March 29, 2014

Race, addiction, science, public policy: Carl Hart writes an oversold book

I just got done reading a pretty new addiction-related book, and no, it's not (yet) that hot new book by Dr. Dodes, profiled on Salon, The Atlantic and NPR. Rather, this is "High Price," by Ph.D. neuroscientist Carl Hart.

Carl Hart is good on the basics of what we know, and don't know, about addiction and neuroscience. He's decent on telling the story of his life, and on public policy, minorities and the "War on Drugs." However, where parts 1 and 2 intersect, he sometimes seems to soft-pedal part 1 for the sake of part 2.

Basic point 1 is that he is African-American, and grew up in lower-class neighborhoods in greater Miami, and therefore in a unique position to talk about race and addiction, race and other races' beliefs about addiction, etc.

But, that's not my first primary point. Rather, per ideas I've heard from people who think that AA is unscientific, it's about "following the science" on addiction. More specifically, it's about updating one's scientific knowledge of what may cause addiction, the little knowledge we have, being updated rather than being 20 years old. More specifically yet, that involves moving beyond simple, or simplistic, ideas that we can reduce addiction to a matter of brain neurotransmitters.

Neurotransmitters and neuroscience

And, specifically, addiction is NOT "All about the dopamine," or anything similar. I quote from his book:
When dopamine's prominent role in reward was first proposed, there were only about six known neurotransmitters: dopamine, norepinephrine, serotonin, acetylcholine, glutamate and GABA. Now there are more than a hundred. Furthermore, we now know that there are specific receptors -- or specialized structures that recognize and respond to a particular neurotransmitter -- for each neurotransmitter, and most neurotransmitters have more than one type of receptor. For example, dopamine has at least five receptor subtypes -- D1-D5. We also now know that hormones like oxytocin and testosterone can act as neurotransmitters.
But despite these ever-intensifying complexities, our theory about dopamine's role in reward has not been appreciably revised since it was first proposed [in the early 1990s]. And, as you will see later, a growing body of evidence casts doubt on this simplistic view of reward.
I knew a fair amount of this before I read Hart's book. But, his directly applying it to addiction, combined with his ethnicity and sociological background, gave me the perfect excuse, or reason, to blog about it more directly.

For more on neurotransmitters, which may, depending on how widely the term is defined, include a variety of peptides and even minerals like zinc, see Wikipedia. I mean, histamine and products related to several amino acids are neurotransmitters. It's much more than the few neurotransmitters that health-food stores, and Big Pharma, try to pitch us on. More on that in a minute

And, folks, that's why addiction isn't all about the dopamine. And why truly understanding addiction will proved to be more complex than current ideas.

Related to this is why an anti-craving drug like Naltrexone doesn’t work equally well for different addicts with different addictions and never will.

And bingo on who might be behind the “cravings” idea. Per Wikipedia, anti-craving drug Naltrexone's first clinical trials? 1992. And, also per Wiki, all the different addictions it's now possibly supposed to help on cravings? I think we've struck Big Pharma gold, or at least silver.

Also, while Naltrexone is an opiate receptor antagonist, Campral, also marketed as an anti-craving drug for alcoholics, works, or “works,” as a GABA receptor agonist. Different mechanism entirely than Naltrexone. Campral was first approved, in Europe, in 1989. That’s a bit earlier than the 1990s, but still in the same framework. Don’t let the European start fool  you, though; Western Europe is at least as Big Pharma friendly as the US. And Wellbutrin, marketed to help smoking cravings as well as being a non-SSRI antidepressant? It targets, in various ways, dopamine, norepinephrine, and acetylcholine. And, its actions on dopamine don’t seem  to be enough to explain its alleged effectiveness. (All three of these may target neurotransmitters beyond members of the “original six,” which Big Pharma hasn’t looked for. Material on Campral and Wellbutrin is also from Wiki.)

There’s more, just from basic browsing of Wiki. We’ve long known that nicotine is an agonist for certain acetylcholine receptors and triggers the release of sever al “old” and “new” neurotransmitters; why would we focus on dopamine?

And, even if dopamine has a fair role to play in addiction, Wellbutrin alone shows that it’s not a primary role.

Oh, and substitute "serotonin" for "dopamine," and what's said above about addiction is just as true for depression. And, the "serotonin deficiency causes depression" idea was proposed at the same time as the "dopamine shortage causes addiction" idea. Yet, despite early hype, we still don't know a lot about depression, other than knowing SSRIs often don't work a lot better than older anti-depressants.

Beyond that, other neurotransmitters, like acetylcholine, have various types of receptors, too.

Hart himself addresses the issue of “craving” near the end of the book. He says that for apparently non-addicted but regular users of various drugs, as tested in laboratory settings, “craving” did not seem to be a significant concern, on average. I question that. Also, given some libertarian-type political "connectedness" the book and Hart apparently have, I also "question" that he did not spell out how much of the "low dopamine = addiction" idea, like "low serotonin = depression," was pushed by Big Pharma. And, that may be why he doesn't talk about anti-craving drugs that much, and minimizes the issue of craving.

Unfortunately, Nora Volkow, head of the US government's National Institute on Drug Abuse, is one of the biggest pushers of the dopamine theory. I'm not sure if I would go so far as to claim this is a new version of the "disease theory" of addiction, though, as Stanton Peele does. Especially given that Peele is one of the most tireless promoters of theories of addiction that largely deny the existence of addiction, one can usually depend on him to overswing, and therefore, take what he says with a 1/3 off grain of salt.

Now, public policy issues in the book

Hart, as noted, is a black male, of about the same age as I am, who grew up in greater Miami in the late 1970s and 1980s. As such, he remembers the Reagan-era paranoia about crack cocaine vs. powder, which he covers in detail, including showing no difference in addictiveness levels, just as other researchers have done.

From there, he looks at what he sees in many ways as being a very similar alarm over methamphetamine, or “meth,” in the past decade. He notes that the number of meth users is much lower than cocaine users, first. Second, most stories about superhuman strength, etc. of alleged meth addicts are anecdotal, he adds. Third, and to the point, he notes how there is little chemical difference between amphetamine, the main ingredient in Adderall and other anti-hyperactivity drugs, and methamphetamine. After all, per basic chemistry, methamphetamine is just a methylated version of amphetamine, with a single methyl radical added. Or, in other words, it’s like Celexa and Lexapro. But, both of them are legal and heavily prescribed. On stimulants, Adderall and Ritalin are legal and heavily prescribed; meth isn’t.

Skepticism of some of his claims

I don’t totally agree with Hart. I think he tilts the scale toward “abuse” rather than “addiction” at times, and doesn’t allow for even people who are addicts, not just abusers, still having enough self-control to moderate their behavior in lab settings. I mean, the stories of alcoholics and addicts trying to pull one over on people are legion, and at some point, per the old cliche, "anecdotes" become "data." Hart talks about how some of his test subjects appeared intimidated about getting to the lab, but doesn't ask if any were still intimidated later.

Nor does he seem to ask himself if he’s over-reacting to some of his own personal, and his larger background as an African-American’s, take on things like the “crack menace” or “reefer madness” long before that.

Related to both points, he doesn't ask, as a very rare minority Ph.D. neuroscientist, if some of his test subjects are "trying to help a brother out." I hate to stereotype, and I'm not a minority, but, I've been around a boatload of drinkers and users. I'm liberal enough to know the War on Drugs is a crock, but I've been plenty a person be sober or clean for years, even a decade or more, "slip," and not be able to get back on track.

Nonetheless, he’s right indeed, in my opinion, that addiction is a complex issue. And why should this surprise us?

Some “purely physiological” issues are far more complex than originally claimed and even than some claim today. Cancer immediately comes to mind. Fifty years on, we’re not close to “winning” a “War on Cancer.”

At the same time? His wanting to make it look like addiction isn't that common approaches simplicity itself. I gave this three stars on book review sites. It's barely that, I think.

Political issues, of his own

Finally, I raise at least a partial eyebrow at his crediting Maia Szalavitz for helping get the book done. Szalavitz at least has a few of her toes in the pool of right-wing funded journalism, or "journalism," or is at minimum a "fellow traveler." Her association with places like, which, per Wiki, has connections with Scaife money, American Enterprise Institute, etc., and is affiliated with George Mason University, is a red alert right there. That would probably explain, per some Amazon reviewers, Hart visiting Fox News, and ... more than once! I suspect, per those Amazon reviewers who would be clueless as to why, this was to get "in" with libertarian Fox watchers, not the religious right. Hart explicitly calls for decriminalization, which is neither neuroscience nor memoir.

Related to that, I'm tired of libertarians, starting with Glenn Greenwald, talk about what a success drug decriminalization is in a place like Portugal when most of them know that Portugal has a better "safety net" than we do and spends more government money on it than we do now, and than many libertarians here are willing to pay.

Greenwald, and Hart here, if they want to propose this, then fine ... be honest with how much this costs. And, if you're either too lazy to have researched that, or are afraid to tell people that, or else are a committed enough economic libertarian that you don't want the government paying that price, then shut up about the "Portugal solution."


You can find the neuroscience work, including on neurotransmitters and related issues, from other neuroscientists, or else from psychiatrists doing research work. In many cases, it won't be explicitly tied to the decriminalization issues, and possible peddling of harm reduction over abstinence, which reportedly Hart has done on some of his TV appearances.

This is a book that has more froth than substance, after a first look.

There is a sort of political silver lining. Maybe the US needs a few more black libertarians of prominence, if that's what Hart is becoming, as well as black social conservatives.


Simon said...

I was impressed with interviews and talk by Hart but don't have the time or inclination-maybe ability as well- to dig deeper.

I also think the whole 'War' of drugs is a crock but I do wonder with addiction how broadly one can use the brush. I would have thought given the complicity of the topic and individual differences that sure for many people it isn't an addiction but for others it will be.

Interestingly I'm reading the Winner Effect by Ian Robertson where it is claimed where one takes the drugs can impact on the effect. Someone can take a certain amount in a regular location but if they then took the same amount in a new place that can cause an overdose. Similarly many servicemen in Vietnam had addictions but once removed from the environment that ceased.

Simon said...

Related to that, I'm tired of libertarians, starting with Glenn Greenwald, talk about what a success drug decriminalization is in a place like Portugal when most of them know that Portugal has a better "safety net" than we do and spends more government money on it than we do now, and than many libertarians here are willing to pay.

To be fair is that really a criticism of Greenwald? It's something I would have said ;)

That it needs greater funding like universal health care isn't a negative to people who don't have the sort of 'baggage' libertarians and conservatives on that particular topic.

Gadfly said...

Agreed on environment of use. Science even talks about state-dependent learning and drug influence.


Cost is not a burden for non-libertarians, no. I just want libertarians to be upfront about the cost of the Portuguese-style drug counseling safety network.