Saturday, January 23, 2016

Do Recent Events Support Drug Prohibition?

Do those recent events refute drug policy libertarianism?

The number of drug-related poisonings is up dramatically over the past 15 years, and much of the increase appears to be attributable to prescription opioid painkillers and benzodiazepines. Very recently, heroin related poisonings have shot up. Very, *very* recently, fentanyl poisonings have shot up dramatically. (Fentanyl is reflected in multiple cause of death code T40.4, “Other Synthetic Narcotics”, a category that actually includes a few other drugs. There’s a steady increase in T40.4 deaths over the past 15 years, then a sudden surge in the 2014.)

Supposedly these recent trends prove that we need to be tough on drug use. If this viewpoint is correct, those recent trends refute drug policy libertarians who believe partial or full legalization can occur with little or no negative consequences. There are stronger and weaker versions of this viewpoint, so I’ll deal with the stronger and better articulated version. It goes something like the following: “The recent increase in drug poisonings is a result of relaxing constraints on prescription opioids, along with other potentially dangerous medicines such as benzodiazepines. This proves that there is a very large demand response to relaxing prohibition, contrary to what drug-libertarians believe. Prescription painkiller users can’t handle their shit, so they pop so many pills that they overdose. We would have saved ourselves these overdoses if we’d stuck to our guns on strict prohibition. The taste for opioids whetted the appetite for something stronger, and in very recent years we have seen a heroin epidemic. This refutes the drug-libertarians’ belief that people will always stick to the low-concentration versions of a drug when given the choice. Weak drugs are indeed a ‘gateway’ to stronger drugs.” In this narrative, a supposedly lax policy toward painkillers led to a huge increase in deaths, and an unforeseen side-effect of people moving to even more dangerous drugs. There are many assumptions and assertions in here to unpack. Overall I don’t find it a convincing story at all. It’s not a good description of what’s happened in the recent past.

Have constraints on prescribing painkillers slackened recently?

The above narrative would be credible if there had been a recent relaxation in controls on painkillers, but that’s not the case. If anything the opposite is true. There were some very high-profile prosecutions of pain doctors in the early 2000s, which is just around the time the increase in overdose deaths started happening. The DEA really started going after doctors who (supposedly) prescribed too many painkillers. These events even got the attention of the National Association of Attorneys General, who sent a letter to the DEA in 2005 telling them to cool their jets. Still, the DEA’s actions had a cooling effect. The early 2000s, when prescription opioid overdoses started to rise, was an era where doctors were increasingly paranoid about prescribing painkillers. Whatever caused the rise in painkiller use, it certainly wasn’t federal drug policy. This is consistent with a major tenet of drug libertarianism: usage rates increase and decrease over time of their own accord; government policy has little effect on these trends. 

One can speculate about why prescriptions rose despite an apparent crackdown. Did pain specialists retire or stop practicing, and naive primary care practitioners pick up the patient load? Did primary care practitioners prescribe more recklessly? Were they more easily manipulated by drug “seekers”? If so, than the recent rise in painkiller prescriptions is, if anything, a negative consequence of strict drug prohibition. In this case recent events refute strict prohibition, not drug-libertarianism. Or maybe the DEA got slapped back so hard by the Attorneys General and doctors’ lobbies that they backed off entirely, in which case there really *was* a slackening of government policy. But then why were painkiller overdoses rising up until 2005, when the Attorneys General sent their letter to the DEA? I’m really not sure what happened, but it definitely looks like there was an official crackdown at exactly the time that painkiller use started to explode.

Does the availability of low-dose drugs satisfy or merely whet the appetite?

The other piece of the above narrative, that low-dosage painkillers whetted the appetite for harder stuff like heroin, is highly speculative. A major tenet of drug policy libertarianism is that users will opt for the softer, low-dose version of a drug whenever possible. We have decades’ worth of observations on this point, and it appears to be *mostly* true. Bolivians chew the coca leaf, while drug smugglers prefer the more compact powdered cocaine. People preferred beer and wine before and after alcohol prohibition in the 1920s, but they preferred hard liquor during prohibition because its compactness made it easier to distribute. When given the chance they stick with the leaf and the beer. They don’t inexorably escalate to crack and bourbon. Prohibition drives people do the hard stuff; liberalization leads people to the softer stuff. Recent events may actually bolster this point. If the recent leveling-off of prescription painkillers is due to a law enforcement crackdown (I confess I don’t know the real cause), that would cause some of the former abusers to substitute toward heroin. Some of the recent overdoses are due to fentanyl poisoning. Fentanyl is so powerful in such low doses that people have OD’d from handling the drug in the production process, and illegal suppliers have been spiking their heroin with it. These overdoses are almost entirely avoidable. Quite a lot of harm reduction, precluded by a prohibition regime, would be possible in a legalization regime. In a legal market, doses can be specified, advertised, regulated, standardized, titrated to the user’s tolerance, tested for impurities (like freaking fentanyl), etc. That’s not to say there would never be any overdoses, but there would almost surely be fewer.

Another point to consider is that our long-standing policy of drug prohibition has pushed people toward drugs with higher toxicity, away from drugs that aren’t very dangerous. No marijuana overdose has ever killed anybody, a fact that is widely known by potheads and admitted even by many staunch drug warriors. LSD, while a potent psychedelic at low doses, has no known lethal dose. Other psychedelics are similarly non-toxic. MDMA, Ecstasy, is also very non-toxic compared to other drugs. (No, it doesn’t cause you to burn up from a fever or turn your brain into Swiss cheese.) Many of these are potentially therapeutic. So while a very limited view of the past 15 years might superficially indicate a failure of drug libertarianism, under a longer-term view drug prohibition has pushed people toward more dangerous drugs. I’ll admit that this is *a bit* speculative; we don’t know if recreational opioid users and recreational pot smokers (or LSD or MDMA or psylocybin users)   are the same people. But there does seem to be a great deal of substitution; when one drug becomes unavailable people switch to something else. Insofar as we’ve missed the opportunity to direct people to safer, non-toxic recreational drugs, we’ve missed a chance to save lives.

Is the recent surge in overdose deaths attributable to drug addicts and recreational users?

An implicit assumption of the “recent events refute drug libertarianism” narrative is that most of the recent increase in painkiller use is actually misuse by addicts or recreational users. That assumption appears to be contradicted by the SAMSHA and Monitoring the Future surveys, which do not show any increase in the illicit use of pharmaceuticals . As I’ve written in previous posts, many of these deaths are accidental drug interactions by unwary patients (perhaps encouraged by their unwary doctors) who didn’t realize what they were doing. Surely recreational use accounts for some of the drug poisoning deaths, but it can’t really account for the *increase* in deaths. (Unless the surveys are completely missing an increase in illicit use, or the increase in opioid use represents the same people taking greater volumes of the drugs.) If the additional deaths are accidental interactions by unwary people with legal prescriptions, then the past 15 years don’t offer an example of relaxing drug prohibition. It’s not as though we’ve instituted a government policy of giving addicts and recreational users free access to their favorite drugs.

Superficially, the past 15 years look bad for drug policy libertarians. I must admit a 3+ fold increase in overdose deaths surprises me. Most people, drug libertarians and drug warriors alike, probably didn’t realize the problem could get so bad. But only a shallow reading of recent history impugns drug libertarianism. A deeper look shows that this recent trend occurred under a regime of strict (in fact, tightening) drug prohibition. Most of the increase is probably not attributable to recreational or compulsive use of these drugs. The heroin overdoses were to a very large degree avoidable, as countries that have taken a “harm reduction” approach to drug policy have seen both overdoses and addict populations plummet. I’d like to see our country try a combination of legalization and harm reduction. That would be a wonderful experiment, and we’d learn a lot from it. To determine whether libertarian drug policy works or not, we’d have to actually *try* it first. 

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