A number of correlational studies have shown that at the individual level, cannabis use is positively associated with opioid use, misuse, and addiction, whereas at the state level, availability is negatively associated with opioid prescriptions and overdose rates. Many people have responded to this ambiguous situation by asserting that the correlations which fit their marijuana politics represent rigorous causal evidence and those that don’t are just correlations, nothing to see here, let’s move on.
Assuming you actually wanted to know the answer about whether cannabis and opioids are substitutes, and saw science as a tool to learn things rather than prop up your ideology, what would be a rigorous way to test the question? Experimental designs are tough to implement because of the ethical issues surrounding introducing people to addictive drugs. However, my colleague Beth Darnall and I lay out a strategy in the current issue of Addiction that doesn’t present this ethical quandary.
Millions of people are taking prescribed opioids long-term and many of them want to reduce their dose or stop taking them entirely. Tapering protocols have been developed to help such people. Critically, a significant number of these people also use cannabis.
This presents an opportunity: Run a randomized clinical trial on such individuals who are interested in tapering opioids and also measure what happens to their cannabis use if their opioid use changes. Beth did this is a small tapering study which didn’t have the power to assess effects rigorously but demonstrated proof of concept (FWIW, three people quit marijuana use, all of whom had also quit opioid use). With support from PCORI she has now launched a much bigger study in which this question can be addressed within a multi-site randomized trial of opioid tapering.
This isn’t the only route to pushing the science in this area. Ziva Cooper at Columbia is doing inventive experiments on the interaction of opioid use, cannabis use, pain, and drug liking. It’s an intriguing area and good science will out, even if only a minority of people are willing to accept the results whatever they are.
Lenny Bernstein of Washington Post moderated this panel with Vanda Felbab-Brown, me, and Pagan Harleman. The audience and panelists had just watched the first episode of Pagan’s Showtime documentary series The Trade.
The synthetic opioids – usually referred to both in the press and by law enforcement as “fentanyl” – have now outstripped not only the prescription opioids such as oxycodone but also heroin in terms of overdose deaths, and (as you can see below) the trend line is almost vertical.
Keith Humphreys warns of “fentanyl’s potential to permanently alter illegal drug markets.”
Kevin Drum asks about the causes of the change: “Fentanyl has been around for a long time, and only recently has its use become widespread. Why?”
Why, I thought you’d never ask. Settle back; this is a complicated story, and it’s going to take a while to tell. But Keith is right: this is a BFD. So it’s worth understanding. Continue Reading…
There’s been lots of chatter about the cannabis-opioid substitution question.
People whose background is medical research tend to distrust anything that’s not a randomized controlled trial. They point to the positive correlation between cannabis use and opioid use at the individual level, and the fact that opioid deaths continue to rise even where cannabis is most freely available. Their position is, “We don’t know anything about this. Let’s due the clinical studies before taking action.”
But “not taking action” now means continuing to criminalize even the possession of cannabis. If cannabis substitutes for opioids, those laws cost lives: lives that can’t be regained ten years from now, after the clinical-trial results are in.
Moreover, the relevant clinical trials can’t actually be done in the U.S. Continue Reading…
Cary Coglianese and Nancy Nord of the University of Pennsylvania Law School organized a panel called “The Cannabis Conundrum: An Experiment in Federalism or States’ Rights Run Amuck?” with Peter Conti-Brown of Wharton talking about banking regulation and Judge James Colins of the Commonwealth Court talking about a case brought against the Commonwealth by some unsuccessful applicants for growing and distribution licenses under Pennsylvania’s new medical-marijuana program. I’m on (from about 9:45 to about 26:45, aka “too long”) talking about how the states are screwing up legalization and only federal legalization can unscrew it.
Today I had the pleasure and honor of testifying before the Foreign Affairs Committee of the Canadian Senate. It really was a pleasure; the Senators asked precise and perceptive questions and avoided speechifying.
In my oral presentation, I stressed the idea that cannabis prohibition is no longer operationally feasible in the U.S. or Canada, and that we can get the drug under better control if we recognize that fact and create a well-designed system of legal availability, where by “well-designed” I mean a system crafted to provide convenient access to safe and properly labeled cannabis for moderate use by adults, without creating either a commercial industry or a revenue-hungry public enterprise. Any entity devoted to making money from cannabis sales will by its nature be devoted to the spread of cannabis use disorder, since temperate majority of cannabis users are of little commercial value compared to the minority of very heavy users, who account for more than 80% of sales.
Full text after the jump.
Iâ€™ve been puzzled why Richard Thalerâ€™s â€œnudgeâ€ idea attracts such hostility from some people to my political left (including very smart people such as Henry Farrell and Cosma Shalizi). The worst thing you can say about nudging as I understand it is that it’s not very powerful; other than that, nudging is like chicken soup: it can’t do any harm.
So Iâ€™m grateful to Tyler Cowen for clarifying matters for me. Either Cowen or I badly misunderstands Thalerâ€™s idea; if Cowen is right, you can add me to the list of anti-nudgers. But Iâ€™m pretty sure the Cowen is wrong about what Thaler says, and certain that his account confuses things that ought to be distinguished.
Nudging, as I understand it, involves changing â€œchoice architectureâ€ â€“ altering the way options are presented or the time choices are made, or changing the â€œdefault outcomeâ€ if no option is explicitly chosen â€“ in order to bring peopleâ€™s actual choices more closely in line with their true preferences, as measured by the choices they would make with full information after serious reflection. That is, nudging is simply the opposite of temptation.
One of the defining features of a nudge (understood this way) is that it doesnâ€™t narrow the range of outcomes available to the chooser. For example: presented with a menu of retirement-savings options, many employees will pick none of them, in part because of the psychological costs of decision-making and the fear of getting it wrong (“analysis paralysis”). This can be true even in the case when inaction is clearly the worst option (e.g., when the employer is picking up all of the cost). In that case, a nudge strategy would be to make enrollment in the plan that seems to experts most appropriate for the largest number of employees the default option: i.e., what happens if an employee just doesnâ€™t fill out the form.
Crucially to the definition of a nudge, an employee who doesnâ€™t want that option can costlessly (other than the effort of making the decision) switch to another, or none at all. As long as thereâ€™s no deception involved, and the people designing the choice architecture know what theyâ€™re doing and have the welfare of the people making the choices in mind, nudging seems to me almost entirely benign. A program that doesnâ€™t limit freedom of choice canâ€™t properly be said to reduce liberty, so replacing â€œopt-inâ€ with â€œopt-outâ€ should be thought of as facilitative rather than coercive. The same is true of, e.g., putting the salad bar first in the cafeteria line.
However, Cowenâ€™s understanding of nudgery has a much harder edge. He gives examples where a choice less preferred by the government (or whoever is setting up the system) is made materially less attractive or more expensive, such as legally complicated and expensive divorce procedures, or abortion restrictions that force women to travel inconvenient distances. Cowen even wants to call restrictive immigration laws â€œnudges,â€ because would-be immigrants who canâ€™t get visas can always forge documents or sneak across the border!
In my view, that sort of cost-imposing policy is radically distinct from â€œnudging;â€ Steve Teles calls it â€œshoving.â€ I donâ€™t doubt that some such â€œshovesâ€ are justified on paternalistic grounds: taxation to reduce cigarette consumption is an example. (Shoves are often justifiable on non-paternalistic grounds, such as taxes to reduce air pollution.) But such strategies arenâ€™t always benign; people who keep smoking in the face of heavy tobacco taxes wind up just as sick as they would have otherwise, and poorer. And of course for those with limited means making something expensive can amount to barring it entirely.
Now, I agree with Cowen that the â€œshovingâ€ for paternalistic reasons he wants to label as “nudging” is often preferable to more drastic means of protecting people from their own bad decisions: means that we might call â€œmanhandling.â€ A tax on cigarettes is more respectful of liberty, and less prone to generate bad side effects, than an outright prohibition would be. But â€“ in contrast to nudging â€“ shoving is like manhandling in making those who donâ€™t take the hint worse off. Changing incentives isnâ€™t the same thing as changing choice architecture, and requires much stronger justification.
Nudging is no panacea, because changing choice architecture can only go so far in changing choice. Some people will continue to fall into behavioral traps even if the traps are clearly marked. And when the intervention is on non-paternalistic grounds, a considerable amount of shoving, or even manhandling, may be both justified and required. But there is clearly some room for improving outcomes at low cost and without diminishing liberty from the use of pure nudges. Itâ€™s therefore worthwhile to distinguish clearly â€“ as it seems to me Cowen’s analysis does not â€“ between generically benign nudges and the less benign alternatives he wants to include under the same label.
Many thinkers have analyzed the relationship between the person we are right now and the person we will become. A young Tom Schelling habitually went to bed without blankets only to wake up hours later as “cold boy” who cursed “warm boy’s” earlier decision but could not stop the next day’s warm boy from making the same decision again. Derek Parfit wondered why we save for retirement, given that the person we are 40 years from now might as well be a stranger to us.
In behavior change, the difference between the current and future self can be observed in the gym every January. Early in the month, resolution makers crowd the place, but within a few weeks their future selves will have undone their earlier resolve.
Probably no group of people struggle with this duality as much as those who are addicted to alcohol, nicotine, and other drugs. I write about their experiences and what new pharmacology can offer them — a chance to bind their future selves — today in STAT/Boston Globe.
It’s not “carnage,” and it’s not a reason to panic or adopt cruel, stupid policies, but it really isn’t good news.
Yes, year-to-year homicide rates are statistically noisy, especially at the city level, because homicide is a relatively rare event. But an increase of roughly 20% over two years isn’t just statistical noise. And though there are indeed dramatic increases for identifiable local reasons in places such as Chicago, that’s not what’s driving this train: the 2016 increase showed up in small tows as well as big cities. [Update: Robert VerBruggen makes a key observation: white-on-white homicide rose more in percentage terms than black-on-black homicide.]
But the real reason to be concerned isn’t that homicide has gone up for two years in a row; it’s that it was flat in the two previous years, pretty clearly breaking the 20-year downtrend starting in 1994. Yes, even after two bad years, we’re much better off than we used to be. But even at 5 homicides per 100,000 – about half the 1994 rate – our current rate is three times the Canadian rate, five times the UK rate, and ten times the Norwegian rate. That’s nothing to write home about. Getting the homicide rate moving back down ought to count as an important national goal.