High Price

by Carl Hart

  While at a D.C. Metro stop waiting for a train, I began what turned into a lengthy conversation with a machine technician who was working in the station, repairing the ticket vending equipment. I had complimented him on his dreadlocks, thinking that he wore them as part of the Rastafarian religion. For years I had considered growing dreads myself, but I’d always held back because I believed that it was disrespectful if you weren’t a part of that religion. I also did not want to be seen as faddish or simply following the crowd: that was not how I wanted to live.

  But this man said that for him, wearing dreads was a way of showing homage and respect, even though he wasn’t religious. That resonated with me, as did his self-assurance and thoughtfulness. By the time I left, we were no longer strangers. And I decided right then to grow my hair. It would remind me that I could be myself and be a conscious spirit, no matter what other people might decide a scientist should look like. It would connect me both to my heritage and my new son. It felt right.

  I found myself thinking about this and about Damon’s future a few months later, when Louis Farrakhan gave the keynote speech at the Million Man March on October 16, 1995. I’d been unable to attend since I was back at work on my research in Wyoming by that time, but I watched on TV as I minded Damon. Here were hundreds of thousands, perhaps more than a million black men. They were leaders, businessmen, professional people like Barack Obama (who attended himself), mainly middle class, and virtually all employed. It was inspiring to see.

  And yet, the rhetoric was tightly focused on hard work and responsibility, on pulling ourselves up by our bootstraps and supporting our families. No demands were being made of Congress; no delegations sent just a few streets over to meet with our senators and representatives. Here were people who had done what we were supposed to do—not people who were uneducated or unmotivated—and they still didn’t get it. They had bought into the mainstream narrative that we ourselves were the problem; that we were to blame for things like the selective enforcement of drug laws, the underfunded schools, and biased hiring that hindered so many.

  These were men who still tried to fit into a country that didn’t want to recognize their contributions. They were all folks who could still be put in the equivalent of a lineup outside a bank, while carrying a statement and a photo ID identifying them as a scientist at the premier government health research institution in the world.

  It infuriated me, but that’s what I realized my son would soon face. A world where even in the most clear-cut situation, someone with our skin tone could still be seen as a “crackhead” just because he dressed a certain way—or to use the language of an earlier wave of drug hysteria, a “Negro cocaine fiend.” And all of this made me think a lot more critically about my research and about how to think about drugs.

  CHAPTER 13

  The Behavior of Human Subjects

  It is not heroin or cocaine that makes one an addict. It is the need to escape from a harsh reality.

  —SHIRLEY CHISHOLM

  Robert sat on a hospital bed, surrounded by about a half-dozen people. He was a tall, slender, light-skinned brother with a goatee and short hair, in his early thirties. He was reclining in a typical, austere single room, with a small window and the usual pale and sterile hospital decor. At the center of the group was Dr. Ellie McCance-Katz, the woman who had recruited me to a postdoctoral position in Yale University’s Psychiatry Department.

  A short, fortyish woman with auburn hair, Ellie led the team. A nurse and another doctor monitored Robert’s blood pressure and other vital signs. A female research assistant and I were also clustered around Robert as he slowly received an intravenous injection of cocaine. It was December 1997.

  Postdoctoral work is an important step in scientific training, which, if things go well, can lead to the ultimate academic prize: a tenure-track job at a reputable university. My Yale postdoc was also my first experience of studying the effects of psychoactive drugs on a human being. It was exciting to finally get to do this work.

  Over time, I’d come to see the limitations of the animal research that had been my initiation into neuroscience. For example, there’s a phenomenon seen in animals, called sensitization, that occurs when they are given stimulant drugs like cocaine. Typically, when rats take a drug repeatedly, they become tolerant to its effects and a higher dose is needed to reproduce the initial response. But with some effects of stimulants, animals actually become more sensitive to the drug and they have a bigger response to a smaller dose than they did at first: the opposite of tolerance.

  In humans, this sensitization was said to cause addicted stimulant users to become more paranoid and anxious over time. However, that result isn’t seen consistently in human drug users and it isn’t seen when stimulants are used therapeutically, which suggests that it is not an important pharmacological effect for people. As I continued to study drugs, I found many similar phenomena that just didn’t carry over. It all made me think that in order to discover what I really wanted to know about drug use, I’d have to study it carefully in humans.

  Robert was an affable, handsome man. Dressed neatly but casually, he didn’t look overly thin or sickly: there was nothing to suggest to anyone who saw him that he was a crack cocaine user. While we were blinded as to the dose of drug he was receiving and to whether it was a placebo, cocaine, or a cocaine-related compound called cocaethylene, I soon learned to tell when he got a decent dose of drug. Then all he wanted to do was talk. He’d go on and on, sometimes describing how cocaine gave him insight and creativity.

  Our study was designed to compare the effects of IV cocaine to IV cocaethylene, a compound that is created in the body when cocaine and alcohol are taken together. At the time, there were concerns that cocaethylene was more potent and more dangerous to the heart and blood vessels than cocaine taken alone. Under carefully controlled conditions, we wanted to learn whether this was true when the drug was given to healthy people who typically used cocaine and alcohol together.

  I recognize that some may question the ethics of giving drugs like cocaine and cocaethylene for research purposes. Over the course of my career, however, I have come to the conclusion that it would be unethical not to conduct this type of research, because it has provided a wealth of information about the real effects of drugs and the findings have important implications for public policy and the treatment of drug addiction. From this study, for example, we found out that fears about the dangers of cocaethylene were not supported by evidence. Cocaethylene turns out to be less potent than cocaine.1 It actually has less of an effect in terms of raising heart rate and blood pressure than does cocaine itself, meaning it probably carries less risk for heart attack or stroke.

  Back in 1997, when I started working on this study, I still had many misconceptions about drugs myself. Like the idea that cocaethylene was a major new threat, my other hypotheses were being repeatedly contradicted by the data during my graduate and postdoc studies. I’d had a previous postdoctoral appointment at the University of California, San Francisco, in 1996, which I’d received right after graduating from Wyoming. I had been eager to start studying human drug users and I knew I’d have a chance to do so at UCSF.

  But in California, I wasn’t able to study people actually taking drugs in the lab: the researchers I worked with were focused on drug craving, which was supposed to drive addiction. These scientists didn’t study the effects of drugs themselves; they examined only what drug users were reporting about their desire for them. I rapidly discovered that craving wasn’t as important as I had initially thought. This was another step in the evolution of my thinking about drugs.

  The problems with craving first became clear when I interacted with real people who had sought help for addiction. To try to understand their desire for drugs, I had become a facilitator for group sessions required of the patients in a methadone program. Almost immediately, however, I began recognizing that I had much more in common with them than I’d expected. Although they did discuss drug-related is
sues, unless they were prompted, craving wasn’t their primary concern. The patients’ real issues were mainly related to practical things like the high cost of housing and other essentials. That was something I’d had a very acute personal experience of as I started my postdoc.

  It had been so hard for me to find an affordable place to stay in the Bay Area that I’d actually spent the first several weeks of my postdoc sleeping in my office. This was one of the many frustrations I experienced during my postdoctoral training that sometimes made me seriously question my desire for a future in science. Postdoctoral work is critical to a scientist’s career, but even now in 2013 it pays only $40,000–$50,000 a year. Back then the salary was a meager $19,000–$24,000. I understood what these men and women in treatment were going through, trying to survive on not much money and manage their work and relationships. I’d thought these drug users were going to be much more different from me than they actually were.

  Instead, I found that people with addictions weren’t driven only by drugs. Moreover, they weren’t any more antisocial or criminal than people I’d grown up with, many of whom rarely or never got high; in fact, their behavior wasn’t much different from what I’d engaged in myself with my friends back home. They didn’t seem overwhelmed by craving: they basically sought drug rewards in the same way that they sought sex or food. I began to see that their drug-related behavior wasn’t really that special and to think that perhaps their drive to take drugs obeyed the same rules that applied to these other human desires. The notion that addiction was some kind of “character defect” or extreme condition that created completely unpredictable and irrational actions began to seem misguided.

  And when I heard lectures by addiction researchers who studied animals, I began to realize how they extrapolated from extreme situations in ways that created a caricature of addiction. One researcher talked about how you could leave a hundred-dollar bill in the room and “you or I wouldn’t take it” but a drug addict always would. They talked about humans in simplistic ways that, ironically, lacked the careful qualifications they always included in their discussions of animal research.

  Later, I also came to see how our distorted images of addiction played out in the attitudes the researchers had toward the study participants at Yale. For instance, Robert’s musings on how cocaine made him more focused and creative were discounted as drug-induced drivel—and yet studies of the impact of cocaine on concentration do show that it can improve alertness and concentration, exactly as he claimed.

  Other experiences led me to see even more similarities. David, a thirty-five-year-old Italian-American construction worker, also participated in the cocaethylene research. He once described his experience to me of the day he was recruited to participate in the study. He’d seen an ad in a local alternative newspaper, seeking frequent cocaine users willing to be in an experiment in which they might be administered cocaine. They had to be otherwise healthy and willing to live in the hospital for two weeks. If accepted and if they stayed the whole time, they’d be paid a thousand dollars upon completion.

  We’d interviewed David and determined that he was an appropriate candidate. Then we arranged for him to get a physical at a clinic at Yale–New Haven Hospital. The building had a strange address—it was 950½ or something like that, which sounds distinctly fishy. As he left our facility and sought this bizarre address, he noticed that there were several police cars parked outside.

  That made him anxious. But he did want to participate in the study and possibly make some money, so he persevered. When he got near to where he thought the address was, however, he saw police outside that building, too. He began thinking that we’d set him up, that when he got inside and asked about the study, he’d be arrested. He walked around the facility a few times, trying to figure out what to do and whether he should even ask someone about the weird address. Maybe asking for that number would be the cue for the police to arrest him?

  From the perspective of a nonuser of illegal drugs, of course, this sounds like sheer paranoia. When I told the story to other people working on the study, they laughed knowingly about how cocaine can make users paranoid. But from David’s perspective, there was nothing irrational about his fears. He was involved in illegal activity. Police actually were engaged in an intense war on drugs. Tens of thousands cocaine users had been arrested. And we had all seen those movies or TV shows where lawbreakers are lured to some building by promises of a prize of some sort, only to be arrested for some earlier crime.

  David had been asked to go into a government building and admit his drug use, which is a crime, in order to supposedly get paid to possibly take an illegal drug. His worries were an understandable response to his experience in the cultural setting in which it took place. While cocaine and marijuana can certainly increase these kinds of fears, anyone engaging in illegal activity does need to be cautious if he wants to avoid getting caught.

  It became increasingly clear to me how our prejudices about drug use and our punitive policies toward users themselves made people who take drugs seem less human and less rational. Drug users’ behavior was always first ascribed to drugs rather than considered in light of other, equally prominent factors in the social world, like drug laws.

  And in reality, virtually all of us sometimes find ourselves in situations where we persist in behavior despite negative consequences, just like addicted people do. Most people can’t stick to a diet, many continue to eat fatty and sweet foods when they are gaining weight, or have had periods of heavy drinking or stayed in bad relationships and ignored the negative results, which is the same pattern of behavior seen in drug addiction. Sure, there are extreme cases where addicted people commit absurd crimes—but there are plenty of equally stupid crimes planned or committed by people who are stone-cold sober.

  I thought about my friends and family back home and where they’d wound up while I was working my way up in academia. I considered behaviors that were impulsive and often seen as associated with alcohol and other drugs. I myself had shoplifted and stolen batteries and sold drugs. But while I had plenty of less than perfect qualities, I had no addictions. Many of my siblings and cousins also engaged in petty theft as teenagers, but again, this was usually unrelated to their alcohol or other drug use or lack thereof.

  In my immediate family, three of my five sisters had had teenage pregnancies. One of my sisters did become a heavy drinker (although she nonetheless always met her occupational and family obligations). And she had her first child at age nineteen but married the father a few months after the child’s birth. They are still together. But she is not the sister who stabbed a woman in a fight over a man and was later stabbed herself in a similar situation. The sister who got into those altercations does not have substance abuse problems.

  One of my sisters’ husbands was arrested in connection with a deadly shooting but not convicted—but that is not the brother-in-law who went to rehab for crack cocaine abuse. And the in-law who did have a crack problem? He went on to get a job in plumbing, has a house twice the size of mine, and is a loving father and husband.

  Where was the connection between drugs and problems here? Among my family—just as I was beginning to understand from the research as well—the link between addiction and other forms of dysfunctional behavior was not as prominent as the stereotypes suggest. In some cases, alcohol use or its aftereffects exacerbated violence: for example, when my father beat my mother. Some of my cousins had struggled with crack. But illicit drugs and addiction were far from the greatest threats to our safety and chances of success. There seemed to be at least as many—if not more—cases in which illicit drugs played little or no role than there were situations in which their pharmacological effects seemed to matter. And if the drug highs themselves didn’t explain behavior, for me that meant behavior related to lack of drugs—that is, craving—was even further away from allowing us to predict it.

  I had left my San Francisco postdoctoral position disillusioned by the whole concept of crav
ing. Some addicts certainly reported drug craving: there was no doubt about that. But it didn’t really predict whether they relapsed, according to the majority of research. Sometimes people would report severe craving but not use drugs; other times, they’d use drugs in situations where they said they’d experienced no craving at all. It seemed to me that it would be much more useful to study people’s actual decisions about whether to take drugs, rather than focus so much on what they said about what they wanted or craved in some hypothetical future. That’s why I responded with enthusiasm when Dr. McCance-Katz had suggested I do a postdoc with her at Yale.

  Although I didn’t get to study drug-taking decisions at Yale, at least with Dr. McCance-Katz, I was able to observe people’s behavior while under the influence, not just their ratings of their desires to use drugs. That brought me closer to the types of experiments I really wanted to do so I could understand the real effects of drugs, not just our projections of them.

  In order to find people to participate in our research in New Haven, I also had to interview many drug users. At the time, I wasn’t even making a distinction between drug use and addiction. Despite what I was starting to learn, I still thought all illegal drug use was problematic and that most people engaged in it were headed for addiction if indeed not already there. I didn’t distinguish between addictive use that interferes with major life functions like relationships and work, and controlled use that is pleasurable and not destructive.

  Like the addicted people I was studying, I was influenced by my social milieu. Everyone around me in the addiction field acted as though pathological use was more common than controlled use. Certainly if you read the scientific literature unskeptically, this is the impression with which you are left. Consequently, when I interviewed users at this time whose lives seemed unscathed by their drug use, I figured I just hadn’t yet become skillful enough to ferret out their denial. After speaking with dozens of them, though, I started to think twice. Maybe I wasn’t the one who was wrong.