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 “A primer on fentanyl(s)”
Writing about President Obama’s record on drug addiction treatment without mentioning the passage of the Affordable Care Act and the development of the regulations for the Mental Health Parity and Addiction Equity Act (MHPAEA) is analogous to writing about LBJ’s record on health care without mentioning Medicare and Medicaid. But alas, Christopher Ingraham of the Washington Post is the latest journalist to do so. The transformative impact of the ACA and MHPAEA on addiction treatment is not a hard-to-uncover secret. It has been written about extensively in the scholarly literature (see for example here and here) and in the mass media (see for example here and here). But like a number of other journalists, Ingraham critiqued the Obama Administration’s alleged lack of commitment to drug treatment without even mentioning either landmark piece of legislation.
To Ingraham’s credit, he did at least look at some data, which was the budget for federal drug control spending across agencies:
So on the one hand, yes – it’s true that more federal dollars are going toward drug treatment. On the other hand, treatment and prevention account for less than half of federal drug spending, most of which still goes toward law enforcement efforts.
This conclusion rest on the false assumption that an administration’s financial commitment to addiction treatment is equal to federal spending on addiction treatment. But the ACA and MHPAEA are major federal actions that drive private dollars into addiction treatment by improving coverage for over 100 million people with private insurance. Analyzing what an administration has done in any health care policy area without looking at its laws and regulations for private insurance is generally misleading, and is certainly so in this case where none of the private investment is captured in federal drug control budget data.
Health care policy analysts generally see the Obama Administration’s addiction treatment record as the most praiseworthy in at least 40 years, and some journalists (e.g., Jesse Singal) have done a fine job reporting that fact. That does not however make it less disappointing to see yet another misinformed article written as if the ACA and MHPAEA never happened.
My letter to the WSJ about Bill Bennett’s “16.2 million marijuana addicts.”
As predicted, the Wall Street JournalÂ refused to correct the Bennett/White op-ed that strongly implied (without quite stating explicitly) that I believe cannabis legalization would sextuple the rate of cannabis dependence to 16.2 million. (My previous whining about that here.) However, the Journal did publish my letter, with only helpful edits and an accurate headline that’s a pretty good haiku-length statement of the case.
Like the original article, the letter is behind a paywall, so – on the off chance that some RBC readers don’t pay tribute to the Murdoch empire – I’ve pasted it in below.
Legalizing Pot Carries Risks, but So Does Prohibition
To the Editor:
William Bennett and Robert White (“Legal Pot Is a Public Health Menace,” op-ed, Aug. 14) cite my research as support for their claim that the legalization of cannabis would mean creating 16.2 million “marijuana addicts.”
Not only is the attribution false; the claim it purports to buttress is absurd. I made no such prediction, and the idea that legal cannabis could create more addicts than legal alcohol doesn’t pass the giggle test. It would be astounding if the actual number were one-third as high as Messrs. Bennett and White project
Cannabis legalization on the current alcohol modelâ€”low taxes and loose regulationsâ€”would indeed risk a large increase in the extent of cannabis abuse. That is why some of us are working hard for high taxes and sensible regulations on cannabis, as well asÂ stronger controls on alcohol, which is after all a much more personally and socially dangerous drug.
Cannabis legalization in any form will create some harm; every drug policy has disadvantages. But against that must be set the enormous harms from cannabis prohibition: $40 billion a year in illicit revenue, some of it going to violent criminal organizations in Mexico; tens of thousands of people in prison; and more than half a million users arrested each year.
Our goal should be to eliminate as much as possible of the damage from prohibition while minimizing the harms that would result from a badly designed legalization.
An elderly man is found unconscious at the wheel of his idling car in the median strip of a busy interstate. Miraculously, he struck no other vehicle when he careered off the highway. When roused by the police, he blows a blood alcohol level of .18, leading to his third DUI arrest.
A young meth-addicted woman thinks her reflection in a store window is watching her, so she hurls a brick at it. A terrified customer calls the police, who arrest her for shattering the window and spraying the store’s customers with glass shards.
In some people’s eyes, the millions of people like the above examples who come into contact with the criminal justice system each year are dangerous monsters who should be sent away for long prison terms. Others view these same people as helpless and hapless, innocent victims both of a disease and a cruel criminal justice system. From this it follows that the legal system should back off entirely and let health care professionals offer needed treatment.
These two camps argue with each other endlessly, usually in debates about whether society should respond to addicted offenders with punishment OR treatment, whether intoxicated violence should result in accountability and monitoring OR immediate forgiveness and therapeutic support, and whether substance dependence is a public health OR a public safety issue. My own view is that both sides lose every one of these debates, because they have framed the question is a way that makes both permissible answers wrong. People addicted to alcohol and other drugs do indeed suffer terribly; they also do physical and emotional harm to millions of other people each year. Trying to decide whether this population needs help OR whether the rest of us need protection from them is as sensible as trying to decide whether to provide your child love OR limits.
I have long wondered why many intelligent people — even people who have seen the population of interest up close — are so strongly committed to seeing addicted offenders either as villains or victims rather than as a mÃ©lange of both. Cognitive psychology research suggests that it may have something to do with the impact of emotion on perception and reasoning. Continue reading “Why We Struggle to Accept the Dual Nature of Addicted Criminal Offenders”
In his closing contribution to the New York Times, Bill Keller laments President Obama’s unwillingness to invest in drug addiction treatment. It’s a common jab, made by many commentators (see for example here and here).
It is also embarrassingly, verifiably, wrong.
I am sure Mr. Keller and all the other journalistic critics of Obama’s drug treatment record have heard of The Affordable Care Act. Why don’t they know that it expands access to care for over 60 million Americans by mandating that drug treatment coverage be included in every plan and be at parity with that for other disorders? How can they further not know that the Obama Administration’s regulations for the Mental Health Parity and Addiction Equity Act provide benefit parity to more than 100 million Americans with employer-provided health insurance? More generally, how can they not know that independent analysts at CMS consider the current public policy environment the most dramatic improvement in the quantity and quality of addiction treatment in U.S. history?
I submit that Keller and his fellow critics would never confidently make such data-free assertions about cardiology, oncology or indeed any other area of the health care system. But drug treatment, like drug addiction, is a target of great stigma and ignorance. So why bother to take it seriously enough to check your facts like you would with health care for any other group of patients?
I take Keller at his word that he doesn’t want drug treatment to be a third-class part of our health care system. That’s why I feel comfortable asking him to please start taking it seriously himself. Rather than use his platform to make assertions that are demonstrably inaccurate, I hope he will in the future engage in the due diligence any other area of health care would receive from a serious journalist.
Many middle-class parents were appropriately rattled by Ben Cimons’ powerful account in Washington Post of being a “nice suburban kid” who became addicted to opiods and ultimately almost died of a heroin overdose. The desire of people from “good families” to believe that drug problems are confined to low-income urban communities is understandable, but also false — indeed perniciously so.
Ben and I, along with Wall Street Journal reporter Zusha Elinson and Stanford visiting fellow Markos Kounalakis were on Warren Olney’s To the Point radio program last week to discuss how heroin is making a comeback. Among the key themes of the discussion was that the origins of the recent rise of heroin can be traced directly to the recent and continuing extensive availability of prescription opioids.
p.s. I had a brain freeze when Warren asked me for the common trade names of hydrocodone-containing pain medications; I said Lortab but forgot to mention Vicodin.
I had an long and interesting discussion yesterday with Maia Szalavitz about public health approaches to addiction (Her full article is here). One question we kicked around is why extremely troubled street drug users sometimes make dramatic positive changes in their behavior when they come into contact with a needle exchange site or a mobile methadone van or a Salvation Army treatment program.
Mark Kleiman and I have gone back and forth on this many times, with each of us leaning toward different explanations.
Mark emphasizes the role of self-command in behavior change. His hypothesis: People who feel defeated by life at every turn gain confidence when they are taught a masterable skill (e.g., how to clean a needle to prevent HIV infection). When they thereby come to understand that they are not utterly hopeless and incompetent, they feel more confident that they can engage in other positive behaviors that have previously intimidated them (e.g., finding a place to live, enrolling in a methadone maintenance program).
Mark’s theory is entirely plausible, but I tend to lean towards a different view. People are more prone to take care of themselves if they think that others care about them. If you are using drugs and sleeping rough, you can go through long periods where no one expresses any feelings toward you other than contempt, disgust or hostility. In contrast, when a stranger stretches an open hand into the cold night and offers to help you, it communicates something markedly different: You have worth. Knowing that you are not worthless after all provides a motivation to try to make changes that will improve your health and well-being.
Mark’s theory focuses on how people change (the mechanism), mine focuses on why they do (the motivation). Both explanations could be true, or more or less true for different sorts of people. They could also of course both be wrong, but that would in no way diminish my admiration for those people who, night after chilly night, extend their hand to those in dire need.
In our recent discussion at Washington Post’s Wonkblog, Harold Pollack and I talked about the astonishing scale of prescription opioid consumption in the US, which has no parallel anywhere else in the world. Americans consume 99% of world’s supply of hydrocodone, with the rest of the human race accounting for only 1%. Each year, U.S. health care professionals write more prescriptions for opioids than there are adults in the country.
Some of this prescribing has unquestionably been a blessing to people in pain. Some of it has however been highly destructive. Sally Satel highlights one of the adverse consequences of flooding the country with prescription opioids:
According to the 2012 National Survey on Drug Abuse and Health, four out of five new heroin users had previously abused painkillers.
The recent surge in heroin use is thus fundamentally different from its 1970s precursor. Its seeds were planted not in Southeast Asia but in doctor’s offices, emergency rooms and pill mills all across the country.
As policy makers focus attention on the resurrection of heroin in American life, they should remember that it remains a small problem compared to the painkiller addiction epidemic that fomented it and is still doing so: Deaths from legal prescription opioids exceed those from heroin by a factor of five. If we want a lower prevalence of heroin addiction five years from now, we should be looking upstream at policies that will combat the mis-marketing, mis-prescribing, diversion and abuse of prescription opioids.
In some users, yes. Now the question is what to do about it as we make cannabis legal.
My dad will never stop smoking pot. Sometimes I wonder about the man he might have been, and the lives we all might have had, if heâ€™d never started.
As I keep saying: the evils of prohibition do not disprove the evils of substance abuse. In the case of cannabis, it’s probable that we could get rid of the former without greatly increasing the latter. But it’s not automatic. And denying that cannabis abuse is a real problem doesn’t help.
Note how the mythology of “addiction” cultivated by the “drug-prevention” effort and the drug-treatment industry interferes with understanding. Most drug abuse is very unlike the horrible picture painted in the linked story: it’s relatively transient. And most people who use “addictive” drugs don’t get addicted to them; substance abuse happens to only a minority of users, and only a minority of abusers actually have the “chronic, relapsing disorder” touted as typical. Bad habits around drug-taking are like other bad habits: they lie along a spectrum, and not everyone who uses a drug that turns out to be habit-forming in others encounters a problem.
But if you have the problem, or your brother, or your son, or your mother, it’s a serious problem. And the risk can’t just be wished away. If you support making cannabis available from profit-seeking commercial vendors, heavily marketed, and cheap – which is the path Washington and Colorado are walking down right now – then the predictable result of your preferred policy will be more people with very bad cannabis habits. And there could be fewer such people if cannabis were kept expensive, if marketing were kept to a minimum, and if users were offered modest helps to their self-command, such as user-set periodic purchase quotas, or if we keep the commercial motive out of the business altogether with state stores or by limiting vendor licenses to consumer-owned co-ops and not-for-profit businesses with boards concerned with limiting drug abuse rather than maximizing revenue.
Of course you’re free to oppose all of that. But if you do so, you ought at least to acknowlege the inevitable human cost.
Update Comments closed due to persistent trolling, using multipe IPAs. I may start to follow Keith’s lead. Alterantively, we could go to some sort of registered-commenter system. Sorry, folks, but I suppose if you have a picnic you have to expect some cockroaches.