Neuroscientist and social critic Carl Hart brings attention to the need for interventions that better address social environments

Last fall’s New York Times feature on Dr. Carl Hart’s new book, High Price, sparked some heated debate about the models of addiction that guide research, policy and treatment.

“Eighty to 90 percent of people who use crack and methamphetamine don’t get addicted,” Hart explained to the New York Times. “And the small number who do become addicted are nothing like the popular caricatures.”

In the popular imagination—think images of opium dens of the 19th century, Reefer Madness of the 1930s, the morality tale of Requiem for a Dream, the degenerate tweaker-hell of Breaking Bad—people who use drugs are caricatured as craven, weak, and simultaneously dangerous individuals, driven mad by their drug use.

The_Cocaine_Fiends_(1935)

The Cocaine Fiends (1935) Credit: Wikimedia Commons

But Hart has conducted a series of experiments that point to the fact that drugs don’t generally drive people mad.

An individual’s substance use is substantially impacted by her social context and environment, rather than simply the pharmacological properties of drugs themselves.  This more complex view of substance use and substance users has not played enough of a role in drug policy or research priorities, Hart has repeatedly argued.

He’s not the first scientist to criticize our tendency to demonize drugs rather than looking at the bigger picture.

Rat Park

rat park

Rat Park (2013) by Stuart McMillen

Stuart McMillen, an Australian artist, published a comic last year recounting the experiments of Bruce K. Alexander at Simon Fraser University in the 1970s and 80s, a scientist who questioned the the idea of drugs as powerful agents singularly causing addiction.

McMillen’s comic is called, like Alexander’s experiments, Rat Park.  It begins by recounting the laboratory research performed on caged rats in the 1950s and 60s that resulted in the rats dosing themselves freely on heroin made available to them.  The research cemented fears in the scientific community that free access to drugs would result in “mass addiction and social crisis.”

But, Rat Park interjects, “Professor Bruce Alexander thought differently.”

Alexander questioned the reliability of experimenting on caged rats to understand human behavior.  Norwegian rats (the breed used in labs), the comic explains, are “curious, gregarious social creatures” and isolation in steel cages “must have been akin to torture.” Alexander wondered if their distress was a factor in their drug use.

Alexander decided to recreate the experiment, this time taking into account the rats’ environment and natural proclivity toward socialization. One group of rats was kept in isolated cages and another group was kept in a large enclosure that promoted social interaction, able to play, fight, communicate, and mate.  This environment, Alexander nicknamed “Rat Park.”

The results were astonishing.  The caged rats acted in accordance with the results from the earlier experiments.  But the Rat Park rats did not, preferring their social interaction over the sugary solution containing heroin.  In fact, when naltrexone—a chemical that blocks the effects of opioids—was added to the solution, the rats drank the solution more, wanting the sweetness without the high.

An especially interesting experiment involved comparing two groups of rats, both physically dependent on opiates. When given the choice between water and morphine, the group of caged rats always chose morphine.  The group who lived in Rat Park, however,  preferred withdrawal symptoms to continuing their previous opiate use.   They chose water over morphine, despite the physical discomfort they experienced.

In a 2011 interview, Bruce Alexander, now a Professor Emeritus at Simon Fraser University, discusses the value of considering addiction as a social problem

Social interventions

Health is social.  Substance use is part of overall health.  Even among substance users who meet the criteria for dependence, amounts and patterns of use are influenced by social environment.

A risky alcohol-using social network, referred to by researchers “network support for drinking,” has been found to predict poor outcomes for alcohol use treatment. Social networks with heavy use of tobacco and other drugs are also likely to increase an individual’s personal use.

And social networks that promote sobriety can affect use in the opposite direction.  A well-known social network designed for this purpose is a 12-step mutual aid group, such as Alcoholics or Narcotics Anonymous. Research supports the social mechanism of AA or similar groups in reducing alcohol use.

But this phenomenon also plays out among people who do not specifically seek support from a 12-step mutual aid group: a supportive social environment has been found to be a predictor of  the initiation and sustainability of what’s been called “natural recovery,” reduction of or abstention from substance use outside the bounds of formal treatment or self-help groups.

Social networks can support risky substance use or sobriety. How can can interventions better address a person's social environment?

Social networks can support risky substance use or sobriety. How can can interventions better address a person’s social environment? Credit: Eric Molina

We need more evidence-based programs that recognize the social component of substance use and recovery from addiction.  Most existing treatment interventions are designed to support change at the individual, not the social level.

Twelve Step Facilitation is one evidence-based practice that treatment practitioners can use to try and impact the patient’s social environment.  But we know 12-step approaches don’t work for everyone.  We need a menu of treatment approaches that tackle the issue of social environment to offer to patients seeking recovery from substance use disorders.

What could that look like?

The Community Reinforcement Approach is an evidence-based therapy that takes an unusually holistic approach to an individual’s substance use as it actually operates in his or her life. Despite research that supports it efficacy, CRA has not been widely implemented.

Another evidence-based approach is called Network Support Treatment, which is based on Twelve Step Facilitation, but does not emphasize participation in 12-step groups.  Network Support Treatment was used successfully in a 2009 study whose results provide strong support for the efficacy of interventions that address social networks.

It was the first long-term follow-up (two years post-treatment) of an intervention based on social network support.  The study found that individuals who received Network Support Treatment had, on average, 20 percent more days abstinent in two years than the control group who received case management alone.