If you are someone who believes that drug decriminalization and legalization will be a hugely beneficial advancement for reducing harm and advancing liberty, and if you believe in the narrative of the opioid epidemic, then you have some cognitive dissonance to deal with. This narrative of a drug “crisis” is a story of how drugs being more accessible to people (even through doctors) creates a dangerous scenario, and it assumes that the causes for addiction are in the drugs themselves, rather than the social conditions that create trauma and hopelessness.

In our third conversation with Columbia Professor Dr. Carl Hart, we take on the contentious subject of the “opioid epidemic,” an endlessly repeated narrative that places opioids and pharmaceutical companies firmly in the villain role, and unsuspecting drug consumers as the victims. Dr. Hart’s views on this subject are highly controversial because they are nuanced and based on data and common sense, rather than the convenient hysteria of irreconcilable villains and helpless victims who are unable to mediate their use of drugs.

Thanks again for speaking with us Dr. Hart. I’d like to talk about one of the sacred cows you take on in your new book Drug Use for Grown-Ups – the opioid crisis. This is a universally accepted concept, yet you point out how the conversation around this is overblown, non-precise, misleading, and it continues to reinforce harmful drug stereotypes.

There’s a trick that’s played by anyone writing about opioids, and that is you are nebulous about what you mean. Are you talking about overdoses, or addiction, or opiate use in general? You don’t have to be precise, even in the most critical publications. And that really bothers me. Because if you are really concerned about overdoses, great, let’s dig into it and find out what’s going on, then we could probably save some people if we really cared. But I saw that wasn’t being done. So what are we really talking about?

Most of the people who use these drugs are not addicted. In fact, these drugs bring a lot of people a lot of relief. I saw that we are changing our policy to restrict opioid prescriptions and use, and that means all these people who have been suffering for years and have been finding some relief with opioids and been doing so safely, they are cut off, and we’re ok with that.

And we’ve seen this play out before, this played out like any other drug crisis. When I see this I say stop, let’s just stop this shit. But it turns out society is still offering incentives for people reinforcing this narrative, so it is still prevalent.

I recently watched the documentary Crime of the Century that covers this subject. Watching that, and then integrating your perspective on this, is definitely some mental gymnastics. They paint a picture of the Sackler family behind Purdue pharma juicing up their marketing campaign in order to sell more opiates. Of course they are a corporation, so they are incentivized to sell more of these opioids and downplay the risks and get doctors to prescribe them more.

This is an example of a legal drug, but they were finding doctors who were prescribing these to anyone – pill mills- they are drug dealers, right? That led to a lot of people getting prescribed opiates and not getting the best information about them. I’m sure this did some good- people found relief for their chronic pain, but anyone could get these and it became a problem.

If you look at these poor communities that were hit hardest by prescription overuse, they have all the factors that can exacerbate addiction- they are poor communities with high unemployment, and you start to see overdose deaths on a higher scale. They don’t have a healthy environment or hope for the future, so they turn to drugs as a means to escape.

So I’m curious about your take on this. They flooded the marketplace with opioids and downplayed the risks and lots of people started overdosing. Was it that people were not given proper education, such as not using them with other depressants and not understanding the physical addiction?

Well, the most important lesson for me when it comes to this, is that once there is a problem, we always have to find a Hitler, a fall guy. And once we have Hitler, none of us have to take responsibility- it’s all their fault, and we don’t have to think deeply about it. That’s the lesson.

Now you said a number of things that were based on assumptions that haven’t been demonstrated. So the connection between overdoses and these opioids being prescribed- I don’t trust that. That’s why in the book I tried to help people understand how these things were being calculated, and people don’t even discuss suicide. There’s no real scientific connection in the data between overdoses and being prescribed these opioids.

Sally Satel wrote a piece in Politico a few years back showing that the assumption that overdoses were related to legal prescriptions was not accurate. Medical examiners, coroners, cops, everybody is being incentivized to count more opioid deaths. You get grant funding, publicity, so everyone emphasizes it, but this connection that everyone takes for granted hasn’t been established, and I know it’s not connected. We change the way we count all of these things. The way that people do this is criminal, because they know better, but they are still doing it.

When you point out the Sackler family, you are right, they are simply doing what any for profit company would do to try and make more money. Their primary problem was they got oxycodone originally at schedule 3 and they knew it was just like any other opioid, that’s their crime right there. And that’s it. But we are attributing all these other things to them- they groomed these doctors, they advertised their products, but this is what all of these companies do, this is what we permit in the United States. If you want to stop this, change the regulation, but they didn’t behave differently than any other pharmaceutical company. But we needed a Hitler, so they’re the Hitler.

There’s also this issue of people who are taking opioids saying “My doctor addicted me.” I mean what the fuck? You have some personal responsibility. We know that in the rust belt, the jobs left. And we pretend that they didn’t. The jobs went to other countries, and nobody is holding the companies accountable that left. Nobody is even mentioning GM and the rest of these people in this whole equation. So I’m not saying that those people aren’t catching hell living there, but they are still responsible for what they do. You know something is going on with your body. If this doesn’t feel right, stop it. Simple. When we start to say your doctor was responsible, then you have no responsibility. If you have no responsibility, then you have no power or personal freedom. It’s an important point that people have to understand- with freedom comes responsibility. No it doesn’t mean that you shouldn’t have a safety net, because we should, we are a wealthy country that should have safety nets for people, but you still have to have some responsibility.

That’s why this whole opioid story, the way we are currently telling it, we are still shutting out people who have chronic pain, they are still cut off, because we are allowing those people to suffer by this bullshit narrative.

I realize that there is still more pressure washing that I have to do in my own mind on these subjects. I’ll casually bring up the increase of overdose deaths related to this epidemic, and Purdue and whatever, without realizing I don’t know if that is actually true. I’ve just heard it repeated so many times.

It’s not, it’s not. You think about countries outside the US where they have drug checking and they also have opioid use, you don’t have these overdose issues. Think about countries where they take care of their people, you don’t have this issue. This is a politician’s wet dream. It allows diverting attention away from the fact that GM and other companies left. They left and they have big lobbies, they contribute. Keep the focus away from those companies and what really happened, and put the blame on opioids. Politicians are happy to do that because they are getting incentivized to do so. So the opioid crisis has a huge cultural significance, we need it.

Another vilified substance as a smokescreen for the real issues at play.

But the problem is, there are real people’s lives being impacted, from the pain patients who can’t get this medication, to the people who lost their lives from ignorance and our unwillingness to make sure there are clean opioids on the streets. And with this crackdown, we knew that the market would naturally come up with more creative and more potent substances, we see it every time, this is nothing new. And that means that more people will be sacrificed.

Taking a solutions oriented approach, it seems to me that the biggest thing we could do in terms of accidental deaths, would be education and legalization. As you mention in the book, it’s very dangerous to mix opiates with other substances, particularly other depressants such as alcohol. Plus it was a perfect storm where they flooded the market then pulled it all away, and so of course street heroin is going to be an alternative, but that is an unregulated black market so who knows what you are getting. So legalizing these substances and sharing clear information with the public about their benefits and their risks seems to me to be the real solution to me.

So when people talk about the “opioid crisis”, and you try to pin them down on what they are saying, they often say the overdoses, so let’s focus there. Short of legalization, what can you do to stop this? We know a proportion of those people commit suicide, and there’s nothing you can really do. And a portion didn’t just have opioids in their system, they had a bad combination of stuff. But in terms of people who were seeking illicit opioids and they died, you could simply have drug testing facilities. Just have a way for people to submit samples anonymously so that they can see what’s in their drugs and if it is what they were told it is. We have that technology, we have that money.

If you really cared about the people, this would have been done yesterday. It would have solved so many deaths. But we didn’t do it, and that tells you that we don’t even believe our own bullshit, and we don’t really care about the people. Because this is so easy to do. You can do it at any university, have people submit samples with a unique number identifier, post it online. There it is. Nobody has to know you submitted it, and you have the information that could save your life. Really easy, and we know this. But yet, when politicians stand up and speak about the “opioid crisis” and they feign concern for the public, notice, not one reporter, not one audience participant asks them about drug purity testing. That’s fucking remarkable, when you say you care about people dying. That’s like saying that you are worried about infections after surgery in an operating room, and then refusing to have people clean up the room after each operation. That’s what this is like.

We are very grateful to Dr. Hart for speaking with us on this controversial topic and shedding some light on a rarely challenged narrative. You can read our first two interviews with Dr. Hart here and here.