Carl Hart on Clinicians’ Bias Toward Drug Use 

Pervasive misconceptions about and bias against drug use in the United States have led to clinical norms that pathologize any use of certain kinds of drugs. This bias has harmful consequences. For instance, conflating substance use with substance disorder is used to justify curtailing certain people’s rights, which has broad consequences. Treating drug use as a brain disease reveals clinician bias. How can these misconceptions, and the actions they lead to, be corrected? And how can researchers and policymakers demystify drug use? 

This episode of Under the Cortex features Carl Hart, a neuroscientist at Columbia University who has studied the behavioral and neuropharmacological effects of psychoactive drugs in humans. His lab attempts to understand factors that mediate drug use, to develop effective treatments, and to translate that knowledge into more humane drug policies.  

In May, Carl spoke about some of his findings in a very popular presentation at the 2023 APS Annual Convention titled “Clinician Bias About Drug Use Contributes to Growing Restrictions on Liberty and Bodily Autonomy.” He explained how the inclination to think that any use of a certain drug, like cocaine or heroine, is pathological reveals a clinician bias. This conversation, with APS’s Ludmila Nunes, was recorded on-site at the convention shortly after Carl delivered his presentation.  

Unedited transcript:

[00:00:14.610] – Ludmila Nunes

Carl Hart from Columbia University is a neuroscientist who has studied the behavioral and neuropharmacological effects of psychoactive drugs in humans. His lab attempts to understand factors that mediate drug use, to develop effective treatments, and to translate that knowledge into more humane drug policies. In his presentation at the 2023 APS Annual Convention in Washington, DC. titled Clinician Bias about Drug Use Contributes to Growing Restrictions on Liberty and Bodily Autonomy, he explained how the inclination to think that any use of a certain drug like cocaine or heroin is pathological reveals a clinician bias and conflating substance use with substance disorder might be used to justify curtailing certain people’s rights. And this has consequences for all of us. I am Ludmila Nunes and this is Under the Cortex.

[00:01:20.090] – Ludmila Nunes

Thank you so much for joining me, especially after giving a talk here at the APS Animal Convention.

[00:01:27.630] – Carl Hart

Thank you for having me.

[00:01:29.260] – Ludmila Nunes

I know you got a lot of questions and a lot of interest after your talk. I was there, but I’m not going to summarize it, I’m going to let you do it. Would you like to tell us what is the main takeaway?

[00:01:41.240] – Carl Hart

Yeah, so my talk was related to drugs and how our view of drug use in the US. Is biased. The feel is biased towards pathology, it’s biased towards anyone who uses certain types of drugs being considered pathological. And the evidence does not support that sort of bias, of course. And for example, simply knowing that someone uses heroin doesn’t tell you anything about the person other than that they use heroin. And so rather than thinking that, oh, you have a heroin addict on your hand, you don’t know that. In fact, the vast majority of people who use a drug like heroin, crack and methamphetamine, whatever, they don’t have a problem. And so I wanted the audience to understand the consequences of that bias. For example, we curtail people’s right to life, liberty in the pursuit of happiness, and it’s inconsistent with the people we say we are. And those people who we curtail their rights, they suffer real consequences. Like we’re here on Memorial Day weekend, George Floyd was killed. People are killed for simply using a drug or being suspected of dealing a drug. And I wanted them to think about the role that we play as psychologists.

[00:03:05.610] – Ludmila Nunes

So there’s a lot of research that has been done not on humans, but then those findings are taken to equate drug use, to brain diseases that are not treatable, that will last someone’s entire life and are fatal. And this is a problem because data don’t actually show that. But instead, we treat drugs and drug use as this thing that can be used to control people and control people’s freedoms.

[00:03:42.460] – Carl Hart

You’ve summarized it all. We inappropriately extrapolate data collected in laboratory animals that weren’t intended for that type of extrapolation. For example, we think about neurotoxicity. This is what we do? We give an animal a large dose of a drug. This animal was naive to the drug, and then we say, oh, this drug causes toxicity. It would be the same thing if you gave an animal a large dose of acetaminophen, which is tylenol in this country or paracetamol in other countries. And so it would be that same thing. It’s inappropriate to do that sort of thing. But the question, as you nicely pointed out the question is why do we do it? We do it because it serves as a convenient scapegoat. It allows us to not deal with problems that really that people really face. So rather than saying, hey, these folks don’t have housing, they don’t have jobs, we can say if they weren’t using drugs, then they exactly. That’s not true. But that’s what happens in our country. It’s important for us to understand that our funding of this thing called the drug war, drug control, functions as a jobs program in the United States.

[00:05:02.040] – Carl Hart

There are a lot of people whose salaries depend upon this sort of illogical view of drugs. And so as long as those people’s salaries depend upon this, it becomes more difficult to actually look at it with some logic and reason.

[00:05:19.190] – Ludmila Nunes

Why is this true for certain types of drugs? And I’m thinking cocaine, especially crack, heroin, but then we don’t do this with, for example, alcohol. Why do you think there’s this difference?

[00:05:32.810] – Carl Hart

Yeah, the example you use with alcohol and tobacco is a really good one. We don’t vilify those drugs to the same extent that we vilify drugs like heroin or crack cocaine or methamphetamine, in large part because alcohol and tobacco has a lobby. So they have groups of people who lobby our congress to make sure those substances stay legal. Whereas there’s no lobby in the US. For cocaine, there’s no lobby for heroin. And so without a lobby and the fact that these drugs serve such great scapegoats, that’s a main reason that we see this differential treatment, because they’re basically.

[00:06:16.190] – Ludmila Nunes

Used as ways to reinforce the systems of power that we have and maintain them and maintain the hierarchies that serve these systems of power.

[00:06:27.580] – Carl Hart

I couldn’t have said it any better. There it is.

[00:06:30.340] – Ludmila Nunes

Well, I got this from your talk, but I think it’s a big problem we have. So what do you suggest?

[00:06:38.110] – Carl Hart

Yeah, what I suggest is that the US. Public. Just read the Declaration of Independence. That’s the first document, founding document of the country, where it guarantees at least three birthrights, life, liberty, and the pursuit of happiness for all citizens. And so if people understand how inconsistent our current approach is with those promises, hopefully it causes them some dissonance, some cognitive dissonance, and hopefully causes them to act.

[00:07:10.410] – Ludmila Nunes

And another thing you suggest is the full decriminalization of any drug, at least as a first step, and that full decriminalization should come with some measures.

[00:07:22.470] – Carl Hart

Yeah. So my ultimate goal is legal regulation such that these substances can be legally sold and legally purchased and you have quality control such that people know what’s in their substance. Of course, with legal regulation that means we can decide on the age that people have access to these things. We can even decide on whether or not there are other requirements people must meet before they can purchase. Whatever we decide rationally and thoughtfully as a society we decide that sort of thing. That’s what I ultimately am advocating for. However, I understand that many people in this society is not where I’m at. And so as an intermediary step, I said full decriminalization, simply meaning that no one will be going to jail for using any of these substances. Of course, under decriminalization, sales remain illegal. You can’t legally sell the substance. And so if you have decriminalization, you have to have these auxiliary measures in place like appropriate education so people understand how to use substances and under what conditions increase the likelihood of positive effects versus negative effects so that people understand that they can have their substance be tested to make sure that it doesn’t contain any adulterance.

[00:08:46.690] – Carl Hart

All of these auxiliary services have to be in place if you’re going to have decriminalization that will increase the likelihood of people not getting in trouble.

[00:08:57.390] – Ludmila Nunes

Because for example, there’s a lot of talk nowadays about the opioid epidemic. That’s mostly because there is a huge number of deaths by overdose and that’s caused by excessive fentanyl in the drug. So this could be avoided if we actually had regulation in place.

[00:09:18.290] – Carl Hart

Yeah, the overdose crises in the US. I really don’t know what’s going on and I don’t believe much of what is said about it. Like we have now incentivized people to count these as overdose deaths. For example, people get grants, medical examiners get grants, coroners get grants based on these overdose numbers and so it incentivizes them to call something an overdose death that probably was not. And so what we understand is that the data does not say that the person died from the drug. It just simply says that the person had a drug in their system at the time of their death or suspected of using a drug. So it doesn’t say anything about the cause of death but the public has interpreted that to mean these drugs caused the death. So you can imagine someone, I don’t know if they were in a car accident and if they had an opioid in their system that could be counted as an opioid.

[00:10:30.920] – Carl Hart

And so we are more likely to include those kind of numbers or those types of debts in our overdose numbers because of these incentives these days. And so I don’t know exactly what’s happening. For my next sort of project, I think I’m going to drill down to.

[00:10:49.650] – Ludmila Nunes

Figure it out when I would be very interested in that because I did not know these about the numbers everything we see, and even in research and good outlets, is there’s an increase in death because of opioids?

[00:11:03.390] – Carl Hart

Yes, exactly. This is the sleight of hand that happens with drugs. People assume that everything remained the same, and that’s exactly what the people who are presenting these data want you to think, that everything remained the same. But it’s not the case. And it really concerns me because one of the things that is happening as a result of this approach is that we are now talking about severely restricting access to opioids for pain patients, people who may be maintained safely on pain medications for a long period of time, but they’re happy and they’re okay. But physicians are afraid to prescribe opioids because of this sort of environment that we are currently in. And so pain patients, as a result, don’t get the medications that they need. And I worry about that.

[00:11:59.050] – Ludmila Nunes

It’s like we cannot have middle ground and based on education in which would be okay to prescribe painkillers and inform patients about what they’re taking and how to use them. Before, everyone would get painkillers in excess, and now it’s the opposite.

[00:12:17.390] – Carl Hart

Exactly. One of the cruel, Ernies, here is that pain patients, the people who’ve been maintained on these medications for some period of time, they know more about these medications than their physicians in some cases, and they’re being taken off of these meds.

[00:12:33.960] – Ludmila Nunes

Exactly. I have another question, and this is something you spoke about these two things in your talk, but separately. On one hand, it seems to me that there is this view of drug use as a disease, mental illness, a pathology, even a biological brain disease. So people who have diseases should be protected, but at the same time, it is used as an excuse for mistreating people, for imprisoning people, for killing people, even. So, how is this conciliated?

[00:13:11.970] – Carl Hart

Yes. So you said people who have diseases should be protected. They should be treated.

[00:13:18.290] – Ludmila Nunes

Treated, exactly. Not protected in a paternalist way.

[00:13:22.630] – Carl Hart

Exactly. And one of the things that happened between, like, 19 92,000 in the United States. We called between 19 92,000, the decade of the brain. And so we pumped a lot of money into studying the brain. In fact, I got a PhD. As a result. My PhD was funded because of this proclamation. And it was a really good thing on the one hand, because we learned a lot about the brain, and we’re still learning a lot about the brain, and it was a bad thing, on the other hand, because then we tried to have a brain explanation for everything. And one of the things that people in the drug abuse field did realize was that if you have a brain explanation for your problem, it increased the likelihood of you looking like a real scientist. You’re doing hard science. Now you can go to Congress and show Congress the brains of someone, and it increased budgets, and it gave the appearance that you were not vilifying the person afflicted with the substance use disorder, because it’s not them, it’s their brain. Right. But really, what you’ve done, I think it could be best summarized by what the former President of the Philippines was doing.

[00:14:50.590] – Carl Hart

Duterte what he did was he said that after a year of methamphetamine use, your brain was so badly damaged that you’re no longer viable for treatment, so therefore we can kill you. Basically, we can exterminate you. And there were a number, there were thousands of people who were killed extra judiciously in the Philippines as a result. So on the one hand, it may start out as, oh, it’s not you, it’s your brain, but then you can see how it gets warped into, oh, your brain is bad, so therefore you’re no longer viable, you can die. That’s the real concern. But when you think about it from just a scientific perspective, just ask the basic question what does the evidence show? The evidence does not show that it’s your brain and that’s where it should have stopped. But it doesn’t.

[00:15:46.150] – Ludmila Nunes

No, exactly. It can contribute to the dehumanization of the person.

[00:15:51.390] – Carl Hart

Absolutely.

[00:15:51.840] – Ludmila Nunes

And instead of looking at social factors that might make the drug use a problem rather than the drug use itself.

[00:15:58.280] – Carl Hart

Being a problem exactly. Right. We look at biology instead of sociology instead of social context. And when you do that sort of thing, you can now just easily blame the substance. And it’s so much easier to say you’re going to get rid of the substance than to say that you’re going to make sure people have the remedial education they need, have the housing they need, have the jobs they need. It’s a lot easier to say, we’ll just hire more cops and put them on the streets and get rid of drugs. Although drugs are not going anywhere because they’re so effective.

[00:16:33.080] – Ludmila Nunes

Yeah, exactly. Thank you so much.

[00:16:35.780] – Carl Hart

Thank you for having me.

[00:16:38.430] – Ludmila Nunes

This is Ludmila Nunes with APS, and I’ve been speaking with Carl Hart from Columbia University. We were live at the 2023 APS Annual Convention in Washington, DC. If you want to learn more about our scientific meetings and APS, please visit our website, psychologicalscience.org. You can also follow us on Instagram and Twitter at @psychscience.