Excerpted from WHAT WOULD YOU DO ALONE IN A CAGE WITH NOTHING BUT COCAINE: A Philosophy of Addiction © 2026 by Hanna Pickard. Reprinted by permission of Princeton University Press.
Keith Richards, lead guitarist for the Rolling Stones and sex, drugs, and rock ’n’ roll icon, famously said that he never had a problem with drugs, he only had a problem with the police. Richards did have a problem with the police. His notoriety as a Rolling Stone and as a drug user meant he was targeted and harassed both at home and on the road, leading to multiple drug-related charges during the 1960s and 1970s and one prison sentence. But Richards was also devoted to drugs. He was a daily polydrug user and physically dependent on heroin at various stages of his life. In his memoir, Life, he is clear that, although drugs sometimes took a toll on his work and his relationships, they also greatly enhanced both. For Richards, drugs are connected to his creativity and his intensity, to living in a way that squeezes the most out of life. He is also honest about the fact that his wealth protected him from costs that other drug users face. Richards was able to use only the purest and highest quality drugs and to get excellent medical care whenever he needed. By saying that he never had a problem with drugs, I take Richards to mean that whatever the costs of his drug habit—which at times in his life were surely severe—they were in his view worth it. His drug use, despite its costs, accorded with his own set of values—his conception of the good life, for him. His problem was that his values did not accord with those embodied by the law—witness his problem with the police.
What counts as a cost and what counts as a benefit and how much weight to attach to either presupposes a set of values by which they are measured, that is, a conception of the good. One person loves to feel wild and chaotic and out of control—to escape from the rigid confines of their ordinary life and self. This is part of the good life, for them. Another person hates it. Their good life is one of calm routine. Their drug of choice is a nice cup of tea. What for the first is a benefit of alcohol or amphetamines or psychedelics is a cost for the second. But how much does the first person love that feeling of wild abandon—enough to risk their job, their relationship, their health? It depends. How much do they value their job and their relationship and their health? The working explication of addiction as a pattern of drug use that counts profoundly against a person’s own good presses these questions. Which values? Whose conception of the good? And how can we know? Suppose we ask these questions about Richards. We might wonder: Was he right that he never had a problem with drugs or was he in denial?
To answer this question, we must begin by noting a standard but underappreciated distinction between addiction and physical dependence. Opioids, alcohol, and nicotine are classes of drugs that, if taken regularly and at sufficient doses, produce physical dependence: a physiological condition defined by the occurrence of a physical withdrawal syndrome upon sudden abstinence or dose reduction. Richards was certainly, at times, physically dependent on heroin. Withdrawal from heroin typically lasts up to one week, and, similarly to withdrawal from any opioid, can include fever, nausea, diarrhea, aches, cramps, runny nose, watery eyes, insomnia, formication, and more. Opioid withdrawal is not life-threatening. But as this list attests, it is awful to experience. It can be alleviated through medication, including methadone and buprenorphine (themselves opioids), clonidine (a psychiatric medication used to treat pain and hypertension) and over-the-counter medications for symptom relief.
Physical dependence is highly relevant to weighing costs and benefits of drug use. Although the nature and severity of withdrawal symptoms varies with drug class, experiencing withdrawal is a significant cost of not using, and avoiding it a significant benefit of using. Indeed, with respect to severe alcohol addiction, withdrawal can be life-threatening. But physical dependence is neither necessary nor sufficient for addiction. Although there are inevitably psychological effects of sudden abstinence or dose reduction if a person is addicted, various drugs to which people become addicted do not have a physical withdrawal syndrome, for example, cannabis and cocaine. This is why physical dependence is not necessary for addiction. But equally, it is not sufficient, because people can be physically dependent on drugs when we would never consider them to be addicted.
Many psychiatric medications, such as antidepressants, have a physical withdrawal syndrome. Antidepressants are psychoactive. They affect cognition, emotion, mood. Sudden abstinence or dose reduction will cause people to go into withdrawal, which typically lasts between one and three weeks and has symptoms that are similar to opioid withdrawal. Yet we do not consider people to be addicted to antidepressants. Similarly, people who suffer from debilitating pain may be on standing opioid prescriptions. This is a routine part of palliative care but can also be appropriate for some chronic, long-term pain patients. These patients will be physically dependent. In the wake of the US opioid epidemic and widespread recognition that—in large part due to relentless propaganda, manipulation, and incentivization by pharmaceutical companies—doctors had been overprescribing opioids, many pain patients had their prescriptions suddenly discontinued. Overprescription was a terrible problem, but this was an equally terrible response. Sudden discontinuation precipitates withdrawal—as well as the return of debilitating pain—pushing people toward sourcing opioids on the streets to relieve both. It also fails to recognize that a patient who is physically dependent on opioids is not thereby addicted. In the context of debilitating pain, a stable opioid prescription can make it possible to function—to work, to sleep, to have the capacity to be present and engaged in relationships with others, to live a fulfilling life. So too can taking the very same opioid at the very same dose if it is sourced not from a pharmacy but from the streets. With respect to psychiatric medications, we do not consider people addicted simply because they are physically dependent. Similarly, with respect to opioids, we should not consider people addicted simply because they are physically dependent—no matter where the drugs are sourced. This is because, in both cases, drugs can make life significantly better, not worse.
Hanna Pickard is Bloomberg Distinguished Professor of Philosophy and Bioethics and Krieger-Eisenhower Professor at Johns Hopkins University.
