Tuesday, July 26, 2016

Drop Drug Prohibition, Issue Specific Warnings Instead

I’ve looked into the drug poisoning data and the drug use surveys in enormous detail. What jumps out at me is that there are certain risk factors that make an overdose death much more likely. Given this, our policy of general drug prohibition is a mistake. We should instead issue *specific* warnings to people with risk factors, and we should warn against specific risky behaviors.

Age and Health

Age and health are both huge risk-factors in an overdose death. As I mentioned in this previous post (here), older people appear to be dying of drug overdoses *way* out of proportion to their use rates. And the opposite is true of young people; the young, while certainly not immune to drug poisonings, are far more resistant than the older users. There is an alternative explanation for these data, which I explore in the link. It’s possible that many of these “overdose deaths” are misclassified, where the decedent dies of a different cause. It’s just that people with drugs in their system are overwhelmingly labeled “drug poisonings,” even when another cause is responsible. The apparent age-disparity is driven by the higher mortality of older age groups. I think there is something to this alternative explanation, but 1) it implies that there are far fewer drug poisonings than we thought and 2) it stands to reason that as people get older and more infirm they’d be more susceptible to something that would not have killed their younger self. General warnings against drug use (“Just say no!”) are not effective and not informative; specific warnings (“Just because your heart could take it at 20 doesn’t mean your heart can take it at 40!”) might actually prevent some deaths.

In looking at the individual records on these poisoning deaths, it really jumps out at you how unhealthy these people are. It seems like every other record has some non-drug related health issue attached. (See my analysis here.) Sleep apnea and obesity are very commonly represented among these drug poisoning deaths. It’s easy to imagine that someone who has trouble breathing is more susceptible to an overdose from drugs like opioids, benzodiazepines, and alcohol, which all can make you sleepy and suppress respiration. Also, heart conditions are fairly commonly listed on the death records. It’s fair to ask if these people would have died if they’d been in better physical health. Once again, a general warning against drug use misses the point. A specific warning to people in poor health might be more helpful. Very specific drug-illness interactions would be even more helpful. “Don’t use cocaine if you have a heart condition.” “Don’t use more opioids than prescribed if you have sleep apnea.” Etcetera. We could still even issue the general warning, so long as it’s followed up with one of these “especially if…” provisions.

Multi-Drug Interactions

Overwhelmingly, these drug poisonings are multi-drug interactions. I thoroughly explored the interaction issue in this post. For every major category of potentially lethal drug, the vast majority of deaths involve multiple substances. Some of these interactions are well understood. Benzodiazepines, opioids, and alcohol interact to suppress respiration. If someone takes a non-toxic dose of several of these substances, the combination can be deadly even though each substance alone would not have been. Once again, a specific warning not to combine certain drugs would be extremely helpful and could save a lot of these lives. A ham-fisted “Drugs are bad. Don’t do drugs” doesn’t accomplish much. The problem is that people start ignoring such warnings as soon as they survive an encounter with drugs. They might start assuming that everything the government tells them is a lie, and then they won’t believe anything else they hear. Well, here’s a quantifiable risk, with easy-to-cite data sources. We don’t even have to wait for a big policy change to implement this warning. People can unilaterally change their behavior once they know the *specific* risks of drug use. Such a behavior change doesn’t require a big congressional battle over drug policy, just accurate information about risks.

One caveat here is that sometimes there are combinations of drugs on the death record that don’t seem to have a dangerous pharmacological interaction. To name a couple of dubious combinations: Does cocaine really negatively interact with benzodiazepines? Do opioids interact dangerously with cannabis? (For that matter, did cannabis actually *cause* any of the deaths in which it’s listed on the certificate?) Or are the medical examiners promiscuously listing everything they find on the toxicology screening? It’s possible that some of these truly are single-drug poisonings and irrelevant factors are listed on the death certificate. But if we admit that irrelevant factors are listed on the death certificate, that once again opens up the possibility that many of these deaths aren’t really drug poisonings in the first place. I suspect that the opioid-benzodiazepine-alcohol interactions are real and really are driving some of these death numbers. A specific warning against using any of these in combination would spare us a large fraction of the total drug poisonings.

The really sad thing here is that we’re missing an opportunity to meaningfully inform people of risks. We’re missing a chance to save lives. And it’s all because the US government has insisted on a puritanical “thou shalt not” policy regarding all questionable substances.

Someone else came to a similar conclusion after doing their own research. See this excellent article, including the comments section (Less Wrong tends to have excellent comments):

The very first comment makes the following point:

“Even the worst drugs that legitimately screw people up do so because those people are taking them in ridiculously stupid ways. These drugs can often be useful tools to have when used responsibly.”

This is consistent with what I’ve seen in the CDC data. Infirm people, often using multiple substances, are driving the death counts. 

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