The House Oversight and Government Reform Committee held a hearing this week about the re-authorization of the White House Office of National Drug Control Policy, which understandably ended up being as much about what to do about the still-exploding epidemic of opioid addiction and overdose.
Video from C-Span below
Professor Ekow Yankah and I were interviewed on Detroit Today by Stephen Henderson. The subject was why the country took a different approach to the current opioid epidemic than it did to the crack cocaine epidemic.
You can listen to the show here. This is a brief summary of my own analysis of why we have had a more public health-oriented response this time around.
1. The opioid epidemic is afflicting white people and middle class people more heavily than did the crack cocaine epidemic. Historically, the country has tended to attribute addiction among oppressed groups as an indicator of moral failing worthy of punishment. That was certainly the dominant perspective on the crack cocaine epidemic in Black communities in the 1980s, which was met with a ferocious law enforcement response. But when a drug epidemic happens among white people (especially white people with economic resources, as Adam Gelb pointed out to me on Twitter, we were not particularly kind to dirt poor white meth-addicted people in the 1990s) the framing of the problem is more sympathetic and the response is much more oriented towards help than discipline.
Ekow made this point beautifully on PBS News Hour recently, and I find particularly powerful his description of how bittersweet the policy change is for Black Americans.
2. The crack cocaine epidemic had enormous associated violence. I was at ground zero on Detroit’s Cass Corridor during the epidemic and it was a frightening place. The violence came about in part from dealers shooting it out, but a lot of it was pharmacologically driven (e.g., people high on cocaine losing their temper and hurting or killing someone). Terrified by all that violence, both blacks and whites demanded tough enforcement and punishment.
The opioid epidemic has been far less violent. Much of the supply came from people who carry stethoscopes rather than guns, and pharmacologically, opioids usually have a sedating effect rather than making people aggressive. Less violence translates into less fear, increasing the likelihood of a more compassionate response.
3. An increasingly successful treatment/recovery movement has achieved major political victories supportive of public health responses to addiction (e.g., the 2008 parity law that expanded access to treatment). You can’t accuse those activists of doing their good work just with whites in mind because they’ve been at it since long before the current epidemic started. They have made a significant difference culturally and politically, and they have benefited addicted people of all races in the process. Good on them, they’ve earned their place in heaven.
We often hope that technology can save us from the work of behavior change or the reality of hard choices, and sometimes it can. Currently, the pharmaceutical industry is trying to carry off such a magic trick by developing reformulated pain medications that cannot be misused.
Will it work? I address that question in my latest Washington Post Wonkblog.
As one would expect in an era of increased legalization and decriminalization, court referrals to marijuana addiction treatment are dropping like a stone. But for a reason that may surprise you, the number of people seeking marijuana addiction treatment is not going down overall.
To find out why, see my latest Washington Post Wonkblog.
As states struggle with what to do about marijuana impaired driving, a new study from Johns Hopkins University makes things even more complicated. Study subjects consumed cannabis by eating it rather than smoking it, after which the research team assessed whether grossly impaired subjects would meet the legal standard of 5 ng/ml of blood THC.
The results were both surprising and disturbing, as I explain in my latest Washington Post Wonkblog.
Three years after the Pennsylvania Supreme Court ruled the state’s mandatory sentencing laws unconstitutional, the state’s DAs and some of the other usual law-‘n’-order suspects managed to get a bill restoring them (even the “school-zone” mandatory, which I thought went out with disco) through the state’s House of Representatives. Today the Judiciary Committee of the State Senate held a hearing on the question.
My prepared remarks are below, after the jump. My oral presentation was somewhat less restrained; after two hours of listening to people assert that objecting to cruel and ineffective punishment proposals must reflect an indifference to the suffering of crime victims, I pretty much lost it: Without raising my voice, I pointed out that the vaunted capacity of prosecutors wielding the threat of long mandatory terms to convert lower-level offenders into “cooperating” witnesses against higher-ups faced the same logical and moral objections as using the threat of torture for the same purpose: the incentive to testify is just as strong for false testimony as for true testimony. If it’s obviously immoral to threaten to break someone’s arms if he won’t testify, and if spending five extra years behind bars is worse than having your arms broken, then why is it considered OK to exact testimony under the threat of an additional five-year prison term?
The broader point is, I think, straightforward. You can decompose the question of mandatories into two sub-questions:
- Would it be a good idea to have more prisoners than we have now?
- For any given number of prisoners, will a system of mandatory sentencing – especially for drug offenses – do a better job of crime control than letting the judges decide?
In each case, it seems to me, the answer is obviously “no.” The case on the other side consisted entirely of insisting that crime was a very, very bad thing and ignoring the notion that sentencing has opportunity costs.
I had lots of good company, including Al Blumstein of Carnegie Mellon, John Wetzel and Bret Bucklen of the Pennsylvania Department of Corrections, former Philadelphia police commissioner Charles Ramsey (now chairing the Pennsylvania Crime Commission), and Kevin Ring of FAMM. I thought the good guys clearly won the debate on points; who has the votes is, of course, a different question.
Video here. My piece starts at Minute 114. (Look for the thumbs-up from Al Blumstein when I’m done. Made my week.)
The distinguished drug policy researcher Brendan Saloner, produced this letter at change.org defending medication-assisted therapy after HHS Secretary Price criticized treatments such as methadone and Suboxone as “just substituting one opioid for another.”
Six hundred of us in the field signed the letter (see below). The Secretary’s comments are inconsistent with scientific consensus, summarized in this year’s Surgeon General’s report on addiction, supporting MAT as a first-line treatment for opioid disorders: to prevent overdose, to reduce criminal offending, to prevent HIV transmission, and more. Over the past several months, my colleagues and I have been researching state approaches to substance use disorder treatment across the country. Democrats and Republicans across the political spectrum have worked effectively to expand access to medication-assisted therapies. Secretary Price’s comments are not representative of this consensus.
Secretary Price’s comments were also part of a larger pattern that alarms many members of the medical and public health communities. As a recent editorial put things in the New England Journal of Medicine,
[Secretary] Price has sponsored legislation that supports making armor-piercing bullets more accessible and opposing regulations on cigars, and he has voted against regulating tobacco as a drug. His voting record shows long-standing opposition to policies aimed at improving access to care for the most vulnerable Americans. In 2007–2008, during the presidency of George W. Bush, he was one of only 47 representatives to vote against the Domenici–Wellstone Mental Health Parity and Addiction Equity Act, which improved coverage for mental health care in private insurance plans. He also voted against funding for combating AIDS, malaria, and tuberculosis; against expansion of the State Children’s Health Insurance Program; and in favor of allowing hospitals to turn away Medicaid and Medicare patients seeking nonemergency care if they could not afford copayments.
I’ll just leave things there. The change.org letter appears below the fold.
Today I have the honor of participating in a service at Westminster Abbey in which we will grieve the lives lost to addiction while also supporting the families who have experienced it. The event is organized by a charity known as DrugFam, which was founded by a remarkable woman named Elizabeth Burton-Phillips. Elizabeth’s twin sons both became addicted to heroin, and only one them survived. She tells this moving story in her book Mum, can you lend me twenty quid?, which I commend to you.
As the 2000 people come to the Abbey today, there will be for each a brochure on the pews which contains the message below. If this message or issue resonates with you, I hope you will consider supporting the work of DrugFam (donation link here).
Addiction never truly happens to just one person. Mothers, fathers, brothers, sisters, and children are pulled into the pain and destruction that addiction to alcohol and other drugs can cause. Many of the emotions addicted people feel – hopelessness, shame, sadness – are also visited on the hearts of everyone who loves them. As family members understandably focus intently on saving the life of the person they love, they sometimes forget that they too are suffering and need help of their own. That’s why the support, compassion, and understanding that DrugFAM provides families is so important.
Today we come together to recognize the terrible damage of addiction and to memorialize the lives of those we have lost. We all need to grieve these enormous sorrows in our own time and way. But though this may be a day with some tears it is not a day of despair, but of hope. We have hope because we recognize that recovery from addiction is a reality that tens of millions of people around the world, including in this very building, are living today. We also know that many families facing addiction who seemed on the brink of destruction received the help they needed and as a result are thriving, loving, and strong today. By bringing addiction out of the shadows as we are doing here — making clear that the lives of addicted people are lives worth talking about — we are giving countless other families who have been too afraid to reach out the precious assurance that we are here for them.
Addiction isolates. It cuts off from society the person who experiences it and the families who struggle to help them. The community of fellow sufferers – the people who have “been there” — is the best remedy for this isolation, and the beginning of healing. As we come together today, we will be strengthened by that fellowship and can go forth from here freshly charged to bring comfort and understanding to families facing addiction.
This Monday the friends, colleagues, family, students, and disciples of Thomas C. Schelling gathered at the Kennedy School to honor his memory. The speakers included his eldest son (Andrew Schelling), the current dean of the school (Doug Elmendorf) two former deans (Graham Allison and David Ellwood), and an academic all-star cast including Mort Halperin, Richard Zeckhauser, and Glenn Loury. Somehow I was also asked to speak.
I didn’t speak from a text, but what follows is a version of what I said, “revised and extended,” just like the Congressional Record.
The dome of St. Paul’s cathedral marks the center of the City of London – a cathedral, and a city, both rebuilt after the Great Fire thanks largely to the energy and genius of Christopher Wren. On the floor directly below the dome appears Wren’s obituary, which concludes: “Si monumentum requiris, circumspice” – “If you’re looking for his monument, look around you.”
Here in the Forum of the Kennedy School, one can say the same thing of Thomas C. Schelling: his monument is all around you. Not the buildings, but the school itself as an institution, the idea it embodies, and all of us and all the others who came together around that idea are Schelling’s monument. The city of Cambridge, among many other cities, also forms part of that monument, since without Schelling’s wisdom about how to avoid nuclear war it might well be a heap of rubble glowing in the dark.
As to the more local monument: Schelling did not re-form the Littauer School of Public Administration into the Kennedy School of Government all by himself. A whole catalogue of giants in that founding generation – Richard Neustadt, Francis Bator, Howard Raiffa, Fred Mosteller, Phil Heymann, and Edith Stokey – helped to start the work. The second and third generations, home-grown or recruited, who carried on the project here and elsewhere, included – in addition to those who have spoken here today – Mark Moore, Mike Spence, Mike O’Hare, Al Carnesale, Ronnie Heifetz, Bob Leone, Michael Nacht, Bill Hogan, Bill Clark, Dutch Leonard, and Ash Carter.
But though Schelling did not act alone, the power of his mind and the force of his personality were indispensable in convoking this community. To cite my own example among many: as a college senior, I was interrupted on my way to law school by reading “On the Ecology of Micromotives,” which introduced the “tipping” idea with its famous checkerboard model of how residential segregation could emerge, almost inevitably, in a population where everyone prefers integration but no one wants to be part of a small local minority. I went to Holland Hunter, the chair of the Haverford economics department and my mentor, and said “I have to learn how to do that.” Ho chuckled and said, “Well, Schelling teaches at the Kennedy School.” I said, “The where?” And I’ve never looked back.
Among the giants of his generation, Schelling was foremost in creating the idea of public policy analysis as a discipline of thought, distinct both from public administration and from the social sciences: a pragmatic discipline focused on the question “What course of action, in these circumstances, would best serve the public interest?”
Of course, Schelling wasn’t only a policy analyst: he was a social scientist of towering stature, the sort of person whose Nobel Prize led people to say not “Really?” but “About time!” Others today have mentioned his contribution to the understanding of strategic interaction, and the role his concepts of imperfect self-command and strategic self-management played in starting what became “behavioral economics.” But the Schelling idea that hit me hardest was the tipping model, and the more general principle of paying attention to the importance of positive feedbacks in the choice of problems to work on.
Reading Schelling on micromotives teaches you to avoid the Sisyphean problems – where, once you’ve pushed the stone up the hill, the power of negative feedback will roll that stone right back down over you on the way to its equilibrium – and to choose instead the exciting positive-feedback situations where a nudge might get the stone over the crest and moving of its own accord down to a much better place on the other slope, or the dangerous positive-feedback situations where a little effort in the right place and at the right moment might keep the stone from rolling irretrievably over the brink. All of my work on focused deterrence in law enforcement is the application of that bit of insight; the book that resulted forms part of Tom’s monument.
In the economics course Tom and Francis taught us as first-year MPP students, we learned many important things explicitly: for example, that an obviously pro-consumer ban on surcharges for using credit cards and an obviously anti-consumer ban on discounts for cash are, in fact and in truth, identical policies. That pointed to the general rule: Ignore the label on a policy, and ask instead about its results.
But Tom taught us even more vital things by his example:
- to use models without being used by them;
- to see the humor in serious situations, and look for the apparent paradox that might make sense of a situation and point toward a solution;
- to be prepared, and willing, to be surprised by the way the analysis comes out, or by the way the real-world situation stubbornly refuses to behave as the analysis says it ought to behave; and
- to embody clear thought in clear speech and clear writing.
Though he never would have put it in these terms, Tom taught us policy analysis not merely as a discipline in the academic sense but as a yoga, an intellectual and moral self-discipline requiring difficult feats of non-attachment: to self-interest, to group interest, to factional loyalty, to received opinion, to one’s own policy prejudices, and – most of all – to the need to have been right in one’s earlier views. No force in the world – not greed, not envy, not party spirit, not even cruelty – does as much damage as the inability to say, without too much discomfort, “I was completely wrong about that; good thing I’m smarter now.”
By his example, Tom also taught us to pursue questions not for their abstract interest but for their practical significance. He was disappointed when I chose to write my dissertation on cannabis policy – where I was convinced I could see the right answer – rather than on cocaine policy, where the stakes were much higher but the right set of policies seemed much harder to find.
That principle led him to choose smoking as the new focus of his attention once his insights about preventing nuclear war had largely been incorporated into the thinking of decision-makers. Tobacco wasn’t a “Schellingesque” problem, ready to fall apart at the touch of a brilliant insight. There is no analogy in tobacco policy to second-strike capacity or focal points or the threat that leaves something to chance. No, Tom chose tobacco simply because it was and is the leading preventable cause of death in the developed world, and a growing problem in the developing world, with tens of millions of lives at stake, and he was convinced that thinking hard about it would help point policy in the right direction.
The same was true of global warming. As Tom freely acknowledged, economic and strategic analysis were only two among the two dozen disciplines needed to address that question. He picked it up not because he saw the answer but because the problem was interesting and hard, and because the consequences of getting it wrong – either ruinously over-investing in fending off what might be a phantom threat, or under-investing and failing to control warming before it becomes self-sustaining, or combining the two errors by adopting expensive but ineffective control policies – might be so disastrous.
In both of those cases, he demonstrated his willingness to follow the analysis where it led, even if it led him away from his old allies. With respect to tobacco, he followed Nietzsche’s advice to “depart from one’s cause when it triumphs.” Having labored mightily to put the health harms of smoking front and center in policy discourse and to break the political power of the tobacco industry, and having helped demonstrate the futility of low-tar-and-nicotine cigarettes as harm-reduction measures, Tom later formed part of a distinct minority willing to speak out against what had become a rigid tobacco-control orthodoxy on behalf of the less dangerous non-combustion forms of nicotine administration, including “vaping.”
On global warming, he started out in the camp of the skeptics: not skeptical about the human contribution to climate change, but somewhat skeptical about what seemed alarmist views of how bad things might get and deeply skeptical both about the capacity of initiatives such as the Kyoto Protocol to control the problem and about the feasibility, constrained by international politics, of mounting the massive coordinated effort that might be required to keep greenhouse-gas levels below what some climate scientists regarded as intolerably dangerous levels. He hoped that geoengineering approaches and measures to adapt to whatever climate change did occur might reduce the magnitude of the required economic adjustments.
But as the temperature data continued to come in, and as sailboats began to ply the Northwest Passage through waters once utterly ice-locked, Tom parted company with the “Copenhagen Consensus” group and started to call for more vigorous action, on the theory that changes in relative prices – especially if phased in – were likely to be easier adjust to than rising sea levels and shifting and rainfall patterns.
From the outside, it was hard to see the influence Tom Schelling wielded over those of us who followed him, without ever handing out orders. Once, in a conversation with Mark Moore about something Mark wanted me to do or not to do, contrary to my inclination – I can no longer remember the original topic, about which Mark was probably right – I defended my intentions by saying, “Mark, you don’t understand; I always wanted to be Tom Schelling when I grew up.” He replied, “What you don’t understand is that everyone in this building wants to grow up to be Tom Schelling.”
Well, Tom is no longer with us, and neither is that unforgettable smile. So it’s time for the rest of us to grow up and get back to building the monument.
Here’s an earlier tribute to Schelling, from the memorial service at the University of Maryland.
Schelling’s most famous book, and the one most likely to be read 500 years from now, is The Strategy of Conflict. Micromotives and Macrobehavior is a similarly stunning achievement, centering around “tipping” phenomena. The best introduction to Schelling’s thought for the non-specialist is probably the collection of essays called Choice and Consequence; the two essays on “self-command” reflect his role in founding behavioral economics.