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Should heroin be legal?

A book review: Drug Use for Grown-Ups by Carl L. Hart (Penguin Press, 2021)

Dr. Carl Hart, a university professor, researcher, and self-admitted user of various drugs (marijuana, heroin, cocaine, MDMA, among others) makes an argument that consenting adults should be allowed to use recreational drugs without legal consequences, and that drugs should be regulated and legalized.

Do you agree?

Dr. Hart argues that the adverse consequences of illicit drug use are wildly overstated, and that occasional and responsible (or “grown-up”) use of substances can be life enhancing. Therefore, all drugs should be legalized, with appropriate controls on their manufacture and distribution, mostly to ensure purity and quality of the product.

His arguments fall into several main categories: most people who use recreational drugs do not become addicted, most adverse consequences come not from the drug but from the “war on drugs,” and that “grown-up” drug use is generally safe. Therefore, consenting adults should be allowed to make a choice to use them or not. While many of his points are valid, his proposition would almost certainly lead to disaster for millions. Let me explain why.

Most recreational drug users do not become addicted

Dr. Hart makes the point that the majority of people who use drugs do not become addicted – which is true. The percent of people who try a drug who then go on to develop problem drug use varies from drug to drug. The chart below is from Warner LA, Kessler RC, Hughes M, Anthony JC, Nelson CB. Prevalence and correlates of drug use and dependence in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1995 Mar;52(3):219-29.

This table indicates that about 32% of people who try tobacco will become addicted to it, making it the highest percentage of all drugs. The number for alcohol is 15%, cannabis is 9%, cocaine 17%, and stimulants (i.e., methamphetamine) 11%. The percent for heroin is high – 23% - although only a small proportion of the population ever tries it – 1.5% (as opposed to alcohol, where 76% will at least try it).

If heroin were legalized, more people would try it. What would happen if the same number of people who try alcohol (76%) were to try heroin? This would result in 17.5% of the US adult population being dependent on having heroin (or some other opioid) every day. I can’t imagine that this would be good.

We had a “natural experiment” of what could happen if heroin were widely available and tried by many people – which was the overprescribing of opioid pain medications that led to the opioid crisis. While the teaching at the time was that “people who are treated with an opioid for pain are unlikely to become addicted,” this turned out to be false. It was based on one published letter, that was not even a study (Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980 Jan 10;302(2):123). The percent of people prescribed opioids who go on to become addicted varies from study to study, but it is probably similar to that of heroin. (Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015 Apr;156(4):569-576).

Most adverse consequences from drug use are not caused by the drug themselves

Many drugs are toxic, either acutely or over time. Tobacco is one of the most frequent causes of death and disability throughout the world. Alcohol can cause consequences in the short term (MVAs, domestic abuse, injuries, etc.) and long term (liver disease, heart disease, memory and balance problems, etc.) Methamphetamine can cause severe weight loss, neurodermatitis, mood disturbances, and psychosis. However, opioids do not have these same types of issues.

Opioids, as a drug class, have no significant long-term toxicity. Methadone has been used for the treatment of Opioid Use Disorder since the 1960s, and patients have been on methadone for decades without consequences. Methadone does not cause problems with the liver, kidneys, heart, lungs, brain, or any other organ (rumors that methadone makes your bones crumble or your teeth fall out are wrong). Almost all the adverse consequences of an OUD come from other sources – illegal activities required to obtain the drug, criminal charges associated with using or possessing the drug, frequent periods of opioid withdrawal that make the person unable to keep a job, or the means of administration using unsterile supplies.

If we were to imagine a world where opioids were widely available at the “opioid store” (much like cannabis in states where it is legal), most of the adverse consequences of using them would disappear. Users would be able to obtain a regular supply of pharmaceutical grade drug (nearly eliminating the risk of overdosing), would not have to commit crimes to get the drug, would be able to carry on normal lives, and might experience benefits – decreased pain, improvements in energy, decrease in depression, maybe even improved social function. Without the “war on drugs,” almost all adverse consequences of using opioids would immediately disappear – which is an astounding concept.

“Grown-Up” drug use does not cause problems

Dr. Hart gives many examples of his own drug use, or that of people he knows, where he perceives mostly benefits and few adverse consequences. He describes one episode of opioid withdrawal (something he is not anxious to repeat), but he got through that in a few days. For the most part, he feels his intermittent use of various drug classes enhances his quality of life and enables him to be more functional and cope better with life stressors.

What Hart does not take into account is that he is not typical of all people who try drugs. As noted above, while the majority of people who try a drug will not go on to problem drug use, a significant proportion will go on to develop a substance use disorder, which can be devastating to their lives, those around them, and lead to death from overdoses or other complications.

Suppose that most adults were to try multiple classes of drugs as Dr. Hart has done – the consequence would be that many of them would not meet his definition of “grown-up” and would lose control over their use. No one uses a drug with the intention of becoming addicted to it – this process occurs in an insidious fashion, relentlessly progressing and eventually taking over the person’s will and ability to control their use. Many of these drugs may be harmless to a lot of people, but they are risky and potentially dangerous, and people who try them bear a high risk of severe consequences.

A measured approach to drug legalization

Alcohol has been legal for many years in the US (except for a break in the 1920s), and cannabis is being legalized for either “medical” or recreational use in more and more states. Both alcohol ($249 billion in 2010 per the CDC) and cannabis are causing adverse effects on our society. (I could not find any overall estimates of the societal cost of cannabis, although one study indicated that for every dollar gained in tax revenue, Coloradans spent approximately $4.50 to mitigate the effects of legalization). Compared to heroin and cocaine, alcohol and marijuana are less likely to lead to problem drug use, and less likely to cause death from overdose or other severe consequences.

The reason that cocaine, methamphetamine, and heroin should not be legalized is that not all of us behave like “grown-ups” all of the time. There is a legitimate role for government controls over potentially dangerous substances (think about explosives or highly toxic chemicals) and activities (such as driving over the speed limit or discharging firearms in crowded areas). Widespread availability of more addictive substances with severe potential consequences will inevitably lead to disastrous effects on society as millions of people succumb to the drugs and lose control over their lives.

Decriminalization of drug possession

While there is a legitimate and urgent need to limit the availability and access to dangerous drugs, there is little to be gained by putting people who are using drugs into prison. Even many who have been supportive of the “war on drugs” now realize that “we can’t arrest our way out of the illegal drug problem.” Regulations such as those in Portugal, where use of drugs has been decriminalized for years, have been successful in decreasing drug use overall and the adverse consequences to society. Drug production, transportation, and distribution are still illegal, which is important in limiting the overall impact of illicit drug use. People who are using drugs, however, need to be offered treatment, not punishment.

The importance of offering treatment

Decriminalization of drug use that is not connected to treatment for those with substance use disorders is not likely to decrease the overall effect of drugs on society. Data show that treatment for addiction works - certainly not all the time, but it is at least effective as many other medical interventions we use routinely. Medications for opioid use disorder (MOUD), adjuvant medication for alcohol use disorder, evidence-based counseling combined with contingency management (giving incentives for people to stop using illicit drugs) for stimulant use disorders, all have solid scientific backing showing effectiveness. These modalities need to be made widely available to those who need them and are willing to engage with them. We also need research into better methods for treating substance use disorders.

Changing attitudes

Due to widespread stigma, judgementalism, and discrimination, many people with substance use disorders hide their use and are reluctant to engage in treatment. We need to fight stigma wherever it occurs, so that people with substance use disorders are treated fairly and compassionately. We have not always done this well in our society, and certainly not within the medical community. We have a long way to go with our own attitudes, and our knowledge and understanding of substance use disorders of all types.

Each of us in the field of medicine, or those treating substance use disorders in any setting, has a responsibility to learn and exercise empathy. In addition, we all should work to increase our knowledge of addiction medicine, and how to help those who are struggling with addiction.

Rather than widespread legalization, what we need is a science-based approach to limiting the damage that illicit drug use causes to millions in our society.

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