbors. Some people think their freedom supersedes everyone else’s. He wrote the book to remind readers they are in this together. Many, he says, have conveniently ignored that layer.

Has the war on drugs done more good or harm? It depends, Hart says, on which world you live in. It has been hugely beneficial to law enforcement, to the media, to people who make bullshit television, *The Sopranos* and *The Wire* included. Many people who provide treatment benefit. So do urine-testing companies, people who run prisons, phone companies that charge prisoners, hotels around the prisons where families stay, and the restaurants nearby. They are making out like bandits. As a society, he says, many of us are getting screwed. Politicians benefit too. Democrats and Republicans have the same stance on drugs, which is one reason the arrangement continues.

If he could snap his fingers, the first moves are concrete. Stop arresting people for drugs. Release people imprisoned for drugs and sponge their records. Then build a system so responsible adults can legally obtain the substances, with a corresponding educational system to teach how. Arresting people for drug use is absurd, he and Fridman agree, especially beside alcohol, which can be destructive and which Hart used to get through receptions as department chair. He recites the line Fridman likes: the years as chairman from 2016 to 2019 were far more detrimental to his health than his drug use ever was. The double standard is the thing that is hard to snap out of.

Fridman says he hates being cynical about narrative, and still wants to believe that truth wins. Hart believes that too. It is why he is out here taking the criticism. He might be wrong. He has to live as if it is true, or he has no hope, and then why be here. Later he will locate the same war in geography. In Northern Ireland, in Appalachia, in West Virginia where the water is polluted and the factories have gone, in Brownsville, in São Paulo, in the Philippines, people catch hell for the same reason. Politicians blame drugs so they do not have to bring jobs back or deliver clean water. If you want a problem not to be solved, give it to the military or the cops.

Asked to steel-man a serious criticism, Hart names one: that he presents too rosy a picture. He does not want that impression. The book acknowledges potential harms of any activity, drugs included. The fact remains, in his view, that beneficial effects far outweigh potential harms, and that technology and information can shrink the downside. The exclusive-harm approach, sold as protection, is what he rejects. On benzodiazepines versus opioids, he says the problem is misuse, whatever the drug. Benzos and alcohol are closely related; withdrawal from either can kill. There are protocols. He hopes Jordan Peterson, whose benzo withdrawal Fridman mentions, is okay. Withdrawal protocols are more standardized than people think. Where it gets murky is treating addiction itself, the whole DSM substance-use disorder. Many of those approaches, he says, are rubbish.

Alcoholics Anonymous is a long process that looks, to Fridman, almost like a whole life. Hart would not send a relative to AA for a drug-related problem. AA is good for social interaction and peers, which everyone needs. He does not think they know much about drugs. Judges nonetheless sentence people to AA, which he finds outrageous, and which happens because the culture treats drugs and addiction as moral failings, so any idiot can provide treatment. He means no disrespect to AA relative to worse shops: at least the social group is real, and that group can help with the environmental issues that, for most people with drug-related problems, are the main source. Not for all. For most.

Psychedelics, Fridman says, seem to take people to places alcohol does not. Hart agrees it is not merely poetry. Some drugs take people where others cannot. Friends of his have never had an experience like ayahuasca with a shaman, and felt they began to heal problems they had failed to solve for years. That is great for them. His argument is the symmetry: if ayahuasca or psilocybin can do that for someone, why isn’t it possible that heroin, cocaine, or MDMA does it for someone else? Fridman half-jokes about a shaman for heroin. Hart does not treat it as a joke. Why not. Even the upper/downer shorthand is clumsy. Cocaine is a stimulant, yes, but if you are already very active, it might calm you. Effect depends on the activity of the person before the dose.

Back on film, Hart is angrier. *The Godfather* and *The Sopranos* have racist killers who announce they do not do drugs, then denigrate Christopher for heroin while drinking. People using psilocybin, he says, are trying to be better people; the characters are killing people and getting away with the lecture. *Scarface*, which he loved as a kid from Miami, depends on the American viewer already seeing drug dealers as animals. In the end the animal kills himself with too much cocaine. The film plays to the worse angels. Fridman begs him not to take the movies away. Hart does not want them gone. He wants writers more honest to reality. Those movies, he thinks, are part of why the war on drugs exists and why people go to jail.

In the epilogue of the book he quotes James Baldwin: you cannot know what you will discover on the journey, what you will do with it, or what it will do to you. How has drug use, or the study of drugs, changed him? It helped him think about other people’s experience, and about how we are connected. Northern Ireland is all white, he notes, and people there suffered for the same reasons Appalachia suffers: neglected by politicians who told lies about drugs instead of dealing with polluted water and vanished factories. Those people are connected to Brownsville, to São Paulo, to the Philippines. He feels this strongly because he knows people whose paychecks are predicated on other people’s subjugation. When we hear about the destructive effects of drugs, Fridman summarizes, it is a scapegoat for the failure of leaders. Hart says absolutely. It is easy to promise more cops.

A formative memory from a tough Miami childhood is his grandmother, after his parents split when he was six or seven. She taught him to think critically, to be self-sufficient, to keep his eyes open, and to watch out for the okie doke, the con. The whole drug thing, he says, is the okie doke. It boils down to a simple fact: we are all similar, trying to live, trying to take care of our kids, wanting the best for them, and somehow made to believe we are different. When people seek pleasure, why not celebrate that instead of denigrating them? If he feels better, he is more likely to treat you well.

Where does the guts come from, at Columbia, to say this out loud? Once you know, Hart says, you cannot not know. He has to look in the mirror and ask whether he has lived honestly. If he cannot face himself, what is he doing here. Fridman describes a heavier thought: some drugs take you to a place of optimism about fellow humans, a wish to contribute, a vision of what a society could be, and then you come back to resistance, to people who will not be better. If you know humans can be better and they refuse, why be here as someone who knows? Hart does not push that back into a dataset. He takes it. He does not want to do it the way we are doing it. The book’s other main point is the possibility: better relationships, more magnanimity, the pro-social things we claim to value, if adults were allowed.

The toughest question, Fridman jokes, is the greatest hip-hop artist of all time. Hart declines the throne, then names Gil Scott-Heron, a father of the form and his all-time favorite, and Chuck D of Public Enemy. Even they, he says, got it wrong on drugs. They did so much other good that helped him develop. He can hold both facts. Glorifying cops on television when rappers age past forty is, for him, dangerous in a democracy. His beef is not with street officers so much as with what they are asked to do. He spent four years in the military, ignorant, doing what he was told, thinking it was right. The real target is the power structure, and the people who play cops on TV.

What have mind-altering drugs taught him? Neurochemically, everything he knows about the brain he learned through drugs: dopamine neurons, norepinephrine, how transmission happens. Globally, they taught him to be more forgiving of people and of himself, more tolerant, more empathic, and they showed him what the species can be. Fridman compares that to meditation and to a hell of a workout: stepping outside yourself, not taking yourself so seriously. Hart lets the analogy stand. Different drugs do it in different ways. He notes that the illicit trade is a multi-billion-dollar industry that poor people cannot be the main customers for. A lot of middle- and upper-class people are in the closet. The book asks them to get out, so honesty can take pressure off the less privileged.

Advice for a young person is not follow your passion first. Whatever career you choose, dedicate yourself and be the best at it. Thirty years of science sit behind his public view; he would have been dismissed if he did not know his craft. Too many people are faking the funk in positions of power, and a society crumbles when enough of them do. A PhD is not required; he would not recommend that path to his own children. Science can be petty. It was the only path he had. He would rather people do something they enjoy, because more happy people make a better society. Does life have meaning? He hopes so, and tries to live as if it does. He loves his life now. He spent the summer in Geneva, in a more civilized place where a responsible adult can enjoy himself, decompressed, then came back to a country where you have to be ready to fight. He does not want to fight anymore. He keeps a place in Europe so he can tolerate coming back. Joy, when he decompresses, is MDMA, a jurisdiction that will not hunt him, heroin if he is in his own head, good friends, good food, family, love. Fridman closes with Frank Zappa: a drug is a chemical compound; the problem is people who treat it as a license to behave like an asshole.