Thursday, April 28, 2016

Bad Comments

It is possible to have productive discussions on the internet. I have seen it happen. But that tends to be the exception rather than the norm. In a sort of taxonomy of bad comments (and bad commenters…sorry, but it tends to be the same people over and over again), I’ll list some of the behaviors that bother me.

I freely admit that I’m wrong sometimes. Unlike many people you will meet on the internet, I am a belief updater, a Bayesian. I have to adjust my Bayesian priors now and then. Don’t take any of the references to previous comments below as an indication that I was definitely right or my interlocutor was definitely wrong in that particular exchange. And it’s extremely likely that the other person would not accept my framing of the exchange that I am describing. That being said, there are certain good and bad habits to commenting, and to correspondence in general, that are best highlighted with examples. I think avoiding these bad habits generally leads to more productive discussions and leads thoughtful people to better belief-updating practices.

1) Hobby-horsing: What’s that, you say? This thread can be illuminated by injecting your favorite topic? Just like every single goddamn thread you comment on? Stop trying to shoehorn your “unique insights” into every discussion topic. If you had an unproductive comment thread regarding your favorite topic on someone else’s page, take that as a sign that it’s a bad venue for airing your exposition. Your idea may even be a good one. It’s just not relevant to every single conversation on the internet. I had one interlocutor who repeatedly interrupted my posts with demands that we discuss the process of human decision-making. I was unable to use words like “voluntary,” “choice”, and “decide” without getting sucked into his favorite bull-session. After several unproductive threads along these lines, I finally told him I was done. I would pursue his line of questioning further only if there was a concrete example where the exact definition of the word we all know changes the conclusion. Hobby-horsing has derailed many a good comment thread.

2) Missing the Point: I’ve had so many comment threads that look like the following. Me: “Hey, here’s an argument that X isn’t true.” Bad Commenter: “Silly! Everyone knows X!” Me: “Um…see above. Feel free to join the conversation at any time.” I’m remembering a particular example. After a series of posts challenging the assertion (which I don’t believe) that “median incomes have stagnated since the 70s,” someone essentially posted the standard argument that “median incomes have stagnated since the 70s.” If you’re not willing to actually engage with someone’s argument or evaluate the evidence offered, don’t bother.

3) Obscurantist Theorizing: Sometimes an argument needs to be formalized or stated in the language of some academic guild. That’s fine when it’s absolutely necessary, but productive conversation usually requires talking to people in plain English. This can involve delving into the technical details, but the “plain-English” interpretation is also needed (even if you are communicating to your specialized academic guild, but *especially* if you’re talking to a general audience). I once had an interlocutor who thought his education in biology gave him special insights into certain political and economic questions. He had blathered on several times in various threads with something about how “human beings are social.” Several requests for clarification of his point were fruitless. It’s possible that he had some kind of point but I was simply unable to grasp it (even though I have a decent education in biology myself). It’s more likely that he fooled himself into thinking he had a deep thought by stating things in the most obscurantist way imaginable.

4) Pure Snark: Of course there is (at least) one wrong person in each argument. The correct approach is to assume it’s you and present an argument that would convince an honest skeptic. If your entire comment is an “Oh, Jeez!” or a “Really!? Reeeeally?” or a “Yeah, right!” or a “That’s absurd!”, don’t bother. If you’re tempted to react this way, you probably have given no thought to *why* the person believes something absurd. A human being, who is capable of higher thought, wielding the most complex structure in the universe (the human brain), has somehow reached a conclusion that you find implausible. This should be seen as an interesting puzzle, not a risible infraction. Keep your snark to yourself. Mentally rewrite all your snarky comments as “You’re stupid for thinking that,” because that’s what you’re really saying. If you actually want a productive conversation, try rewriting a snarky comment as, “Your argument seems to imply (really implausible thing that nobody could possibly believe). Is that really where you want to go?” or “Your argument seems to ignore (incontrovertible facts X, Y, and Z). Can you explain how your worldview is consistent with these observations?” Even snark added to a thoughtful comment can derail an otherwise productive thread. Pure snark without content is considerably more annoying. Stop using it. It’s a bad faith move.

5) Deriding the Importance of the Topic: Don’t bother commenting if you’re not interested in the topic. And don’t complain that the topic is trumped in importance by some other topic. There are threads elsewhere to handle those other items. You wouldn’t go to a Bronie convention and say, “Why are you spending your time and money on My Little Ponies!? Why aren’t you solving world hunger!?” Your thing might well be an important topic or a devastating social issue, but don’t derail every conversation by comparing it to child starvation. I recall once commenting on slightly old news (like, two weeks old), because I thought I had something interesting to say about it. Someone piped up with “Jeez, why are people still talking about it even?!” If it’s not an important topic of conversation, the solution (for you) is to stay out of it.

6) Get Your Own Blog: Comments that come close to or exceed the length of the original post are borderline rude. Try to be concise. Yes, you have a very deep and important point to make and it takes a lot of space to fully make your case. But if your response requires this much exposition, write your ideas up to your own blog and link to it. Don’t post a comment so long that nobody will want to read it. Even when people *do* respond to your long-ass comment, they will likely respond only to part of it, or only to their own summary of the main idea of your argument, which will leave you feeling cheated. And you kind of set it up that way.  I have a tendency to do this, and I have to keep it in check all the time. My instinct is to fully explore the argument presented and preempt any criticism that comes to mind. When you’ve reached your 4th or 5th paragraph, consider writing up your own blog post.

7) Diarrhea of the Pen: Similar to 6), but with more sheer blather. Write out your comment in a Word document, read it over a few times, check for spelling and grammar errors, check to see that the flow of the argument is easy to follow and that after-the-fact insertions into the body of your text actually fit and don’t disrupt the flow of your argument. I have seen very long, rambling, incoherent comments with so many spelling errors that the author could not have possibly been thinking clearly about what they were saying. I personally find this quite rude. It’s like saying, “Look at this wonderful thing that fell from my magnificent brain. Behold! And please sort it out for me, because I didn’t have the time to do it myself.” It’s fine to have a little diarrhea of the pen, but it’s nice if you clean up after yourself.

8) Rapid-Fire Comments and Links: Similar to 7), but with multiple comments after a single post. Also like in 7), it shows that the responder isn’t thinking very deeply or hard about the argument, but rather is just reacting. The solution is similar to 7). Write down your argument carefully, in one comment, and trim anything that’s superfluous. Re-read and revise several times before posting. I once had someone repost the *exact* same link two or three times in the same thread. He would post five or six rapid-fire responses to each of my long-considered responses to him. It left me feeling cheated, like I was giving his arguments full consideration and he wasn’t even entertaining mine. I would sometimes find a post littered with multiple (sometimes more than a dozen) short comments by one of these guys. It emerged later that he’d reacted to the post as he was reading it but before he’d finished; he might have saved us both considerable time if he’d read the entire post and responded to it *in its entirety.* Sometimes an author anticipates and responds to your criticism; rapid-fire response commenting often causes you to post a criticism that author is already responding to. Don’t waste everyone’s time with this stuff. If you aren’t bothering to read someone’s argument, your reaction to it isn’t worth reading.

9) Pretending To Forget Your Shared History: I had one interlocutor who would repost the exact same shallow arguments over and over again, or repeat claims that I had, in previous posts, challenged. That’s not to say that you can revisit your entire history of arguments every time you have a discussion with someone, but it makes you look dense when you ignore the fact that you’ve thoroughly explored a topic before. Don’t act like you can just assert something that is obviously a point of contention. Retain *some* memory of what was said and what was (perhaps) decided in previous arguments.

10) Not Realizing When You’ve Made an Empirical Claim: Some things can be known by logic alone, or even sheer introspection. But most claims about the world are empirical in nature. It’s possible that they are false, and that some piece of information from the world has a bearing on that claim. I’ve met a few people who are either so dense as to not realize when they are making an empirical claim, or they adopt a stance that obscures the empirical nature of the claim (presumably so they don’t have to confront contrary information).

11) Abruptly Leaving the Discussion: We’re all busy, and we have other things on our mind. But be gracious when someone has obliterated your argument. If someone points out a fatal logical flaw or an incontrovertible piece of evidence that decisively refutes your argument, acknowledge it and move on. It’s even possible that your conclusion is still right, just not for the reasons you presented. That’s fine. Acknowledge it. “I will stop using that argument, because it’s not a good argument.” It’s not that hard. I’m recalling a conversation about drug prohibition that invoked the bath-salt using face-eater, who it turns out never took bath salts. If you’re going to use an emotionally compelling example to bolster your argument, then you have to accept the flip-side of it when, oops, the example given *doesn’t* support your argument.

12) Moral/Personal/Emotional Trump Cards: These are the worst. If you can’t enter an argument without getting terribly emotional, even personal, then don’t. We all have disagreements about which government policies are harmful or helpful (on net). Don’t try to bully someone into shutting up because a particular policy they favor would hurt you personally. Your interests aren’t the only ones that matter. Good public policy ought to come from an impersonal, detached analysis of costs and benefits. The analyzer should pretend they don’t know whether they would be a net recipient or net payer for the policy in question. More often policy originates with passionate shouting mobs demanding “More stuff for me! We’re the loudest coalition, and we won’t be reasoned with!” This is how we get lots of incoherent populist government programs. Having a very personal stake in an outcome makes you *less* credible to comment on policy, not more. And *moral* trump cards are often incoherent. So you’re just going to claim the moral high-ground and be done with it? I don’t think so. That’s probably what we’re arguing about in the first place, so let’s at least have a conversation. By the way, a government program that has terrible practical consequences *is* immoral. If you insist on “Right must be done, and may the world burn,” then the world will burn. Wealth will be wasted, people will become poorer, and people will die. Come down from your high-horse for a moment, recast the argument in terms of tangible harms rather than moral presumptions, and try it once more.

13) Questioning the Motives/Interests/Identity of Your Interlocutor: This is the good ole’ ad hominem. Hopefully not much needs to be said about this one, but it does come up, and often. Questioning the funding source of a particular author or think tank is for some reason seen as an acceptable challenge to their argument. And pointing to a person’s membership to a given class (typically the oppressor class) is seen as a devastating critique. If you aren’t engaging with the substance of the person’s argument, don’t bother commenting. Authors and think tanks don’t just state their conclusions and say, “Trust me. I’m an expert.” They typically offer documents full of evidence, logical arguments, and references to sources. You don’t have to take anyone’s word for it. You can check yourself. It requires a bit of intellectual effort and an investment of time, but it pays off. Most bothersome about this habit: most authors don’t attach themselves to the highest-paying think-tank and adjust their views accordingly. Most authors actually start out with some kind of argument or worldview, and they find the think tank (or other institution) that will publish their ideas. Where do you expect literature to come from that questions, say, government spending on education or healthcare? There are people who oppose such spending (in general or to some particular degree), and who wish to research and write about it. Those scholars are naturally going to end up working for an institution sympathetic to their viewpoint. If someone writes and publishes an anti-government research paper or article, it’s no slam against the underlying argument that it happens to get published by the CATO Institute.

14) Talking Across Someone’s Argument: By this, I mean something like the following. Someone presents an argument leading to a conclusion. Rather than engaging with the argument, you present your own evidence for how the conclusion can’t possibly be correct. It’s okay to do this if someone’s argument is so long and convoluted that you don’t have time to read it. I certainly feel I have the right to object to the conclusions of some 600+ page tomes that I haven’t read. It’s possible that Piketty’s “Capital” would thoroughly convince me and answer all my objections if I simply took the time to sit down and read it. So I’ll admit to occasionally indulging #14 here. But if the argument as presented is concise enough, respond directly to it. Without doing that, you’re just shouting past each other.

15) The Spread: This is similar to 6, 7, and 8. Sometimes an interlocutor presents so many not-necessarily-connected arguments that, when someone actually does respond, he can always be confident that some piece of the argument wasn’t replied to. “But what about X?! With all you said, still X!” I’ve heard this debating tactic called “The Spread.” It is possible that there are so many good arguments for a conclusion that it’s worth listing all of them at once. But it’s generally bad etiquette on a comment thread.

16) Acting as if “It’s Just Obvious.”: Very similar to #4, Pure Snark. Sometimes people point out a single factoid or news story, then effectively drop the mic and walk off stage. It’s always good to add a *little* commentary as to the implications. I recall someone commenting with a single link and no actual commentary, responding to something I had posted. This was in response to a link with a considerable amount of commentary by myself (I typically leave a paragraph or two of my own thoughts). I don’t know if he thought the link was so devastating to my point that no commentary was necessary, or if he just wanted to share a contrary viewpoint without adding to the discussion. I responded to some of the content of in the link (which was actually linked to a very nice article), but still no actual discussion.

None of this is to say I never do these things, but these are the behaviors that bother me the most. I think productive threads get derailed by people with bad commenting hygiene. All of these are variations on a few very general themes: be polite, engage with the argument presented to you in good faith, presume good faith on the part of your interlocutor, don’t display anger too bluntly, think about what you are saying, etc. Some of these overlap with the classical “logical fallacies”, which I first learned about (formally anyway) in 10th grade speech class. I obviously won’t bother to list those, but they are worth referencing, too.

I probably go overboard in the “try to comment thoughtfully” department. That's not to say I succeed, just that I agonize obsessively over it. I write out every comment in Word, revise and re-write several times before posting, and feel paranoid that I’ve left out some important detail or failed to anticipate some criticism. I’d probably have more discussions, and thus more productive discussions, if I were slightly less careful and more succinct. But this process of revising and re-writing tends to pay off. I sometimes realize that I don’t believe what I originally intended to say. I sometimes anticipate a criticism that really is devastating to my argument. Far more often, I anticipate how my comment could be misconstrued or dismissed with clever-but-meaningless blather. A thoughtful comment that I had spent 15 minutes, perhaps an hour, agonizing over, is dismissed with an error-laden comment thumbed out carelessly on someone’s iPhone in under a minute. I still feel like I learn something from these exchanges. A bad commentator can be like a game of “Why? Boy”, where a child responds to every answer with another “Why?” You definitely learn the limits of your knowledge, and you learn to spell out every assumption and everything underlying your argument. An already thoughtful person can profit from this exercise. But it’s frustrating as hell and you are always left feeling like somebody is trolling you. 

To What Extent Is Inequality Voluntary?

To the extent that people choose which professions to pursue, choose how hard to work at it, choose in which city to live, choose to avoid an education-derailing pregnancy, and make other choices that predictably affect future income, it makes little sense to complain about income inequality.

Of course the converse is true. To the extent that it’s all just luck, sheer genetics, or other people’s malice/goodwill that determines your life’s status, inequality represents unfairness. But I rarely see this pointed out explicitly. I never hear a call for, say, a progressive tax *only* on that portion of your income which is due to luck. I never hear an inequality statistic that is prefaced with, “Controlling for *and removing* the portion of inequality that is chosen voluntarily…” And on the wealth inequality side of things, I never hear it acknowledged that “X% of people in the low-wealth quantile would be in the top wealth quantile if *only* they adjusted their savings rates to match people in the top quantile.” We’re not all racing toward the goal of “maximize my income” or “maximize my wealth.” We all choose a different mix of income, leisure, and family. And we make different choices about how much of our income to save back and how much to spend.

We’re free to hold differing views on the exact proportions of “luck” and “choice” determining a person’s income. You might say it’s half and half, while I might say it’s 90% choice and 10% luck. (I would push back on any claim that posits an implausible proportion to the “luck” category, and I think 50% is close to the cutoff for what’s reasonable. I also think many things that get labeled “bad luck” are really poor decision making and poor planning interacting with *normal* luck.) But I almost never see inequality alarmists even acknowledge the element of choice, and I literally never see them try to adjust for it when producing alarming statistics or making policy recommendations. The alarmists need to take a closer look at the philosophical underpinnings of their ideology. The question of “choice vs luck” is potentially a fatal flaw in their belief system (and it’s not even the only one!), unless they are tacitly assuming something like 90% or 100% luck. Maybe they are and just aren’t saying so plainly enough. I really can’t tell. This issue needs to be brought out into the light of day where we can all examine it. Stop glossing over important parts of your argument, please. If your goal is to have a productive conversation about this topic, state your assumptions clearly.  

Wednesday, April 27, 2016

Should We Be Consequentialists or Deontologists About Racism?

It’s nearly unanimous. Everyone in the civilized world knows that racism is bad. But nobody has a clear account of why.

Is racism bad per se? Or is it bad because it has bad consequences? My impression is that most people, if pressed for an explanation, would tell a story about how racism led to all sorts of historical atrocities. They are being consequentialists; they think that racism is bad because it leads to bad outcomes for lots of people.

But hold on. My other impression is that most people react viscerally to even the mildest expression of racism. People react negatively to racism even when the potential for harm is small to nonexistent. The owner of a basketball team, who has clearly overcome his internal feelings of racism enough to shell out million-dollar salaries for his players, is reviled by the entire world for making (admittedly venomous) racist comments. So I suspect that people are really deontologists about racism. Racism is a *sin*, not a *harm*. If we worried primarily about tangible harm, we would shrug off these instances of racism and react more viscerally to racists who are actually hurting people.

In a sense, it’s good that we internalize consequentialist ethics into moral rules. If racism is generally pretty harmful, we shouldn’t have to pause to consider each instance of racism individually. Rules save us time and mental effort. “Racism leads to bad outcomes” becomes “Racism is bad” becomes “Racism is evil” becomes “Don’t utter speech that can be misconstrued as racist” becomes “Don’t think racist thoughts” becomes “Don’t even entertain racist ideas, even for the sake of argument.”

We can definitely take this too far, and it becomes worthwhile to open these moral rules up to moral inquiry. It may be worth confronting someone who is racist and needs to be convinced he shouldn’t be. “It’s just wrong!” doesn’t really get you very far in this kind of argument. You have to articulate *why* something is wrong. Otherwise the other person is on perfectly solid ground saying, “No it isn’t!” and continuing on with his life. Also, we risk *overpenalizing* someone for a trivial infraction. A flippant, insensitive comment may deserve a minor slap on the wrist or a scornful look by one’s colleagues, but some individual have brought the full vengeance of the internet upon themselves for some pretty mild indiscretions. In my opinion, this has been taken *way* too far. We’d see a healthier and freer exchange of ideas if we eased up on the throttle a little, as some concepts are bound to be *mis*labeled as racist when they aren’t. Finally, if we take the strict deontologist’s approach to racism, we might fail to analogize to *other things* that are harmful for exactly the same reason that racism is harmful. If it’s a bad idea to mistreat someone because of their race, maybe it’s a bad idea to mistreat someone because of their national origin or religion, too. I actually think this insight is very important and is missing in discussions of the treatment of immigrants.

If we are too strict about treating something as a sin, when it really ought to be treated as a harm, we risk shutting off this kind of healthy moral inquiry. And without that, you slow or stop the discovery of important moral truths. Without this kind of discovery, your society may fail to realize (for example) that things like racism, rape, and child abuse are wrong in the first place. We understand these behaviors are wrong *not* because of some kind of universal human instinct; we understand them as wrong because enlightenment thinkers engaged in the kind of moral inquiry I’m describing above. It took a great deal of courage, work, and patience to convince a society to rethink the moral status of these behaviors and attitudes. Rape was thought of as a tort against the husband or unmarried woman’s father, not as an offense against the girl. And child abuse used to be called “discipline,” by the standards of most parents anyway. Surely it’s for the best that some forward-thinking individuals saw this state of affairs and said, “Let’s take a closer look at our moral assumptions.” 

Tuesday, April 12, 2016

Prescription Painkiller Drug Poisonings: Four Competing Explanations

The number of deaths involving prescription painkillers has increased in the past 15 years. Consider a few different explanations.

1)      Doctors have loosened the constraints on prescribing painkillers. With more people taking habit-forming narcotics, more people are getting addicted, developing harmful drug habits, and overdosing.
2)      There aren’t really any more addicts or users with unhealthy drug habits. The increase in overdose deaths is entirely from within the population of normal people with legal, medically legitimate need for painkillers.
3)      There aren’t really any more addicts or users with unhealthy drug habits (same as in 2). But the drug habits of the (roughly unchanged) population of addicts have become more severe. Addiction has become more deadly. The increase in painkiller-related poisonings is happening within this population of addicts.
4)      There is a reporting bias that is grossly exaggerating the true trend, or even creating a trend out of nothing. Medical examiners and coroners are doing more thorough toxicology screenings than they used to, so naturally they are finding more evidence of drug use in the recently deceased. Deaths are inappropriately labeled “overdoses” when there is evidence of drug use, even if there isn’t good evidence that the drug contributed to the person’s death.

So what’s really going on here? We need to pick the narrative that best fits the available data. These  narrative explanations aren’t all mutually exclusive, as we’ll see. But we need to pick the one or two that best fit with the available information. What follows is a discussion of the evidence that should be brought to bear on any narrative that attempts to explain the recent rise in prescription opioid painkiller deaths. Below I list the pieces of evidence I found most salient, which must be reconciled with any narrative.

CDC Drug Poisoning Data

The claim that opioid-related drug overdoses are increasing is based mostly on CDC cause of death data. The CDC keeps a record of every single death that happens in the United States, including information about the decedent and the causes of death. Up to 20 causes of death are listed in the CDC’s data file. “Other Opioids”, marked by cause of death code T40.2, is the cause of death most often listed on accidental drug poisoning deaths (cause of death codes X40-X44). It is the category that most prescription painkiller overdoses fit into, although there is also a Methadone, “Other Synthetic Narcotics”, and an “Other and Unspecified Narcotics” category. In 2014, there were 12,657 deaths in this category, followed by 10,754 “Heroin” deaths, 8,295 “Benzodiazepines” deaths, 5,992 “Cocaine” deaths, and 5,695 “Other synthetic narcotics” deaths. Were it not for a recent increase in heroin deaths, “Other Opioids” would be the leader by a wide margin. (Then again, were it not for a recent decrease in cocaine deaths, which started declining in 2006, it might not be the top category.) Our best available data is showing an increase in “Other Opioid” deaths. So at the very least some kind of explanation is needed.

Information About Prescription Drug Abuse Rates

Are there any more addicts than there were 15 years ago? Are more people abusing prescription painkillers? Apparently not. See the National Survey on Drug Use and Health, page 7 (page 11 of the pdf here). The number of people using painkillers illicitly is flat or even decreasing for some age groups. You will find a similar story in the Monitoring the Future survey here (page 31 of this report). MTF focuses on high school students, but the question about “Availability” is telling. Apparently our society is not awash in these drugs if high school students are finding them *less* available. If you look at this document (here, page 32), you can see where people are getting their illicit supply of painkillers from. The largest single source, representing 53% of responses, is “Free from a friend.” This is hardly a reliable source of drugs for a hardcore drug user. Most of the people who self-report illicit use of painkillers are getting the occasional pill from a friend or relative, not buying in bulk from a “pill mill.”

Maybe the survey results aren’t as telling as they seem. Perhaps there is one really hard-core, self-harming painkiller abuser for every 5 recreational drug users (or 1 for every 10, or for every 20, or whatever ratio seems plausible). If illicit use of painkillers is in the 2% of total population range, and if problematic illicit use is in the few-tenths-of-a-percent range, then this sub-population of abusers could grow substantially without changing the overall “Past month use” numbers. Well, see page 84 of this document, the 2013 SAMHSA drug abuse survey (once again). In the paragraph directly under the chart (which shows number of people in millions, *not* % of population), it says that about 0.7 percent of the adult population are dependent on pain relievers, while (recall from above) about 2% of the adult population are past-month users. So about a third of people who have recently used painkillers are experiencing some sort of problem with them, and this ratio has been very stable (and the numerator and denominator of that ratio have *both* been very stable). We might still posit that there are some *really* hardcore painkiller addicts who represent 0.1% of the population, and that the growth in problem usage and overdose deaths are all attributed to this subpopulation. But if we go down that path we are increasingly dismissing what the available data are telling us and grasping at straws to explain it away.

Evaluating the “Loose Prescription Pad” Hypothesis

There is conflicting information about the availability of painkillers. Supposedly it’s much easier to get a prescription, and indeed the number of legal prescriptions has been rising. It’s a few years old, but see the graph at the bottom of this page showing the tonnage of opioid pain relievers sold. It has since leveled off at about 7kg/10,000 population (I have data e-mailed to me by a CDC employee that shows the “OPR Sales KG per 10k” for the next several years), but clearly it has increased over the past 15 years. Both opioid prescriptions and opioid deaths per population have increased by about a factor of 4. This seems reasonable, and it’s a piece of information worth committing to memory: a given prescription is no more deadly that it was 15 years ago. It’s just that there are more prescriptions.

It’s odd that this increase happened at the time that it did. The DEA launched a massive crackdown on prescription painkillers in the late 90’s and early 2000’s. See Ronald Libby’s paper on the topic here. If you don’t want to take a CATO scholar’s word for it, you don’t have to. The National Association of Attorneys General was alarmed enough about the DEA’s crackdown that they sent a letter to the DEA’s director, registering concern and asking for an explanation (here ). Perhaps the crackdown succeeded in putting a few high-volume pain doctors out of business; there were certainly some high-profile prosecutions. But the tonnage of opioids prescribed quadrupled anyway. What’s happening here? Did the remaining pain doctors pick up the slack, and then some? Was the medical community becoming more enlightened about the need for adequate pain management, and the DEA’s efforts just weren’t sufficient to stem the rising tide? Did naïve primary care doctors pick up the slack left by pain doctors and prescribe promiscuously? Whatever is going on here, it happened *in spite of* a government crackdown. Some people have claimed that the past 15 years demonstrates a need for prohibition and a refutation of drug-libertarianism. That explanation is *a bit* silly considering that the past 15 years have seen an increasingly severe regime of drug prohibition.  

Evaluating Drug Poisoning Trends

It’s impossible to know how accurate the CDC’s drug overdose figures are, but a spurious trend of rising overdoses shouldn’t be ruled out of the question. What’s interesting about the rising rates of overdose deaths is that we’re seeing them in almost every single drug category. See the lines in the above chart. Everything appears to be going up. Even if we focus on drugs that don’t kill very many people (Antiparkinsonism drugs, Cannabis, antitussives, beta-anrednoreceptor antagonists not elsewhere specified), death rates are rising 2- or 3- or 8- or 9-fold. (Less-lethal categories of drug plotted here, bottom figure.) There are for sure a few categories that are fairly flat or declining. Cocaine is only slightly up over 1999 and has in fact been declining since 2006; it used to be the biggest single killer and now it is 4th. Barbiturates, which only kill about 350 people a year, are also pretty flat over the period. A plausible explanation is that, with so many additional drug overdoses, medical examiners are checking those additional bodies and jotting down whatever other substances they find. In this view, the increase in opioid painkiller overdoses is real but the trends in the other drug categories are spurious. Another plausible explanation is that the medical examiner are simply doing more checking (as an exogenous change) and finding more of every drug category. In this (perhaps less plausible) view, the recent increases in opioid painkiller deaths are also spurious. It is notoriously difficult to diagnose an opioid overdose. A person who has been using opioid painkillers for a long time has built up a tolerance and may have blood levels of the drug that would be toxic to a new user. I don’t really think the *entire* increase in opioid poisonings is spurious, but it’s clear that death certificates are including more information about the drugs in the decedent’s system than they used to. It’s implausible that some two dozen drug categories have increased in lethality by a factor of 3 or 4, all at the same time. Clearly some of the substances that are being written down on death certificates aren’t actually related to the cause of death. If we’re willing to apply this observation to Cannabis and antiparkinsonism drugs (for which there is no obvious narrative to explain the increase), we should go a step or two further and apply it to opioid painkillers, too.

In support of the “spurious trend” hypothesis, cocaine use is correlated with death rates after about 2006 (when both are falling) but uncorrelated with death rates before 2006 (when use rates are roughly flat but overdose deaths are increasing). Heroin deaths are hard to measure, because there are so few users, and so many heroin addicts probably aren’t part of a household where a drug use survey would reach them. Survey numbers tend to be noisy, and even a large apparent year-to-year difference in the number of users can be “statistically insignificant” (indistinguishable from noise). Still, use rates on the SAMHSA survey are correlated with heroin overdose deaths from the CDC data. Someone relying on the SAMHSA use rates would have predicted the recent surge in heroin-related deaths. So clearly the self-reported drug use in these surveys is *somewhat* accurate. If the CDC’s numbers for cocaine-related drug poisonings was rising between 1999 and 2006, when the survey data said that cocaine use was flat, this is evidence that there was some kind of reporting bias, at least for part of the period we are talking about.

In evaluating narrative 4), the “spurious trend hypothesis”, I would fixate on the fact that opioid poisonings, expressed as a rate per legal prescriptions or per kg of opioids sold, are roughly constant. It makes sense that this ratio wouldn’t move much. Whatever risk prescription painkillers pose to their users, that risk doesn’t change when you add more users. In this view, the trend is real and is roughly accurate (a 4-fold increase over 15 years), but the total number of deaths might be higher or lower than the CDC data shows.    

Multi-drug Interactions

Most prescription opioid “overdoses” aren’t true overdoses. They are multi-drug interactions, usually with benzodiazepines or alcohol. In combination these drugs decrease respiration, often with fatal results. Just over 30% of prescription opioid poisonings also involve benzodiazepines, and about 15% involve alcohol. Only about 15-20% of opioid poisoning deaths involve only one substance. (By that I mean the CDC death record has only one drug-related “multiple cause of death” code in about 15-20% of cases.) Overwhelmingly these are multi-drug interactions, which bolsters hypothesis 2) above: the additional overdose deaths are coming primarily from normal people with legal prescriptions who unknowingly mix dangerous combinations of drugs. If this were specifically a “prescription opioid epidemic”, I would have expected to see more drug poisonings that are exclusively caused by the “Other Opioid”, “Methadone”, or “Other Synthetic Narcotics” categories. The pattern of multi-drug deaths I’m describing here is also pretty stable across the past 15 years. If I go back to 2000, I see the same pattern: most poisonings involve multiple substances, the distribution of number of substances is about the same across all years, and certain substances tend to be found in combination at the same rates, regardless of which year you’re looking at.

A Reiteration: Competing Narratives and Evidence

I found it impossible to write this post without interjecting my own discussion and opinions, but let me try to reiterate the competing hypotheses and the data that need to be squared with them.

Hypothesis 1: Looser prescription practices led to more opioid addicts, which led to more overdose deaths.
Hypothesis 2: There aren’t any more addicts. The increase in overdoses came from an increase in the total number of people with legal prescriptions, mostly *not* using the drugs recreationally.
Hypothesis 3: The population of addicts and recreational users of painkillers has been constant, but the intensity of drug use within this population has increased, leading to more overdoses.
Hypothesis 4: The increase in drug poisonings isn’t real. It’s a spurious trend created by a reporting bias.

Whichever hypothesis you prefer, you need to square it with the following information:
  1.       CDC data shows a dramatic increase in opioid painkiller deaths.
  2.      CDC data shows a dramatic increase in *all* categories of drug related deaths, even those for which there is little evidence of increased use.
  3.       Most drug-related poisoning deaths involve multiple substances.
  4.       Many death records include mentions of drugs that aren’t plausibly related to the cause of death.
  5.       It is difficult to determine a cause of death.
  6.       A toxicology screening can be misleading, because a chronic drug user can tolerate a dose that would be lethal to a naïve user.
  7.       Drug use surveys show that the proportion of the population using prescription painkillers illegally is unchanging.
  8.       Drug use surveys show that the proportion of the population with painkiller-related drug abuse disorders is also unchanging.
  9.       Most illicit users of prescription painkillers received their drugs for free from a friend (not from a doctor or drug dealer).
  10.    CDC drug poisonings are correlated with survey-reported drug use rates for cocaine and for heroin, but *not* for opioids (or other prescription drugs).
  11.    The government crackdown on prescription painkillers began before painkiller-related deaths started to rise.

Happy hunting.

Thursday, April 7, 2016

The Strange Double-Standard: Benzodiazepine vs Opioid Poisonings

Suppose I showed you alarming statistics that benzodiazepine overdose deaths have risen 7-fold in the past fifteen years. I say “There is an epidemic of benzodiazepine abuse!” I tell a narrative that doctors have been loose with the prescription pad in recent years, and so these drugs have become readily available for recreational use. I try to warn doctors against prescribing these drugs, and I try to scare patients against taking them. It would be a superficially plausible story, especially given the scary body count. But there would be very good reasons to doubt it.

Someone could politely point me to SAMHSA drug abuse survey and show me that abuse of tranquilizers (the category including benzos) is flat, and in fact has apparently declined in recent years. (See here on page 32 of the pdf.) The Monitoring the Future survey, which also measures drug abuse rates but concentrates on 8th, 10th, and 12th graders, shows roughly the same pattern. A bit more tellingly, the “Availability” numbers have been falling. That is, high schoolers are finding it more difficult to get these drugs, not easier. (See here on page 39 of the pdf.) Someone could also point out that benzos are extremely difficult to accidentally overdose on. You can do it, but it takes a lot. Only about 1-2% of benzodiazepine-related deaths *only* involve benzodiazepines. Most of these deaths involve a multi-drug interaction, usually opioids or alcohol, which in combination with benzos suppress respiration.

Abuse of these drugs certainly exists, but it isn’t *rising*(unless two separate surveys are missing the trend, and unless the “availability” survey trend is moving in the opposite of the true direction).  So it can hardly explain the *rise* in benzodiazepine-related poisoning deaths, unless the population of recreational users is being far more reckless than it was 15 years ago. The “moral panic/rising epidemic” story just doesn’t make any sense when you start to include other pieces of information from various other sources. That’s what a good narrative should do: collapse information from several disparate sources into one coherent story. I think anyone who has all the data at hand will say something like: Okay, benzos aren’t dominating the will of helpless drug addicts and forcing them to swallow pills until they keel over. Rather, naïve users are mixing them with bad combinations of alcohol and opioid pain killers. Stopping the interactions will fix 98-99% of the problem. Let’s not raise the alarm bells of a moral panic here. Let’s just tell people to stop mixing drugs.

The double-standard referred to in the title of my post is the different standard by which the opioid painkiller poisonings are judged. Everything about the benzodiazepine story is true of the opioid story. Single-drug overdoses are rare; not in the 1-2% range, but more like in the 20-25% range. It’s still the case that the low-hanging fruit is avoiding drug interactions, not deterring use of these drugs *entirely*. Once again, according to the SAMHSA and Monitoring the Future surveys, abuse rates for these drugs are flat (in fact declining in very recent years) and perceived availability is down. So it’s probably the case that most of these deaths are legitimate users with legal prescriptions, naively taking different prescriptions in dangerous combinations. I don’t understand why we’re hearing about an opioid painkiller abuse epidemic but not a benzodiazepine abuse epidemic. The recent trends in drug poisonings are the same for both, suggesting an increasingly severe epidemic. Abuse rates, as determined by drug use surveys, are flat for both, suggesting abuse is not the problem. Multi-drug interactions are the culprit in the vast majority of poisoning deaths for both classes of drugs. So I’m not sure what’s going on here. Maybe the “benzodiazepine abuse epidemic” narrative is too easy to debunk, but the “opioid painkiller abuse epidemic” narrative is *just* plausible enough to get past a fact-checker?

I hear another “drug epidemic/moral panic” story on the radio or in my news feed every week. This is the wrong narrative. It is based on a single piece of information (CDC drug overdose figures), often with an anecdote or two thrown in for color. The correct narrative would be consistent with these other pieces of information. The journalists and “public health officials” who are selling the moral panic story could at least comment on these items that contradict the official narrative.