Thursday, December 14, 2017

Political Popularity as a Constraint

Suppose you favor Policy A, and you are arguing with someone who favors a less optimal Policy B, but you both agree that either choice is superior to a third Policy C.

You insist that Policy A is optimal. Your opponent insists that if we try to implement Policy A, a populist backlash will turn it into Policy C. If we instead opt for Policy B, we won't get the backlash. We might even gradually drift toward Policy A, but we need B as a stepping stone. You say that's all very well, but plainly A is better than B if only we get it implemented. Questions of realpolitik aside, if A is better than B we might as well say so. Your opponent again cautions you that you can't simply pick policy in a vacuum. Those brutish masses clamoring for bad policy are part of the world, and we can't simply assume them away. "A brief stopover in Policy A followed by collapse into Policy C" is no progress at all.

I recently saw something like this play out between Don Boudreaux and Rick Manning. It was on the question of free trade. Boudreaux favored unilateral elimination of tariffs (call it "Policy A"). Manning favored trade agreements that bilaterally (or multi-laterally) eliminate tariffs (call it "Policy B"). Both were duly afraid of high tariffs, protectionism, and economic nationalism (call these things "Policy C"). Boudreaux was taking the position that even unilateral elimination of tariffs would benefit the nation that does it, regardless of whether its trading partners reciprocate. It's not a prisoner's dilemma, in which both parties need to cooperate to get the reward. Either party can unilaterally make itself better off by eliminating its own tariffs or import quotas. Manning's argument was that unilateral elimination of tariffs leads a nation's citizens to feel like they're getting a bum deal, and protectionism raises its ugly head. It's frustrating to watch. Boudreaux is saying, "Sure, there are political constraints that lead us to pick bad policy. But Policy A is the best possible choice. I might as well say so." And Manning is essentially saying, "Political considerations are hard constraints on what we can actually do. Better choose a path of trade liberalization that doesn't lead to populist backlash." These are my own paraphrases, not actual quotes. (BTW, I thought Manning was rude and made borderline sexist remarks. "I can't support an import ban on chocolate because my wife would object!" And in case you didn't get this knee-slapper the first time, he repeats it. His dismissal of Boudreaux's graduate assistant's scholarship struck me as incredibly rude. But I absolutely take his point about acknowledging the realities of politics.)

I found this interesting. It is usually the libertarians who are reminding leftists and conservatives of political constraints. "You don't just get Obamacare as envisioned by its authors, rather you get Obamacare as implemented by a future Republican congress, and implemented in states with Republican leadership and Republican governors. You can't just say it's good policy in a vacuum, assuming away all of those nasty people who don't agree with you." The political process imposes hard constraints on what kinds of policies are actually feasible. If your policy to correct market failures requires an all-wise and infinitely compassionate bureaucrat to actually implement it, it's going to fail. Even if it requires merely above-average-yet-still-mortal intelligence and civic-mindedness, good luck finding enough competent and self-motivated people to run your bureaucracy. In fact, forget that. Good luck getting your grand scheme passed through the political process without being hopelessly mangled into something else. A political favor here, a carve-out for government unions there, a concession or two to legislators who are up for reelection this year, and the grand scheme to optimize society gets morphed into something nobody actually wanted.

(Note that this post is not about Obamacare. I could write an identical example about neoconservative nation-building being hamstrung and underfunded by Democratic opposition and eventually taken over by a future Democratic leadership and perhaps abandoned by an exhausted or apathetic voting public. If you can imagine such a thing happening. This constraint is bipartisan.)

It's interesting to think about how this same political hobbling might apply to libertarianism. A grand mobilization to shrink government could conceivably backfire, and the populist backlash could leave us with more government (or anyway worse government) than we had before. I'm not sure how much I really buy this idea, but it's definitely something libertarians need to think about. Maybe legalizing drugs suddenly, rip-off-the-band-aid style, would lead to a temporary surge in overdoses while people figure out which drugs are truly dangerous and in what dosages. Maybe this would lead to a crackdown and leave us with even worse drug policy than we currently have (supposing that's possible). Or maybe we'd have blown the one chance in a generation to accomplish drug liberalization. The traumatic experience will take even milder liberalizations off the table, even if a temporary rise in overdoses is a perfectly acceptable loss from a utilitarian point of view. Most members of the voting public just don't have the patience or the bandwidth to process these policy questions. Stark yet misleading examples loom large.

Likewise, maybe a temporary experiment with open borders leads to a few minor terrorist attacks. Opponents of open immigration say, "See!" The voting public, oblivious to the utilitarian calculation, over-weights a few murders without comparing them to the millions of lives lifted out of poverty. They say, "Yes, I see. Close the borders down!" Again, the experiment could ruin immigration reform for a generation.

Maybe a tax reform includes lots of future cuts to government spending, but if those cuts don't actually happen we'll just end up with higher and less efficient taxes in the future. And maybe no sane person believes those cuts will actually happen.

I still think I should state clearly and honestly what the best policy is, without regard to political considerations. I'd love to see open borders, or even nearly open borders with basic background checks. I'd also love to see something more likely, like expanding immigration from ~1 million a year to ~2 million a year. But I think vastly liberalized immigration verging on fully open borders is better policy, and I might as well say so. I also think that complete and instantaneous drug legalization is probably better than a slow draw-down of existing penalties and barriers. I sometimes argue in favor of these other policies, like punitive taxes or user licensing, that achieve what current law tries to achieve more effectively and humanely and cheaply. "Drug legalization light" is probably more politically palatable and less likely to cause a backlash. But I still think that full legalization without guardrails is the better policy, and I feel I should say so honestly. If I were in a position to actually make a political deal and shape policy, I'd change my tune.

I also think it's possible to change the minds of the voting public. I know it's crazy, but I've seen it happen. If we say "Policy A is better than Policy B" often enough and clearly enough, maybe the voting public will come around. We shouldn't have to settle for "sub-optimal but palatable" policies. So there is a niche for people like Don Boudreaux, who ignore the political constraints and openly speak their minds.


I feel like two different concepts crept into my discussion of political constraints. One is popularity. Given enough political will, this constraint disappears. If there is political will for immigration reform, drug legalization, or tax reform, it will happen. The other concept is intrinsic government inefficiency. The incentive structure for government is inherently different than it is for voluntary institutions. You can't just "quit" a bad government program; you have to continue paying for it and perhaps submitting to it or being punished by it. All the political will in the world doesn't fix this problem. Unless the voting public becomes infinitely vigilant, government institutions will not be as responsive to their "customers" as voluntary institutions. Bureaucracies will seek to maximize their budgets while individual employees seek to minimize their workload. Some gunner-bureaucrats may seek to maximize their authority and acclaim, perhaps in pursuit of a nicer job or political career. Private bureaucracies have these problems, too, but they more quickly run up against budget constraints and the vetoes of shareholders and ultimately their customers. I meant for this post to be about the first kind of constraint, but lapsed into talking about the second kind.

Wednesday, December 13, 2017

Trolls: An Important Niche In the Internet Ecosystem

As much as I despise people who deliberately or negligently derail a perfectly good thread, I want to give trolls their due. Note that my definition of "troll" is perhaps more expansive than the official one. There are plenty of people who aren't deliberately trolling but are so incapable of controlling their outburst that they might as well be doing it on purpose; these folks are just as deserving of our opprobrium as self-conscious trolls.

First of all, an unscripted opinion is a valuable thing. The tamer, more refined conversations (like you might see on Steven Landburg's The Big Questions blog or Scott Alexander's Slate Star Codex) are sometimes too sanitized. That very nice person who is trying to counter your argument might have had initial thoughts such as "You're an idiot" or "You're an asshole." It's good etiquette to suppress these reactions and give a more considered response. But doing so conceals some information about your interlocutor's mental state. It's occasionally useful to have this information, and trolls provide it freely. The problem with giving this information up too freely is that it leads to escalation, even if done delicately. "Oh yeah? Well I think you're an asshole!" So it's probably best that we politely keep these things to ourselves, but use trolls to reveal hidden information.

Also, even really bad counterarguments can be useful. It's like a game of "'Why?' Boy," in which you keep asking yourself how you know something to get at deeper and deeper layers of understanding. This process is named after the stereotypical small child who constantly asks "Why?" to each one of your successive explanations. Even if you yourself fully understand the details of your argument, all the way down the rabbit hole to the deepest layers of comprehension, not everyone will grasp it on the first pass. A troll who is playing "'Why?' Boy" with you forces you to refine and recast your argument, making it simpler to understand and digest. Don't pass up the opportunity to respond to a very bad argument. It may not do the troll any good, but an onlooker might be impressed and actually learn something.

I hope there are more elegant ways of getting information about people's emotional reactions, or refining your arguments, such that we can do away with trolling. At least for the second thing, you can practice on your own. Just imagine someone blurts out a flippant response and try to respond to that. I try to do this, and it pays off. I often anticipate a counterargument ("anticipate" meaning "to plan for", not merely "to predict"), so I have a ready answer. And, of course, sometimes I say something wrong and someone corrects me, often politely but sometimes not. I learn from these exchanges, too. (Sometimes, it's fun to play, "What if I'm the one being a troll?" It forces you to be more charitable to someone who appears to be spouting gibberish; always entertain the possibility that they aren't but that you are.)

I'm not quite saying "Hail trolls!" More like, "If we're stuck with these shitty behaviors, we might as well make the best of it."

Unbroken Brain

[This is a very long post, but only the top 1/5th or so is "the post". The remaining ~4/5th is excerpts from Unbroken Brain. Feel free to consider the top 1/5th "the post" and the rest footnotes. How do I include enough detail to answer objections/issue qualifications without making the post so long that nobody will read it? This "the bottom bulk of this post is just a big footnote" is  my clumsy attempt.]

I strongly recommend the book Unbroken Brain by Maia Szalavitz. It is half autobiography and half a treatise on the science of addiction, with both halves merging together into a brilliant synthesis. Szalavitz describes in some detail her own addiction with heroin and eventual recovery. I have read some non-fiction books that attempt to interweave the scientific with the autobiographical and failed, but Unbroken Brain made it work.

Szalavitz pushes back hard against the "chemical hooks" theory of addiction. It certainly isn't true that the pharmacology of drugs compel people against their will to continue using. She points to the example of patients who spend weeks recovering from surgery on high doses of painkillers. They are gradually tapered off throughout their recovery and the vast majority of them never have addiction problems. Some of these people may not even connect their physical discomfort to the opioid withdrawal that's causing it. They may go home and experience a nasty "hospital flu," but it never occurs to them to go down to the corner and try to score some heroin to stave off the cravings. Indeed, the withdrawal doesn't even register as a craving. The drug-seeking addiction behavior is a learned behavior, not some once-and-you're-hooked effect of the drug. Likewise, babies who are born "addicted" don't grow up craving the drugs their pregnant mothers used. They go through incredibly unpleasant withdrawals and these newborns are very costly to treat, for sure. But they grow up with no memory of their "addiction." If they are more likely than the general population to become addicts as adults, that is far more likely a consequence of heritable causes of addiction. (Many personality traits are highly heritable, conscientiousness/impulsiveness included.) These babies born of addicted mothers did not have the self-awareness to connect their early suffering to the drug, and we don't retain memories from below age two anyway. Certainly not from the first few days and weeks after birth.

Szalavitz describes getting busted by the cops and being processed by the system. She goes through withdrawals and completes a treatment program. According to the biological/pharmacological/"chemical hooks" theory of addiction, this should have fixed her problem. It didn't. She describes being in custody, post withdrawal, and desperately wanting to get back to her apartment because she was quite sure the cops hadn't found her stash of Dilaudid pain pills. This story reminded me of a long passage in Chasing the Scream by Johann Hari in which the author describes his relationship with caffeine. Even after cutting out coffee cold turkey and going through those nasty withdrawals, Hari still felt the occasional craving for a hot cup of coffee with the resulting jolt of energy. Physical dependence is gone, but you're still sometimes left with a feeling of "Man, it sure would be nice..." or even "Today, I really need it." The point here is that addiction is not simply physical dependence. These are learned patterns of behavior that are deeply psychological; they persist long after the physical dependence has been beaten. Just as Szalavitz "learned" that an opioid high made her problems go away, Hari had "learned" that caffeine brings him superhuman creativity and productivity and lets him meet all his journalistic deadlines. Until these chemical fixes cease working. Tolerance sets in. A normal dose doesn't do anything for you. Withdrawals start hitting you when you're not taking your drug of choice, and you just feel shitty unless you're doing it all the time.

(I'm reminded of this post at Econlog by James Schneider. Apparently it's fairly common for heroin addicts to go through withdrawal while incarcerated, then to relapse when they get out. Relapsing when your tolerance has disappeared is quite dangerous. This is one of the most common causes of heroin overdose, at least it was until very recently.)

Szalavitz reminds her readers that the "drug-seeking addict-zombie" story is overplayed and defies common sense. Addicts don't shoot up in front of cops or judges. They often engage in deliberate, sometimes elaborate, planning to acquire their next high. Explanations of addiction in which the drug completely dominates the will are probably wrong, given these glimpses of self-restraint and deliberate planning. Salient alternatives seem to matter, too. Unbroken Brain reminds the reader repeatedly that people tend to outgrow their addictions. Most addicts develop their habits around their mid-20s but outgrow their addictions by their late-20s to mid-30s. Szalavitz describes this as undeveloped brains maturing and finally learning appropriate coping mechanisms. I think there's also a "salient alternatives" explanation lurking here. Perhaps early- to mid-30s is when you have to make a hard choice between a rewarding career and family, and a pathetic existence on the margins of society. A fully mature brain may be better at making decisions than an immature one, but incentives matter too.

(BTW, for more evidence of the "meaningful alternatives to drug use" thesis, read Carl Hart's book High Price. He describes a series of experiments in which drug users, heavily screened by the experimenters to ensure it was ethically done, are offered the choice of high-quality crack or money. Sometimes it is trivial amounts of money: a few dollars or a gift card. More often than not, the drug user turns down the crack. Yes, really.)

There is a long discussion of various drug treatment programs toward the later half of the book. There are "tough love" programs that emphasize responsibility, punishment, and withdrawal of privileges (and withdrawal of affection and even of contact with addicted loved ones). People in these programs are often committed against their will, confined to severely restricted living quarters, and punished or verbally abused for trivial infractions (or for no infractions, or for failing to adequately recite the programs catechisms). There have been many truly heart-breaking cases of abuse and even death resulting from these kinds of programs, and several multi-million dollar lawsuits have been won by the victims of the organizations that run them. And for all this misery, they just don't seem to work very well.

Twelve-step programs are another form of treatment that just don't seem to work very well. Szalavitz herself went through a 12-step program and had a pleasant experience with it. She describes it as working "for her," but she is extremely careful to caution the reader not to believe anecdotal evidence like the kind provided by her example. She goes so far as to say (paraphrasing): The next time someone tells you that some treatment "worked for them," ask them if they have an identical twin who did not receive the treatment. This is scientific journalism at its very best. It must be irresistible to sing the praises of a treatment that "worked for me," but Szalavitz nonetheless resists. She also discusses some of the hidden dangers of 12-stepping. She describes how some of the male members of 12-step groups use them to hook up with women, who they must assume are weak-willed or loose. In fact she describes barely escaping one such male who tried to rape her, and several friend who "weren't so lucky." If this is happening in 12-step programs, which I understand are meetings of equals, I can't imagine what must have been happening in some of the "tough love" programs which often have an authoritarian power structure with designated disciplinarians. (I once overheard a conversation at a coffee shop. Some old guy was saying that 12-step programs weren't much good for anything but picking up loose women. He said it in a tone that disparaged that kind of opportunistic behavior. Still, this is apparently a common perception. It's not something Szalavitz is making up or some weird idiosyncrasy of her group.)

There is one kind of treatment that works particularly well for opioid addiction: maintenance therapy. Give the addict a maintenance-level dose of a drug over an extended period of time. Taper them off when they are ready to quit. Given the discussion above about people eventually aging out of their addictions, maintenance therapy has the obvious advantage of keeping people alive until they are ready to quit. Because opioids don't cause the kind of cumulative organ damage that some other drugs cause, you can keep people on high doses for a very long time and they will come out of it unharmed. Alcohol damages your liver and kidneys and cocaine damages your heart, at least if you overuse these substances. No such problem for opioids. The biggest risk with heroin or prescription painkillers is an accidental overdose (and most so-called "overdoses" are actually mixtures of drugs that interact to slow your breathing, such as with benzodiazepines or alcohol). People have moralistic hang-ups about maintenance therapy. They think it's simply "trading one high for another." But for the most part maintenance therapy patients aren't getting high. Maintaining someone on a very high dose of opioids might actually make it hard or impossible for that person to get high. Maintenance therapy patients do relapse and overdose occasionally; it's not like this is a 100% cure or a magic bullet. But it seems to work better than any of the alternatives.

Unfortunately, drug addicts who are processed by "drug courts" or who are on probation may not legally have access to maintenance therapy. These people may have strict abstinence conditions applied to them. They may be forced into a twelve-step program. Their "treatment" may be overseen by someone with no psychiatric or clinical training. Szalavitz describes encountering one such clueless "counselor" during her treatment; the book The War on Drugs: An Old Wive's Tale by Christine Shuck describes similar frustration with poorly qualified individuals. In responding to the recent "opioid epidemic," some people are positively giddy about expanding drug treatment and drug courts. Unless these treatment programs are strictly voluntary, and unless drug courts are assigning people to maintenance therapy, I'm extremely skeptical that these policy levers will do any good.

Anyone who is interested in drug policy should read Unbroken Brain. I've read every book I could find on drug policy, and this one had some novel ideas and information I hadn't seen elsewhere.


Below are some passages I highlighted.

On brain maturation:
Brain maturation stage is also important: Addiction is far less common in people who use drugs for the first time after age 25, and it often remits with or without treatment among people in their mid-20s, just as the brain becomes fully adult. In fact, 90% of all substance addictions start in adolescence, and most illegal drug addictions end by age 30. The implications of the developmental perspective are far-reaching. For one, if addiction is a learning disorder, fighting a “war on drugs” is useless. Surprisingly, only 10–20% of those who try even the most stigmatized drugs like heroin, crack, and methamphetamine become addicted. And that group, which tends to have a significant history of childhood trauma and/or preexisting mental illness, will usually find some way of compulsively self-medicating, no matter how much we crack down on one substance or another. In this context, trying to end addiction by attempting to eliminate particular drugs is like trying to cure compulsive hand washing by banning one soap after another. Although you might get people to use more or less harmful substances while in the grips of their compulsions, you aren’t addressing the real problem. Second, given that addiction is a learning disorder, it isn’t necessarily a lifelong problem that demands chronic treatment and the acceptance of a stigmatized identity: studies find that the majority of cocaine, alcohol, prescription drug, and cannabis addictions end before people are in their mid-30s and most do so without treatment. Similarly, between one third and one half of children diagnosed with ADHD no longer meet criteria for it as adults, and treatment doesn’t seem to affect whether they outgrow the disorder or not, although it certainly can affect their ability to thrive.
 On the rareness of addiction, even for "dangerous" drugs:
Though drug education programs tend to avoid publicizing these statistics, the expert consensus is that serious addiction only affects a minority of those who try even the most highly addictive drugs, and even among this group, recovery without treatment is the rule rather than the exception.
On the bizarre double-standard for alcohol:
These ideas about the failure of Prohibition to arrest addiction are now widely accepted—at least in the case of alcohol. However, they aren’t nearly as well established in relation to illegal drugs, even though addiction rates for users of heroin, methamphetamine, and cocaine are comparable to those seen with alcohol, and addiction rates for marijuana are lower.
 On how people "learn" addiction through repetitive behavior:
But in OCD and Asperger’s, as in addiction, over time the behavior stops serving its intended purpose. Rather than making things better, it starts to make them worse. Unfortunately, by this time, habitual responses are already deeply engrained and well learned; and even if you know the ritual you perform to try to make you less anxious will actually make you more so, you don’t believe it. You feel compelled to repeat it, even when you are utterly sure that it will not help. This is the heart of why addictions—and, not incidentally, OCD—are learning disorders. It also has critical implications for drug policy. OCD is not driven by the wonderful anxiety-reducing properties of, say, hand washing. There is not something hidden in soap or water that makes people want to wash and wash again. People don’t “catch” OCD by simply washing their hands—and, by the same token, they don’t develop drug addictions by just taking drugs. Preexisting differences in temperament and in negative experiences are what drives the learning of addiction.
 On the futility of punishment as a "cure" for deeply ingrained behaviors:
A child with autism may seem more typical if he stops flapping his hands—but this by itself doesn’t alter the underlying reason for the activity or change his autism. As a result, the behavior will either be hidden or replaced by a substitute action if the real driver of the behavior isn’t addressed. Indeed, many autistic adults describe being traumatized by therapies aimed at suppressing their self-soothing and self-stimulating behavior because this left them exhausted, upset, and without alternative means of coping.
 On the difference between dependence and addiction:
Addiction is, first and foremost, a relationship between a person and a substance, not an inevitable pharmacological reaction. A striking example of this can be seen in people who are treated for pain with opioid drugs like morphine or Vicodin for several weeks in the hospital following surgery or accidents. That is enough time for some people to develop physical dependence, although even something as seemingly biologically standard as the amount of time it takes to become tolerant and dependent is actually quite variable. People who do become dependent will experience symptoms like nausea, vomiting, cramps, sleeplessness, and diarrhea when released to go home without medication. However, many of them never realize that this “hospital flu” is actually opioid withdrawal. They don’t suddenly, out of nowhere, get an urge to “cure” the problem by buying painkillers or heroin on the street, because they haven’t learned that lack of drugs is the source of their symptoms. Because they haven’t identified drugs as the source of their comfort or as the best way to cope, they don’t have the severe anxiety levels seen in people with addictions during withdrawal. If you haven’t learned that a drug “fixes” you, you cannot be addicted to it, even if your body is dependent on it. Past ideas about “physical” and “psychological” dependence, which still shape public opinion on drugs today, led us down the wrong road. The idea that physical dependence was “real” addiction but psychological dependence was a mere trifle led people to ignore the role of learning.
 The failure to distinguish between physical dependence and the learning that creates addiction is also why, contrary to claims you may see made in the media, babies can’t actually be “born addicted.” Infants can be born with physical dependence on a drug like heroin or Vicodin, but since they do not learn the vital relationship between choosing to take the drug and feeling better, they can’t crave it.
 Addiction may have some genetic causes:
And genetics interacts with learning in many ways to create addiction. Consider the fact that about one in seven people seriously dislikes opioids—the drugs themselves make them feel nauseous, dizzy, and uncomfortably, rather than comfortably, numb. While many people think that heroin or Oxycontin are heavenly for everyone, that’s only true for a minority of users. Longtime CBS News anchor Dan Rather, for example, once took a shot of heroin for a news program. He said that he’d never want to repeat the experience and that it gave him a “hell of a headache.” Two normal volunteers who injected heroin for several days (in a 1969 experiment that would now be considered unethical) also found it primarily unpleasant. “My personal view at present is just one made grey and utterly grim by heroin. The extraordinary thing is that it brings no joy, no pleasure.… At most, some hours of disinterest … how can people want to take this stuff? To escape to all this—life must be hell if they want to escape to all this.” A more recent study, which gave 228 healthy adult twins an intravenous infusion of alfentanil—an opioid around five times stronger than heroin—found that only 29% emphatically liked it. Most had mixed (58%) or neutral (6%) experiences—and 14% found it outright unpleasant.
This rings true to me, incidentally. I was prescribed hydrocodone after oral surgery several years ago. It made me feel sleepy and uncomfortable without actually helping my pain or allowing me to fall asleep. I must be one of those people who has an unpleasant reaction to opioids.

Some interesting data on people with very well controlled heroin habits, which is quite contrary to the popular wisdom:
The way cultural pressures, individual expectations, and other aspects of people’s state of mind affect the amount of control people have over their drug use was first explored in Norman Zinberg’s classic, Drug, Set, and Setting. The book examined controlled use of marijuana, heroin, and psychedelics in the absence of addiction and was among the first research to show that nonaddictive drug use was even possible. Zinberg found people who took heroin only on weekends for decades without negative consequences; he also did the first study showing that although nearly half of American soldiers in Vietnam took drugs like opium and heroin, 88% of those who had been addicted while overseas did not become readdicted upon returning home. Other researchers later confirmed that even among those who used heroin a few times after coming back, when they were out of the war zone, the overwhelming majority did not return to addiction, to the great surprise and relief of the military leadership. Indeed, those who relapsed—around 1%—were mainly those who had had drug problems before the war.
 The amazing effect of maintenance therapy on mortality:
Maintenance treatments are the only therapies that can lower mortality by 75%—something that would be considered a miraculous success in any other type of treatment but addiction care.
 Maintenance might even block the ability of addicts to get high by building up their tolerance to very high levels:
The end result is that on a dose that could kill a user with no tolerance, stable maintenance patients can work, drive, and be otherwise unimpaired, simply because their dose is not varied and is taken regularly and consistently. Tolerance also means that maintenance does not block emotional growth or automatically make people distant in relationships. In order to use opioids to escape emotion, you need to get “high,” and stable maintenance patients are too tolerant to do so. Unfortunately, because people don’t understand these basic facts about the role of timing and dosing in addiction, maintenance patients are stigmatized as being constantly “high” and “not really in recovery,” even though tolerance means that this is inaccurate.
 This is something weird that I remember reading in a high school psychology textbook. This passage brought it back to me:
In these cases, the unconscious cues that normally activate tolerance don’t do so—and without tolerance, the normal dose becomes an overdose. It seems that sometimes, context alone can change a safe dose to a lethal dose. And this effect can even be seen in rats: if they are made tolerant to a high dose in one place and then given the same dose in a new environment, 50% will actually die of overdose.
I remember reading about some sick, dying old man who got his morphine in his study rather than the living room where he usually got it, and promptly died from respiratory suppression. I guess it's a real effect after all.

The double-standard for alcohol might be warranted if only it worked against alcohol:
Alcohol, incidentally, also does not work for maintenance. Unlike opioid tolerance, alcohol tolerance doesn’t completely eliminate impairment, even if the drug is given in steady, regular doses. That means that even with high levels of tolerance, heavy alcohol users on a consistent dose are still significantly impaired. Contrary to the claims of those who criticize opioid maintenance as “just replacing vodka with gin,” the difference is that opioids produce complete tolerance in steady-state dosing, while alcohol does not.
 On salient alternatives:
People with decent jobs, strong relationships, and good mental health rarely give that all up for intoxicating drugs; instead, drugs are powerful primarily when the rest of your life is broken.
 On Rat Park:
Although a few early experiments failed to replicate the Rat Park effect, most did so.
I think these experiments on Rat Park are a little beside the point. These were experiments in which rats were given enriched environments: larger cages, more toys, more rats to socialize with. They were found to consume less cocaine (or sometimes not!) than rats kept in very small, desolate cages. I don't particularly care if the replications are real or not. The lessons of Rat Park may or may not apply to rats, but they certainly apply to humans.

On the decision-making of adolescents and young adults:
CORNELL’S VALERIE REYNA studies how young people’s risk decisions can go awry—and her conclusions are counterintuitive. Her research suggests that the major reason that teens and young adults are unreasonable about risk is not that they are too emotional when they consider it—but rather, that they are too rational. Although my own behavior during my late teens and early 20s now seems completely irrational to me, her work helps make sense of it. As noted earlier, studies find that adolescents often significantly overestimate their odds of bad outcomes from activities like sex and drug use. For instance, when asked to estimate the odds that a teenage girl who is sexually active will become infected with HIV (in a study conducted in the ’90s, when AIDS was not as treatable as it is now), the average guess was 60%. The actual risk was less than 1% for an American teen in most parts of the country. But even absurd overestimations like this don’t deter youth. And that’s not because they don’t consider them. Instead, there are two important factors. First, young people do tend to weigh immediate benefits more heavily: the visible prospect of pleasure literally looms larger in their minds than anything else that might happen later. Second, adolescents get lost in deliberation when they do consider negative consequences—and being out in the weeds doesn’t tend to spur good judgment.
In contrast, teens and young adults haven’t developed this rapid gut-level calculus. Instead, they “rationally” and deliberately think through the odds of success in things like playing Russian roulette, drinking Drano, or setting their hair on fire.
I found it interesting that young people overestimate the risks of drug use but do it anyway. That suggests that any government program that tries to accurately communicate the risks to young people will be counterproductive.

On the rationality of addicts:
People with addictions typically don’t shoot up when the police are watching; we often work quite hard to hide our behavior. We also specifically plan things like drug deals by taking steps to avoid detection.
 Szalavitz describes her harassment at the hands of police:
Immediately after they arrived, two of the officers took me into the hallway outside my apartment. I was now high, still feverish and completely dazed; I was also terrified. Their guns were prominent and visible to me in their holsters. They promised that if I signed the form that they shoved in my face, they wouldn’t arrest me. Stupidly, I complied. To this day, I still don’t understand exactly why: it must have been some combination of fear, fever, intoxication, and perhaps my ongoing Aspie tendency to take what other people say at face value. Aside from selling drugs, it’s probably the single most idiotic thing I ever did. Of course, the police were lying to me; if I had been thinking at all clearly, this should have been obvious. The document turned out to be permission to search. They had no warrant. If I hadn’t signed, there might never have been an attempt to prosecute me.
I just want to say, I have zero respect for cops who do this shit. Using a drug offense as a pretext for incarcerating someone who's "really" guilty of something else, okay, sure. But deliberately talking drug "offenders" out of their legal rights in order to make a pointless drug bust? This is pure social harm with no corresponding benefit. These cops are doing enormous harm to society because "the law" tells them it's okay. I find this just unbelievably irresponsible. Even granting that police officers have to follow the law, they have quite a lot of discretion regarding who to target and what crimes to prioritize. They have a responsibility to de-prioritize bad mandates that harm the communities they serve. Drug policing is a prime example of something that should be given extremely low priority.

 On the downfall of Synanon, a "tough love" treatment program, run by Charles Dederich:
Ultimately, Synanon’s downfall began when Dederich ordered his henchmen to place a derattled rattlesnake in the mailbox of Paul Morantz, a courageous attorney who’d won cases against the group. The snake bit Morantz, who, fortunately, survived. (Dederich eventually did time for conspiracy to commit murder in the case; when arrested, the “ex-alcoholic” who had found a “cure” for addiction was drunk.)
 Once again, these programs were never tested for effectiveness:
Many Tough Love members became prominent within Al-Anon and treatment organizations. They advocated publicly for tougher laws and for harsh, Synanon-based treatment programs like Straight, Incorporated, which actually traumatized thousands of families. As with AA, however, Tough Love was never tested before it was widely accepted and implemented. While there are clear indications that it can sometimes do harm, no one knows how widespread the problem is because there is virtually no research on what happens to people whose parents or spouses decide to practice it.
 Another "tough love" horror story:
In 1986, though, I was in the grip of the system. That year, I read an article in the New York Times Magazine that terrified me. It was a positive profile of a New Jersey program called KIDS, an unapologetically harsh youth rehab. Treatment at KIDS consisted primarily of sitting rigidly in one particular position on hard chairs for 12-hour days and being subjected to constant emotional attacks. I would later write a book that exposed just how torturous and harmful that particular program was. I learned, for instance, that one thirteen-year-old girl, who didn’t even have a real addiction, was held in it for thirteen years, eventually winning a $6.5 million settlement in a stunning civil case that exposed emotional, physical, and sexual abuse.
Szalavitz describes her encounter with an unqualified addiction counselor:
 Nationally, this lack of genuine qualifications is more the rule than the exception among addiction counselors, even now.
 Here is the part where she tells the reader to not trust her own anecdotal evidence in favor of 12-step programs:
It’s impossible for me personally to know whether 12-step groups were essential for my recovery—or whether another method would have been just as effective. In fact, when someone says to me that the 12 steps or any other treatment were the “only thing that could have helped,” I sometimes ask whether the person has an addicted identical twin who failed all other approaches to provide a counterfactual control. The lack of this type of evidence—obviously, with far larger numbers, not just one case—is the problem.
 Anecdotes, in contrast, can make quack treatments seem effective and thereby deter progress for years, even centuries. A critical part of why addiction treatment fares so poorly in contrast to general medicine is that it has not been held to a standard that requires scientific proof. It isn’t even held to the Hippocratic oath of ensuring first and foremost that no harm is done.
 Bravo. Her relief at the end of her legal troubles:
The official end to my encounter with the Rockefeller laws was so bureaucratic and anticlimactic, thankfully, that I can barely remember it. According to records that are now sealed, it occurred on July 17, 1992, nearly six years after my arrest. That day, Judge Snyder granted a motion by my lawyer to dismiss the case “in the interest of justice.”
 Harm reduction as universally accepted in another context:
In alcohol policy, harm reduction (though not labeled as such) has long been both successful and relatively uncontroversial. The “designated driver” is a harm reduction approach: it accepts that people will drink to excess and works to cut drunk driving, not drinking. Media campaigns against driving while intoxicated also fall under this rubric. Just as needle exchange is neutral on needle use per se, campaigns that criminalize or stigmatize stigmatize taking the wheel while drunk do not argue that drinking itself is wrong. Their target is impaired drivers.
It would be nice to see this context-dependence applied more broadly to other substances.  It's like I've said before, drinking per se is not the cause of drunk driving. Likewise heroin use per se is not the cause of property crime.

Interesting bit about how opioids may be useful for treating depression:
Historically, in fact, opiates were among the first antidepressants—and there is now research suggesting that the opioid maintenance drug Suboxone can help with depression that is resistant to other treatments.
 On her response to antidepressants:
Of course, for a person who is undersensitive, reducing emotionality could truly be awful and perhaps even produce suicidal thoughts or pathological ennui. For a sociopath, it might reduce empathy even further, which could be catastrophic. In other people, it might be neutral. However, for me, it was positive. The action of a drug depends not just on its pharmacology but on the person’s baseline. If you are starting out way too high on a dimension—even a seemingly good one like sensitivity—going lower may be helpful. The wide range of responses to antidepressants probably has to do with the huge variety of natural human wiring, which can make the same drug into a poison, a panacea, or a placebo, depending on the dose, the timing, and the patient.
Once again, drugs don't simply have one effect on all humans. There is heterogeneity in human responses to drugs. It makes sense that this will be particularly true of psychiatric drugs, given that the symptoms are incredibly subjective experiences (and certainly no less real for that).

On the total hypocrisy of American drug policy:
No sane policy maker, for example, could justify allowing commercial sales of a drug like tobacco, which cuts life expectancy by ten years on average, while using incarceration to punish those who take marijuana, which is not associated with increased mortality at all. Our policies are not based on rationality, risk assessment, or logic—just history.
I have never heard a serious response to this point. I have heard plenty of unserious responses.

 An amusing story of a bureaucrat in New Zealand testing a popular synthetic drug and concluding that there's nothing to worry about:
Given that it was his job to investigate BZP, Sellman decided to try it himself, as an added data point for his research. “I went down to Cosmic Corner,” he says. “They gave me this little packet. I went home on a Friday night and took it and sat in front of the television, waiting.” Nothing happened at first. “But the extraordinary thing was that I was still sitting in front of the television at four o’clock in the morning and I just didn’t need to sleep,” he says. The next day he had what he describes as the world’s worst hangover. “I went back to the [committee] and said, ‘You don’t have to worry, really, about this drug,’” he says, citing the lack of euphoria and the aftereffects.
There is a long and interesting section about New Zealand's attempt to legalize and regulate its synthetic drug market. Of course, governments who attempt to ban new synthetic after new synthetic are missing the point:
AS MANY OTHER countries have since discovered, outlawing one legal high doesn’t solve much. The Kiwi BZP ban set off an early version of a pattern now familiar globally: the legal highs arms race. One substance would be banned, only to be replaced by another, sometimes more harmful than the last. “I’ve banned 33 separate substances, 51 or 52 different products, and they keep being reformulated and reappearing,” New Zealand Associate Minister of Health Peter Dunne told a local paper, looking back at the worst period, in 2013. By then over 4,000 New Zealand stores were selling legal highs.
Keep pushing that boulder up the hill. Maybe one day you'll get there!
There are legal complications, too:
The inability of experts to agree on what an analog really is makes prosecuting these cases complicated—and the U.S. Supreme Court recently ruled that prosecutors must prove that sellers know the drug is an analog if they are to be convicted.
This isn't a problem that you can just "legislate away." Fundamentally, the law has to be predictable and pre-defined. Otherwise police and prosecutors are just making up the law as they go. Err...more so.

Pleasure counts:
But these issues are where values shape science and where the rubber hits the road in recreational drug regulation. Typically, pleasure and transcendent experience have not even been seen as worth consideration in discussions of recreational drug laws; only harms are counted, with benefits seen as being products of user delusions or simply ignored.
 Bravo. It makes no sense that any drug that's fun is automatically banned, no matter how insignificant the risk. There are broad classes of drugs that have almost no overdose risk, do no cumulative organ damage, and that aren't addictive. Psychedelics and dissociative anesthetics, for example, are mostly harmless. The knee-jerk urge to ban them is literally puritanical.

On cops and prosecutors playing doctor:
In essence, the drug court system allows judges to practice medicine without a license—deciding what medications and treatments are acceptable in a way that they never do for other illnesses. No judge, faced with a mentally ill defendant, says that he can take only Haldol but not Risperdal, or that talk therapy must be psychoanalytic, not cognitive. However, drug court judges frequently require that patients be denied or tapered from medications that are the standard of care, and often, they only allow them to attend certain programs.
Law enforcement folks are fundamentally unqualified to make these kinds of decisions, but they give it a go anyway. It doesn't have to be this way:
 Police enforce laws—unless these laws are changed to make drug possession for personal use legal, people with addiction will face prosecution for what they do every day in order to cope.
 On the shining example of Portugal:
Since the law was changed nearly 15 years ago, Portugal’s results have been astonishing—at least to those who predicted that such a move would produce a chaotic, drug-crazed country. HIV infection rates in drug users have fallen, the number of people in treatment rose 41%, and drug use rates by teenagers declined.
BTW, the Portugal example is also something to which I've never heard a coherent response but have heard many flippant ones.

On the self-limiting nature of drugs that are "too good":
Healthy users, who make up 80%–90% of those who try drugs, often become scared when a drug is too euphoric, rather than purely delighted. They frequently say things like, “It was so good; I knew I couldn’t risk taking it again” in response to the same experience that people who go on to develop addictions respond to by using more as soon as possible.
In other words, people anticipate addiction risk and (mostly) adjust their behavior for it. People don't just keep doing "good feeling thing" over and over again until they collapse. They anticipate the bad consequences and the onset of tolerance (or mere habituation for non-drug thrills). They avoid behaviors that are "too tempting", or relegate them to strict scheduling.

Drug prohibition is "reverse-optimized" to target the people we don't need to worry about and miss the people we should worry about:
However, because there is always a demand for mood-altering substances and the most vulnerable people are the most likely to get addicted, absolute prohibition tends to deter those who aren’t at risk and harm those who are, by criminalizing them.
I've also noticed this.

Reiterating that drug addicts retain their free will:
Although the traditional disease model suggests that people in the grip of addiction have no free will, this has never fit the facts. As noted earlier, addicted people don’t get high in front of the police; they plan specifically to ensure their supply and to avoid being detected. They frequently end addictions when circumstances change, such as when they fall in love, get a new job, or graduate college. On the other hand, addicts certainly also behave compulsively and apparently irrationally.
Advocating decriminalization:
 One policy change that is completely supported by existing data is decriminalizing low-level possession and personal use of all drugs. Arresting and jailing users makes no more sense and is no more effective for heroin and cocaine users than it is for marijuana users. There may be some drugs for which prohibitions of sales remain sensible—but this shouldn’t be the unquestioned default because our policies were not originally made rationally.
I loved this short bit (emphasis mine):
 People who use drugs also need access to accurate harm reduction information—and this includes high school and college kids, who are at the age when use is most common. They need to know, for example, that mixing depressant drugs like alcohol with pain relievers can be deadly, but that there is no way to overdose on marijuana. Telling kids that all drug use is bad is not effective: teens are exquisitely sensitive to hypocrisy and this makes them dismiss fear tactics that don’t jibe with their own experience.
The "just say no" and the hyperbolic scare tactics are likely to backfire, in other words. And, yes, it's perfectly fair for junior to point to your scotch and cigar and even your coffee when you scold him for his marijuana use.

On stigmatizing drug use:
  It is impossible to simultaneously criminalize and destigmatize a behavior: one of the key points of criminalization is, in fact, to deliberately create stigma in order to deter lawbreaking. How can you destigmatize a condition as you argue that your patients only respond to the brute force of the law?
I had an interesting conversation recently in which someone claimed that the social stigma against drugs is a "free lunch." It's a punishment that deters conscientious people, but that low-conscientiousness/high-impulse individuals, the kind who are especially prone to drug addiction, don't feel it. It was an interesting attempt to push back against the arguments I presented in my recent post Against Drug Prohibition, but I think it fails. People who persist in their drug use are definitely harmed by the social stigma. They feel the censure, if not viscerally, in denied job opportunities or the dismissal of their real problems by uncaring third parties.

I loved this excerpt in which Szalavitz describes being given naloxone. It speeds up withdrawal, but it also intensifies the very unpleasant withdrawal symptoms:

I lay on a gurney, shaking and crying, holding my mother’s hand. At some point, I was given a shot that seemed to have no effect. The nurse wouldn’t say what it was. I later learned that I’d been injected with naloxone, an opioid antagonist that is merciful when used to revive overdose victims but slightly sadistic for someone already in withdrawal, as it can intensify the symptoms. It works as an antidote, removing any remaining opioid drugs from their receptors. (It is the same drug now being made available to addicts, their loved ones, and police officers to reverse overdose, and this way of using it undoubtedly saves lives.) 
I guess the “therapeutic” rationale for administering naloxone in detox was the theory that this would more rapidly remove the drugs from my system; the punitive one is that it increases your distress. Naloxone worsens withdrawal symptoms and it was given without my consent—another sign of the paradoxical way addiction is viewed as both a sin and a disease. The idea that addicted people should have the right to informed consent like any other patient wasn’t even considered. Though treatment and punishment were supposed to be opposite approaches, in fact, harsh moralistic tactics were the rule, not the exception, when I sought help, and they are still part of the treatment experience for most people with addictions.
Emphasis mine. What a crazy idea, that an addict be treated like a human patient?  That their preferences should be acknowledged and their consent acquired?

Tuesday, December 12, 2017

The President's Opioid Commission

I was going to read the recent report by the President's Commission on Combating Drug Addiction and the Opioid Crisis and give a scathing review. It turns out that Jacob Sullum pretty much nailed it so I don't have to. Still, I read the first 50 pages and skimmed the rest (the report is very repetitive so I'd be surprised if I missed any major themes). The report starts with 56 bullet points, not a single one of which says, "Let's back  off of this failed program." Almost every bullet point is a call to expand existing government programs or add new ones. My response after reading their list was, "No thanks, you've done quite enough already." The whole thing stinks. The authors of the report and the policymakers they are writing for apparently lack any ability to be self-critical. It's like they can't see, or can't even imagine, that this whole sad episode is the fault of bad policy, namely drug prohibition. The report utterly fails to address or even acknowledge the argument put forth by legalization and harm-reduction advocates. That's why it's hard to take seriously any report that comes out of the official government drug policy bureaucracy. If this was at least a conversation, where critics make arguments against government policy and the relevant government agencies respond honestly to those arguments, I'd have more hope. Instead, what I see is a bureaucracy spews nonsense, then plugs its ears and shakes its head when you try to explain how insane it sounds. On the few occasions when I've gotten drug prohibition advocates to actually engage in argument with me, they offer ridiculously flippant and obviously ad hoc arguments, promptly leave the conversation when challenged, and occasionally reappear to make the same silly arguments with no apparent memory of the previous discussion. I'd like to be more charitable than that, but I've seen this pattern a number of times. I think the drug enforcement and drug policy-making apparatus is so entrenched and conservative that it isn't allowed to question its existence. It seems that certain policies are not even allowed for consideration. The report confirms all of these impressions for me.

The report pretty much rehashes the standard narrative of the opioid crisis, which goes something like:
Lax prescribing standards and a dramatic increase in the amount prescribed lead to opioid abuse and increasing overdoses. With their appetites for opioids now stoked, normal patients graduated to opioid abuse, and prescription opioid abusers graduated to heroin.
As I've argued, this story makes no sense. You would have expected to see a rise in opioid abuse over the period when opioid prescriptions were trippling, but this trend of rising abuse utterly failed to appear. A few irresponsible journalists are writing silly articles about how drug libertarianism is a failure, when in reality we haven't tried anything vaguely resembling drug legalization. The rise in heroin overdoses doesn't necessarily have anything to do with the earlier increase in opioid prescriptions. More likely, it's just an effect of fentanyl and other super-powerful opioids making street "heroin" cheaper, with the lower price attracting new users. Heroin definitely got deadlier. It's not simply that the number of users increased; the deaths per user also increased by a factor of two or so. This supports the notion that heroin today is more likely to be adulterated than it was six or seven years ago, before heroin deaths started rising. This issue of heroin adulterated with fentanyl is 100% a product of drug prohibition. When asked, heroin users say they are scared of fentanyl. They know about the overdose risk and try to avoid it. From a testimonial that I can't find now, they tend to say that heroin gives them a more "mellow" high, whereas fentanyl just knocks them out. It's not pleasant and it's downright frightening. If these addicts could get their hands on legal, pharmaceutical-grade heroin of known purity, we wouldn't be seeing any of these fentanyl or heroin overdoses. Once again, you can read the entire report by the president's commission without learning any of these important details.

A couple of useful links from Sullum's Reason piece. Here is an absolutely heartbreaking list of suicides that happened after chronic pain sufferers were cut off from their opioids. These poor people were treated with suspicion by their doctors and eventually cut off from the only thing that worked for them. Expect more of this if we continue with current policy, that is if people like Robert VerBruggen and German Lopez actually succeed in influencing policy with their misleading and incomplete reporting on opioids. When people are choosing death over an existence without opioids, that probably means those people have very real and very serious problems with chronic pain. They weren't just "faking it" in order to score. Even admitting the caveat that these are merely plural anecdotes and not true data, for every one of these stories there are surely dozens or hundreds of chronic pain patients suffering in silence. For each suicide on this list, surely there were several that didn't generate a media presence or didn't pass the author's vetting criterion for inclusion. There is little doubt that patients are being denied necessary medicine, medicine that they are deadly serious about needing. (I can't find the link, but Radley Balko has said he's received hundreds of e-mails from chronic pain sufferers who couldn't get the opioids they needed. They started writing to him after he published some blog posts and articles on this topic.) Keep in mind the journalists who are critical of "loose" opioid prescriptions don't actually have a better mechanism for sorting true pain sufferers from fakers. They are just saying "tighter prescribing guidelines." It's not "We have a better predictive model," it's more like "change the threshold." They are in effect saying, give us fewer false positives but more false negatives negatives, fewer abusers but more untreated pain.

Sullum also links to a suggestive study from Massachusetts. It seems that only about 8% of decedents had a prescription in the months prior to their overdose. If this is reflective of nationwide patterns, it seems that most overdoses aren't normal pain patients who just accidentally mix substances, but are more typically people abusing opioids that they weren't legally prescribed. I could believe either way. If these stats were more definitive and nationally representative it would render a verdict in favor of the "illicit use" theory (over the "sloppy/inappropriate legal use" theory).

Finally, there are some useful statistics about the fraction of painkiller users who become addicts.
According to the National Survey on Drug Use and Health (NSDUH), 98 million Americans used prescription analgesics in 2015, including both legal and illegal use. About 2 million of them qualified for a diagnosis of "substance use disorder" (SUD) at some point during the previous year. SUD is a catchall category that subsumes what used to be known as "substance abuse" and the more severe "substance dependence." The Substance Abuse and Mental Health Services Administration, which oversees the survey, does not report the breakdown between mild, moderate, and severe SUD. But based on this survey, it looks like somewhere between 1 and 2 percent of prescription opioid users experience addiction in a given year. By comparison, NSDUH data indicate that about 5 percent of past-year drinkers had an alcohol use disorder in 2015. That group was about evenly divided between "abuse" and "dependence."

The NSDUH numbers provide a one-year snapshot. Some studies of patients who take opioids for extended periods of time find higher addiction rates, but they are still generally modest. A 2010 review found that less than 1 percent of patients taking opioids for chronic pain experienced addiction. A 2012 review likewise concluded that "opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence." A 2015 review noted addiction rates in various studies ranging from 3 percent to 26 percent in primary care settings and from 2 percent to 14 percent in pain clinic settings.

The risk of fatal overdose among patients is very low. The CDC cites "a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain" who were followed for up to 13 years. The researchers found that "one in 550 patients died from opioid-related overdose," which is a risk of less than 0.2 percent. A 2015 study of opioid-related deaths in North Carolina found 478 fatalities among 2.2 million residents who were prescribed opioids in 2010. That's an annual rate of 0.022 percent.
If you're suffering from chronic pain, or even acute pain that's only expected to last a few days or weeks, this might not seem like a bad deal. Yes, there is some non-zero risk of addiction, diversion, and overdose, but it's overwhelmingly worth the risk. Especially considering that anyone can simply decide to be cautious, take their medicine as prescribed, and not become an addict. (Call me crazy, but I'm one of those weird people who believes in free will and freedom of choice.)  It's clear from the report that the commission places almost no value on pain relief. They recommend removing it from patient satisfaction surveys. They want doctors to cease considering it "the fifth vital sign." That's truly sad. Sure, they might succeed in stopping doctors from juking the stats by over-prescribing pain medicine, but they're also going to leave a lot of people suffering in a living hell. Keeping pain medicine away from chronic pain sufferers is possibly the very worst thing our government does. Even separating it from the drug war generally and giving it its own heading, I'd put it at the very top, right up there with "draconian immigration restrictions."

Wednesday, December 6, 2017

It's Very Hard to Deter Illegal Drug Production

See the table of annual death rates in the middle of this post

 The death rate for a Chicago crack dealer is actually higher than the death rate for a Texas death row inmate. About 7% per year for the crack dealer and about 5% per year for the death row inmate. That means it should be very hard to deter drug dealers, given that they are willing to pay (are indeed already paying) a very high cost to work at their job. If crack dealers are facing a 7% annual chance of death, presumably they’d laugh off a milder penalty, like a small chance of a long prison sentence or a fine of almost any conceivable magnitude. The penalty would have to be something comparable to what they’re already paying to have any effect at all (unless we propose there’s some weird cliff in the supply function). The penalty would have to be comparable to actually placing them on death row, and that’s after multiplying by the probability of catching them. Presumably this is less than 100%.

Sure, sure, pick nits. The data are out of date. But presumably the magnitudes aren’t too far off. Even if the risk of death comes down by an order of magnitude or more, that’s still a very large cost and it’s going to be very hard to deter that person. Or perhaps: Texas death row inmates all eventually get put to death, but crack dealers don’t face the same certainty. Fair enough, but let’s do a multi-year comparison then. Ten years as a crack dealer nets you a ~52% chance of death (under the 7% per year assumption). Twenty years gets you a 77% chance. That’s not 100%, but it’s still big. And I’d imagine some large fraction of death row inmates escape execution, even in Texas. I don't know what the fair comparison is, but you don't get away from "Drug dealers are willing to endure very large costs to keep being drug dealers."

Imagine someone is spending a million dollars a year to produce something, which he sells at a profit. You say, “Stop doing that! Or I’ll fine you $100!” He’ll laugh you off. “Okay, $100,000!” He talks to his accountant and decides to up the price a little to cover this fine, which he just considers a cost of doing business. “Okay, $1 million!” Now you’re hurting him a little, because presumably he’ll have fewer customers if he raises his price to cover the cost. But he can still raise the price to nearly cover the cost you’re imposing on him. If what he’s producing has very inelastic demand, as many drugs do, the price will rise high enough to recover most of the additional costs. 

The legal penalties for drug production and distribution are very high, at least in the United States where I live. I consider them draconian, downright evil in fact. But compared to a 7% chance of death per year? Good lord! 

Scattered Thoughts on Net Neutrality

I have a few scattered thoughts on net neutrality. It seems to have left the news cycle after a brief flare of outrage. That’s fine, by the way. I don’t mind commenting on “old news.” It’s more useful to thoughtfully research something and try to actually learn something useful than to shout slogans and emote at the news. My impression is that 95% of the pro-neutrality people on my Facebook feed have no clue what they’re talking about, and the few knowledgeable techies who know how the internet works don’t understand how markets work. This will not be an essay, just some scattered thoughts. 

Zero-rating is fine and customers seem to love it. But strictly speaking it violates net neutrality. If a service provider’s data plan allows you to stream infinite Youtube videos, or play unlimited songs on a music app, or doesn’t count your Facebook use against your data plan, it is treating some data different than other data. But customers seem to love this. A friend was telling me how awesome his new data plan was because it zero-rated his music streaming app. He loved this feature. He didn’t even realize that it was connected to the “net neutrality” issue. I suspect he has a lot of company. I suspect that if you polled some random people and told them “X, Y, and Z won’t count against your data plan,” they’d say, “Great!” Most of them would not say, “This opens the door to an internet dystopia of walled gardens where a few media moguls decide what you can and cannot do online.”

Walled gardens tend to get broken down by the market. Theoretically a monopoly internet service provider could tell you, “You get this service for e-mail, this service for video streaming, this service for social media…” and could simply pick its own services or the services of a partner company. But people want to pick and choose a little. AOL tried to be a walled garden but failed. Thomas Hazlett, in his book The Fallacy of Net Neutrality, describes a similar process happening in Japan’s internet service provider market. Supposing a walled garden persists and is not broken down by market forces, that probably means that internet users don't mind them so much and ISPs are basically giving their customers what they want. 

If you’re seeking a knowledgeable critic of net neutrality , Thomas Hazlett is the guy. He’s a former economist at the FCC. His above-mentioned book is only 53 pages, and he has a longer book covering the same topics that I haven’t yet read. Here he is on Econtalk. I’m sure for technical, knowledgeable advocates of net neutrality, the knee-jerk libertarian position (that the government is generally bad at regulating things) is pretty unsatisfying. I think Hazlett does a good job of specifically addressing the concerns of neutrality advocates, not simply starting from a libertarian premise and pretending all policy implications fall out from there.

Without monopoly power, the case for net neutrality falls apart. If there is more than one ISP trying to sell you an internet connection, neither of them can simply call the shots and have their way with you. If there’s even a limited demand for a neutral internet, one ISP can steal a lot of customers from the other by providing it. “But what if all ISPs do the same wrong things?” Ok, sure, it’s possible, but not likely. Everyone is foregoing an obvious profit opportunity? And for a service that people are loudly announcing that they want (namely a "neutral" internet)? Sure, it's possible to get stuck in a bad equilibrium, but you need some explanation for why the equilibrium persists when any party could benefit by unilaterally breaking free of it.

I’ll submit that ISP’s don’t really have monopoly power. You can get a pretty big data plan on your phone. It’s not quite the same as having broadband through cable, but if you just read articles all day and listen to a few podcasts, this probably meets your needs. If even a small percent of internet users meet that description, that’s powerful competition that the cable-based providers have to contend with. Alleged “monopolies” are always too narrowly defined. There are less-than-obvious competitors to your cable company. You can rent or buy DVDs rather than streaming movies, sometimes getting them free from your local library. You can get your news from newspapers and magazines rather than the internet. Even if the cable company completely corners the market for internet service in your town, you can get most of what you get from the internet in other ways, some only slightly crappier than the internet versions of those things. This is a point I am stealing from Thomas Sowell, who pointed out that perhaps plastic or other metals can sometimes substitute for aluminum. This potential substitution limited the so-called “monopoly power” held by ALCOA, for which it was sued under dubious legal reasoning. At any rate, mobile internet will rapidly improve in the coming years and decades. A bad regulatory regime, such as “net neutrality done wrong”, could lock existing technology into place.

On that note, my understanding is that most of the bad behaviors neutrality advocates warn us about are already prohibited under existing anti-trust and deceptive practices law and regulations. If an ISP says, "Stream as much high definition video as you want, but if you want quality you'll need to purchase a fast lane," that's not deceptive. But if the ISP clandestinely throttles Netflix so as to make it unusable in a scheme to make you purchase more cable channels and Watch Instantly movies, that's deceptive. It's not actually providing the service that you paid for and is probably breaking the law. (I'm trusting the opinions of people who know the law here, like Ajit Pai and Thomas Hazlett. If someone knows a good contrary source on this point, please share.) That's not to say I like the idea of a government that aggressively pursues monopolies. The history of anti-trust action by the US government is kind of a joke.

ISPs are very high fixed-cost, very low marginal-cost entities. Even more so than utilities, like water or electricity. You have to lay a lot of expensive infrastructure, but then you can basically pipe out the service almost for free. Economic theory tells you that this gets you a "natural monopoly," because it doesn't make sense for a second provider to build all that infrastructure knowing that the marginal cost (=price) is going to be zero with even one competitor. So the notion that ISPs are some kind of monopoly isn't totally crazy, by any means. I just think that the policy implications are not so obvoius.

Internet fast lanes are a perfectly reasonable idea. Suppose you have a robot surgeon in Indiana being manipulated by a physician in New York. You’d want a dedicated, high-bandwidth connection. Less importantly but no less obviously, a high-powered gamer might want a similar service and be willing to shell out for it. Frankly, if there are bandwidth hogs who are slowing down my internet connection, I think I want my ISP to identify them and throttle them or otherwise get them to purchase a fast-lane. If these people are imposing a cost on other internet users, it’s perfectly fair to treat them “non-neutrally.”

Some people think that non-neutrality and fast-lanes means that ISPs will throttle your existing connection until you buy a “fast-lane”, which will only get you back up to the speed you’re used to but at a higher price. Or they think it means they’ll charge everyone more for the same service, but offer the former price for a slower service (that has been deliberately throttled). Somehow non-neutrality means things can only get worse: pay more for the same service or pay the same for less service. I think this is nonsense. Even assuming ISPs hold “market power,” this isn’t even an accurate description of how a monopolist tries to maximize its profits. Non-neutrality would probably mean more tiers of service. That’s a good thing! Scenarios where this makes everyone worse, or even scenarios that make the typical customer worse off, make little sense.

I think it’s funny that everyone was mad at cable companies for not allowing you to purchase channels a la carte, and now people are worried about the internet being sold a la carte. Maybe it’s different people, but I smell a deep inconsistency here.  Speaking of which, cable companies in effect “dedicate bandwidth” to your television and telephone service, which is non-neutral. I don’t see the big problem in going the extra step and treating some apps or websites different from others. Cable TV is just an app for streaming video. Phone service is just an app for making calls. Maybe I want dedicated bandwidth for streaming audiobooks, too. 

I also think it's kind of funny that people were cheering for Go Daddy and Google when they effectively kicked The Daily Stormer off the internet. Maybe my saying this will earn me a pedantic lecture about how a registrar is different from an ISP, but this would be to miss the point. Should internet choke-points be used to determine content, or shouldn't they? Why insist on "dumb pipes" but not "dumb registries?" Isn't this kind of editorial decision-making exactly the kind of thing neutrality advocates are worried about? That's what supposedly makes a neutral internet so useful: tiny niche groups can still get together and communicate without being overwhelmed. With a neutral  internet you get 100 million tiny "channels," rather than just ABC, NBC, and CBS. And wouldn't it be a shame if the big players stifled this diversity and creativity? Maybe it's okay if this kind of awesome power is used for good but not evil? (I hope everyone feels deeply uncomfortable about making that kind of argument.)

My cable company sells me movies for a pretty hefty rental price, about $5. It is, in a very obvious way, a competitor with Netflix. It would sell me more movies if I didn’t have the Netflix option, or if they throttled Netflix so much that it became unusable. So far they have declined to exploit this opportunity, despite being a “monopoly” in the narrowly-defined market of streaming video.

Many big internet companies are pro-neutrality, particularly the big bandwidth hogs Netflix and Google. I see “net neutrality” as mostly a fight over who is going to pay to upgrade the infrastructure. Netflix wants Comcast to upgrade its own damn pipes, and Comcast wants Netflix to shell out the cash for some of this since they are the big bandwidth hogs who are forcing the issue. Netflix and ISPs actually do work together to solve some of the bandwidth issues; Netflix installs a caching appliance at local ISPs. I understand none of the details about how this works, but the take-away is that both parties realize there is a problem and are working to solve it. Netflix wants its customers to have an enjoyable viewing experience or it will lose them as customers. Comcast realizes that a huge fraction of internet usage (and thus customer value) is thanks to Netflix, so they want the same thing. I have no dog in this fight. I don't really care whether Comcast or Netflix "pays for" the infrastructure. I feel like the net neutrality people are telling me I should care without really telling me why.

Some of the best information I've gotten on this issue came from the comments section of a Coyoteblog post, probably this one. I think the guy basically has his economics and his political economy/public choice theory right. But maybe he flubbed some of the technical details? A bunch of techies show up in the comments to "correct" him. Although often the technical details don't actually refute the economic arguments, which revolve around monopoly power. This lesson generalizes pretty well: if you have a good filter and cross-checking habits, you can learn a lot from reading the comments. If not, don't bother, because you'll just get frustrated and give up. Anyway, this kind of back-and-forth is often instructive. On this topic, I see the occasional pro-neutrality techie sneering that "You just don't understand how the internet works." I'd like to sneer back, "You just don't understand how markets work," but I doubt that would be very productive.

I wish I could offer you a neat, flowing essay tying this all together, but instead I've written another long-ish post filled with random thoughts. Bless you if you've read this far. Feel free to offer any useful information in the comments. 

Sunday, November 26, 2017

Against Drug Prohibition

There are numerous posts on this blog that argue against drug prohibition. Here I am trying to gather the concepts from those scattered posts into one long-ish piece. Having read everything I can find about this topic, I have found the arguments for drug legalization to be overwhelming. Indeed, I have had trouble finding a serious argument in favor of drug prohibition ("serious" by my own not-exactly-strict standards). Basic economic theory provides a powerful case that drug prohibition will fail. Theory aside, our actual experience with drug prohibition has been an unmitigated disaster.

"Basic economics?" you say. "Make something more expensive and people will do less of it, right? Prohibition should work according to basic econ." I think this is the starting point for most people who favor prohibition. What it misses is the cost imposed on the people who continue to use and the people who stop using. Of course, you can deter a few marginal drug users by increasing the cost of drug use, say by imposing legal penalties on use or driving up the market price with supply-side interdiction. But such a policy is only "working" in the narrowest possible sense. To "work" in the sense of passing a cost-benefit test, someone has to tally up the harm done by the policy and seriously compare it to the supposed benefit. One cannot simply claim some deterrence has been achieved (no matter how minuscule) and claim victory.

An important insight here is that "prohibition" doesn't mean "you can't do it anymore." It is more realistic and more useful for analysis to think of prohibition as raising the cost of certain behaviors. These behaviors, namely drug use/production/transportation/sale, still happen. It's just that the users/producers/mules/dealers incur a higher cost. Obviously these things are still worth doing under a prohibition regime. It's important to keep track of exactly how much higher the cost is, who is paying it, and how much society as a whole benefits. When people continue to engage in the prohibited behaviors at a higher cost (as compared to the cost if the behavior were legal), it's possible that this "higher cost paid" swamps the supposed benefit from whatever deterrence it achieves, making the policy as a whole a net loser. As we'll see, when the prohibited behavior has inelastic demand, which almost certainly describes drug use, it becomes overwhelmingly likely that the costs of prohibition exceed the benefits.

There are two major rationales for drug prohibition: paternalism and externalities. The "paternalism" line of reasoning is that drug users are irrational and simply don't know what's best for themselves. They don't appropriately factor in the harm caused by their drug use, the thinking goes, so there is a role for government in discouraging their drug use. Under the "externalities" argument, drug users cause harm to innocent third parties who have no say in the drug user's choice. Drug users themselves may or may not be rational, but their choice to use drugs benefits them at the cost of society at large. They do things like go on a public rampage or drive intoxicated. Society has a legitimate interest in deterring these behaviors, even if we reject the paternalistic idea that we should protect people from themselves.

In addition to these, there are also some less-than-serious rationales for drug prohibition. "Drug use is just wrong" or some variation of that theme comes to mind. It's hard to take such assertions seriously. I'd be on equal footing if I asserted "No it isn't." We'd be equally matched in a standoff without ever having discussed any material facts or presenting any actual arguments. Is coffee "just wrong"? How about legal drugs like alcohol and tobacco? If illegal drug use is wrong because it's inherently wrong to break the law, doesn't legalizing drugs solve this particular problem? Someone who dips their toe into this line of argument quickly finds himself arguing that the wrong-ness of a drug depends on the pharmacological consequences or the social acceptance of the drug, which are empirical questions. And once you admit that something is an empirical question, you've completely neutered the "just plain wrong" line of reasoning. If you're mistaken about the pharmacology of various drugs and the related social harms (which I believe are routinely grotesquely exaggerated), then you're likely to be mistaken about the "just wrong"-ness of those drugs.

There are of course other rationales. You could come up with a longer list, depending on how thinly you slice them. But most are some subset of the paternalism and externalities arguments.

Against Paternalism

It is almost impossible to make drug prohibition "work" for the users themselves. When government threatens that it will fine, harass, imprison, and beat people if they use drugs, they are not doing these people any favors, even granting that they manage to deter some proportion of them from using.

To see why, you have to think clearly about how much you are raising the cost of drug use, and realize that the continuing users continue to pay that cost. You can think about the amount of drugs consumed being some function of the total price. Now, it doesn't matter that users "pay" in multiple ways for their habit: part of the price of drug use is literally the money that chances hands, part of the cost is time and effort spent finding a dealer, plus the pharmacological risks of harm, the risk of legal penalties, social stigma, opportunity cost for the time spent intoxicated, etc. These things are all different and would be measured in different "units," but you could (for the sake of analysis) collapse it down to some dollar figure, or some "total risk of mortality", or "years spent incarcerated," or a portfolio of several kinds of costs. Let's imaging coming to some agreement on the "exchange rates" between these different kinds of costs and put them all on one scale, and let's convert everything into dollars. (This is just a simplification. My argument does not depend on actually doing this, nor does it hinge on agreeing on the various exchange rates.) We can create a function, a curve that tells us how much people will buy at a given price. Economists call these functions "demand curves." See here for a pretty thorough treatment in a previous post.

Suppose there are N total users if the price under legalization is $X. Imagine that drug prohibition doubles the cost to $2X. Demand follows some kind of inverse function of the price. So, for example, doubling the price reduces the number of users to half, and quadrupling the price reduces the number of users to 1/4. Under this demand function, drug prohibition is a wash from the point of view of the drug users. Increasing the cost to kX dollars reduces the number of users to N/k. You always get a total cost of $NX. Ramping up prohibition doesn't avoid social costs; it just means that you have fewer users paying a much greater cost. It's a wash from the point of view of the users, but probably a net loss when you factor in the cost paid by society to enforce prohibition (unless we assume the externalities are implausibly large).

It's probably worse than this, because demand for drugs is relatively inelastic. That means users are relatively unresponsive to price changes. It takes a large increase in price to achieve a modest decrease in demand. In the previous paragraph I was using a f(k) = 1/k type of curve, which describes a demand curve that's neither elastic nor inelastic. This curve gets you something like a ~1% increase in price causes a ~1% decrease in demand. Very inelastic demand means it takes more like a 3% or 10% increase in price to get a 1% reduction in quantity demanded.  Demand for drugs probably looks more like f(k) = 1/sqrt(k). Quadrupling the price will get you half as many users, but each is paying four times the cost. There is a net loss for the users themselves, and once again probably a net loss to society as a whole (factoring in enforcement and other costs). The total cost (to users) actually rises as we increase the penalty for drug use. Hammering users harder doesn't produce a Drug Free America. It just means that we needlessly penalize a shrinking but increasingly desperate population of addicts.

The chart below is a graphical demonstration of what's happening. Moving to the right we see increasing drug costs, reflecting stricter enforcement. The quantity consumed (red) decreases while the cost per user (blue) increases. Multiplying these quantities gets you the total cost "paid" by drug users, the green line, which increases as drug enforcement gets stricter.

(The three curves are on different scales with different units, but that doesn't matter. The result that the total cost to users rises as the penalties for drug use increases. These aren't the intersecting supply-and-demand curves that you see in Econ 101, although the red curve actually is a demand curve.)

I have seen attempts to measure the elasticity of demand for various drugs. I've seen ranges of estimates in the 0.1-0.3 range for heroin, perhaps a bit more elastic (0.3-0.7 range) for cocaine. I don't know how much to trust these empirical estimates, so I won't dwell on them. But it makes intuitive sense that people who compulsively use addictive drugs, or who pay a very large opportunity cost to indulge them, probably have inelastic demand.

It's worth keeping in mind that the analysis above is totally sanitized to remove any trace of human misery. The ways that prohibition increase the price of drugs include throwing people in jail, SWAT-raiding the residences of suspected dealers (often terrorizing their families), subjecting users to dangerous black-market supplies of substances that aren't inherently dangerous, depriving families of a parent or earner, and so on. Abstraction is useful, but it's also useful to step away from the abstraction for a moment and remember we are capable of making moral judgments, too.

The drug user isn't literally a logic-machine, crunching the numbers and converting "probability of incarceration" into dollars in some great decision-making calculus. But s/he's surely doing some approximate version of this. If you suppose s/he is doing no such thing, then it's worth pondering how the legal penalties imposed on drug use are supposed to affect the behavior of drug users. It's fine to claim that people are to some degree irrational, but to dismiss any and all response to incentives is to admit that prohibition is futile. I think it is special pleading to claim that drug users are highly responsive to legal penalties while they are at the same time immune to considerations of the other kinds of costs.

Against the Externalities Rationale

A more plausible rationale for drug prohibition is that drug users cause "externalities." They operate a vehicle while dangerously intoxicated. They engage in irrational, violent behavior while under the influence. They commit property crimes to finance their addictions. And so on. I have a long post here discussing this rationale and explaining why it's probably wrong.

For one thing, the externalities supposedly attributable to drug users are grossly exaggerated. These socially destructive behaviors do occur for sure, but they are so rare that it becomes almost implausible to blame the drugs themselves for the behavior. Since there are overwhelmingly more drug users who are not engaging in these kinds of anti-social behaviors, a more plausible story is that poor impulse control causes those behaviors, or perhaps poor impulse control exacerbated by a drug habit.

For another thing, the anti-social behaviors blamed on drug use are already illegal. They are already penalized, and the drug user is already factoring these risks into the decision to use or not use. As I said in my previous post on this topic:
Assuming the penalties for these crimes have been appropriately set, drug-induced criminal behavior is *not* an externality. The potential drug user already faces the threat of a penalty, and moderates their drug use accordingly. It is the same as a potential CO2 emitter facing a perfect carbon tax while choosing how much to emit. The external cost is already internalized, so it ceases to be an externality. That’s not to say there is no harm. When the air is polluted or there is an unnecessary death or beating, somebody surely is harmed. It's just that the polluter (or criminal) pays the social cost of the harm. Suppose we had an appropriately high carbon tax, and suppose drug use induced people toward excessive CO2 emissions. We wouldn’t consider it an “externality” problem or a drug problem. We might adjust the size of the tax to address the problem directly, which is probably what we should do for drug-induced crime.

 If the problem is that people actually don’t understand the causal link, that “crack will turn you into a murderer/thief/assailant with an X/Y/Z% probability”, then the solution is some kind of ad campaign with credible information about these risks. The solution is not a blanket criminalization of drug use.  The potential user with accurate information will grind through the logic: “This habit will turn me into a criminal with probability X, which will almost surely land me in prison for Y years…”(No, he won’t literally do this, but will do so in an approximate fashion.) In this sense drug-induced criminal behavior is already criminalized and the penalty is already built into the cost of doing drugs. It’s already part of the price the user faces. If you object that drug users don’t have the foresight to consider the cost to himself of his future criminal behavior, then you should seriously doubt the entire enterprise of drug prohibition in the first place!  Come up with whatever assumptions you prefer about drug users, their degree of rationality, their behavior, their response to costs, etc.; these assumptions have to be consistent. They can’t contradict each other, which (I think) is what some very confused, very sloppy drug warriors have done. You don’t get to assume that drug users miscalculate the pharmacological risks of drug use but correctly estimate the legal risks. Either their talents for risk-estimation are well-calibrated, or they are not.
Perhaps the large social harms from drug use are due to things that aren’t criminalized. Things like neglect of one’s family or career are either not criminalized or are under-policed. If anyone is proposing we criminalize these behaviors, please suggest a proposal that makes sense, one that doesn’t further destroy the family. Clearly throwing a borderline negligent parent into prison has some harmful ramifications for his/her children, and throwing the same parent in prison on a drug charge has the same effect. If we’re not going to criminalize Behavior A, it makes little sense to criminalize Behavior B which (again tenuously) causes Behavior A.
It turns out that my analogy to an appropriately set pollution tax is a little bit off. In the case of a tax on an externality, society as a whole is compensated for the harm done. A tax serves the dual purposes of compensating the polluted and deterring the polluter. You still get some pollution, but the harm is compensated. In the case of a drug-induced murder or other crime, society at large does not collect the value of the penalty imposed on the criminal. So taking as a given the notion of "drug-induced crimes", the externality is not as fully internalized as it is in the case of a pollution tax. This concept will be important in the discussion below.

If the goal is to deter anti-social behaviors, the appropriate policy is to directly penalize those behaviors. If the penalty for theft and other property crimes is too low, increase it. If the penalty for intoxicated driving isn't sufficient, either increase the severity of the penalty (unlikely to work in my opinion) or increase the probability of being caught (much likelier to work). It would be incredibly inefficient and unfair to target the dozens of drug users who aren't bothering anybody just to deter the one who is. Given the extreme heterogeneity in people's drug habits, labeling a drug as "the cause" of someone's problematic behavior is dubious at best.

It's also worth pointing out that many "drug related" externalities are actually the product of prohibition, not an effect of the drug's intrinsic pharmacology. Intravenous drug use is probably a function of the high market price of heroin and cocaine. The communicable diseases (HIV, hepatitis, etc.) common in communities IV drug user would never have happened if people had access to cheaper drugs, and in fact these diseases dropped off dramatically when needle exchanges started to operate in many cities. (Bear in mind that these needle exchanges were officially illegal, but were tolerated once it was overwhelmingly evident that they were helping.) Likewise, most "drug violence" is actually violence related to the illegal drug market. You just don't see this kind of violence in the market for alcohol...outside of the 1920s when it was actually illegal. If we're going to have an honest accounting of "drug-related externalities," let's put some of the blame on prohibition.

A Tax Beats a Ban

Putting aside all of the above about the "paternalism" and "externalities" stories. Suppose there is a rational reason to deter drug use. Even admitting this, there are better policy responses than prohibition. You can simply place a punitive tax on drug use. The basic intuition here is that in the case of a tax, society collects the value of the punishment imposed on drug users. In the event of a ban (entailing legal penalties like jail time), the cost imposed on drug users is a dead-weight loss to society. You can harass, jail, or flog drug users. But unless the punishers are exceptionally gleeful sadists, nobody benefits from the harm imposed on users.

We'll start with a little bit of basic econ. Don't worry if you get lost in the following discussion; I will try to restate the point clearly in plain English at the end. The formalism isn't necessary to "prove" anything; rather it is intended to discipline our thinking and show critics that their criticisms are being accounted for. The figure below shows intersecting supply (red) and demand (black) curves. The upward-sloping red line, the supply curve, captures the idea that as the price increases, suppliers will want to produce more to sell at the higher price. The downward-sloping black line, the demand curve, captures the idea that as the price increases, buyers will buy less (discussed at length above). Ultimately, suppliers and buyers will agree to a given price and quantity, where the curves intersect. Quantity Q will be sold at price P. If too much is produced, suppliers would have to sell the excess at a loss. If too little is produced, unmet demand will lead to high market prices and encourage more production. There are reasonable debates about whether this model perfectly captures the realities of a market economy. But surely something like this equilibrium is going on. There are forces pushing the price to P and the quantity to Q, and any deviation from this equilibrium will induce market forces to nudge us back to point (Q,P).

The above chart assumes no externalities, no costs to third parties. But now we can suppose that drug use causes significant externalities. Now there is a divergence between the "marginal private benefit" (felt by the users) and the "marginal social benefit" (felt by society at large). Drug users consume too much because they aren't factoring in the costs to others. Effectively society is "subsidizing" the habits of drug users by putting up with all of their anti-social behavior, without being compensated for it. That looks something like this:

The solid black line is the demand curve faced by drug users. The dotted black line is the demand curve for society as a whole. The difference between the two captures the notion that users are "free riding" on everyone else. Users are consuming the higher quantity Q_act, while the optimum for society as a whole is Q_opt. (By the way, MSC is "marginal social cost", MPB is "marginal private benefit", and MSB is "marginal social benefit". The private benefit is higher than the social benefit because the users aren't factoring the costs to third parties into their decisions.)

What's needed here is some kind of policy device that forces drug users to feel the social costs of their actions. A tax or legal penalty will lower the solid black line, ideally until it overlaps the dotted black line.

This lowers the amount of drug use from Q_act (from the previous figure) to Q_opt. If this seems convoluted, it's not. Everyone who favors drug prohibition is following some version of this logic: penalize a behavior and you get less of it.

If we're trying to shift the demand curve, a tax is strictly superior to a ban. We can divide these intersecting supply and demand curves into several areas, each of which has a specific interpretation.

In the untaxed/unpenalized world, the MSC curve intersects with the MPB curve (around Quantity =11 and Price = 10, the point of area E in yellow). A+B+C+E represents the consumers' and producers' surpluses. The producers earn a profit above and beyond their production costs, because otherwise they wouldn't bother to produce anything. The consumer values the goods and services at some value above and beyond what they pay for them, otherwise they wouldn't bother to buy anything. Thus we get the "double 'Thank you'" in market exchanges, in which the consumer values the goods more than the money and the producer values the money more than the goods. Unfortunately, there's more going on here. Society at large is subsidizing users and dealers. Areas C and E represent a transfer from society to drug users and producers, not a surplus for society as a whole. Area D is a dead-weight loss. It is the amount by which the cost of production exceeds the social value of the thing being produced. So areas C and E are a transfer (a wash for society as a whole), A and B are true surplus, and D is a loss. The total surplus is A + B - D

Now suppose we impose legal penalties. The marginal private benefit (MPB line) is lowered to overlap with the marginal social benefit (MSB line). The supply and demand curves intersect right around Quantity = 9, Price = 7.5, where the points of triangles A and B meet. Drug users still enjoy a consumer surplus of A, and producers a surplus of B. We've eliminated the dead-weight loss of D, and the transfer represented by triangle E doesn't happen. Area C  now represents a cost that is paid by drug users and producers, but which does not get paid to anyone. A legal penalty is equivalent to imposing a tax on drug users and then throwing away the revenue. The total surplus is now A + B - C. This might or might not be better than A + B - D from the no-tax-no-penalty world discussed in the above paragraph; it depends on the relative sizes of C and D. But we can do better.

Now suppose we impose a tax on drug use, rather than a legal penalty like harassment, imprisonment or flogging. Once again, we lower the MPB line so that it overlaps with MSB line, and again we intersect at the point Quantity = 9, Price = 7.5. Drug users and producers still enjoy the surplus of A+B. Area C is not a pure loss as it is in the "penalty" regime; it is a transfer. Tax revenue is collected and is not thrown away. Areas D and E disappear from this calculus, because drug use has been reduced to the socially optimal level. So we end up with a surplus of A + B. This is strictly better than A + B - C or A + B - D.

Strictly speaking, a tax beats a ban.

Anticipating some objections to this line of reasoning. One is that a tax "just isn't severe enough." Imprisoning someone is pretty harsh, while paying a surcharge at the pharmacy doesn't seem so bad. Of course this objection would be nonsense. The tax can be arbitrarily severe. Doubling the price doesn't seem to do the trick? Okay, then quadruple, or sextuple, or octuple the price.

Another objection is that prohibition is of an entirely different character than a tax. To purchase an illegal substance, you need to find a dealer, which may require a categorical decision about your lifestyle. On the other hand, a tax just means you shell out more money. That's fine. In addition to a tax, we can impose "user licensing." In addition to paying a surcharge that increases the market price of drugs, users must pass an onerous licensing process. Once again, this is a continuously and arbitrarily adjustable lever with which we can increase the cost of drug use. If the half-day drug safety seminar isn't sufficient, make it a week-long boot camp. The graduate can purchase pharmaceutical-grade heroin. But they have to show they've learned proper hygiene and safety, things like "don't mix with other drugs" and "how to clean your works". User licensing might actually manage to meaningfully inform some drug users of the risks, something that current policy has utterly failed to do. And with a clean, legal supply, there will be far fewer accidental overdose deaths.

Importantly, taxes and user licensing are "high probability" deterrents. The chance of getting caught, much less serving any actual time, is pretty slim for a typical user or even a typical dealer. This deterrent might be sufficient for a typical "risk averse" individual. But the personality type that is attracted to potentially addictive drugs is probably not risk averse. These people are probably risk neutral or even risk-seeking. They obviously enjoy a certain kind of thrill. Deterrence is more effective when the probability of punishment is high, particularly for risk-neutral and risk-seeking personalities. Ramping up the severity of the penalty quickly bumps into diminishing returns. For a given "expected punishment" equal to the severity of the penalty times the probability of getting caught, we're better off trying to raise the probability of getting caught than in ramping up the penalty. (Citation needed. I don't know a lot about this, but have heard criminologist Mark Kleiman say this. Megan McArdle also discusses this at length in her book The Upside of Down, and Alex Tabarrok has made this point repeatedly at Marginal Revolution. I'm trusting that the impression they gave me on this point is correct.)  In a tax-and-licensure regime, essentially 100% of drug users get hit with the deterrent. In a prohibition regime, only a fraction of offenders actually get punished. It's almost like our prohibition regime was meant to target middle-class, bourgeois-values kinds of people, the kind of people who you don't much need to worry about developing a dangerous drug habit. And it fails for lower-class individuals, who probably know people with criminal records, can easily find a drug hookup without accidentally asking a cop, and who don't blush at a small chance of a bad outcome, possibly because they have less to lose. Prohibition is poorly targeted to the kinds of people we want to deter. (Of course I'm not saying that anyone is immune from drug addiction because of their socioeconomic class; I'm merely pointing out that socioeconomic class is a risk factor and that there are policy implications for knowing this.)

It's worth considering the consequences of setting the tax or licensing requirements too high. Make the penalties and restrictions on legal use too high and we will simply drive people back to the black market.

The Black Market

A possible objection to the tax-and-license regime is that drug users might avoid the taxes and licensure requirement by buying on the black market. If we just get a black market again, then legalization would be a failure, right?

I think this objection is probably wrong. For one thing, you'd likely have the majority of the drug supply coming from the legal supply chain, unless the taxes were implausibly high. For example, most people buy alcohol from legal grocery and liquor stores, even though a relatively small amount of alcohol is illicit moonshine and home-brewed beer. People can get around the (onerous) taxes and regulations on alcohol, but most don't. For another thing, even if there is a black market operating alongside the legal market, it's likely that the black market would be diverting from the relatively clean and safe legal supply chain. It wouldn't be a clone of the current black market, where people are cooking up who-knows-what in dirty home labs. There is a black market for cigarettes in states that have set their cigarette taxes too high, but mostly this involves smuggling in cigarettes that are legally produced in other states. People aren't growing clandestine tobacco crops or manufacturing super-concentrated synthetic nicotine in secret labs. They are diverting from an existing, legal, (relatively) safe supply chain.

Again, the legalization regime has a clear benefit over the prohibition regime. If policymakers decide that the black market is too big, they have a continuously adjustable lever to tone it down: they can lower the tax or licensure requirements. If doing this means too many new drug users, they can ramp it back up and decide to just live with the black market problem. There is a classic trade-off here. A legalization regime would at least allow us to be honest about the nature of the trade-off and give us more tools to pick where we want to be on the trade-off curve. Prohibition doesn't give us a continuously adjustable lever in the same sense. Sure, you can ramp the penalty up or down, from a year in prison to two years in prison, or anywhere in between, or anywhere outside of that range for that matter. But prohibition ensures that the entire trade is dominated by the black market. The shift to "100% black market" that we get under prohibition is categorical, not adjustable. You fundamentally cannot adjust this without legalizing the market.

Supply Interdiction

The above analysis mostly talks about targeting drug users themselves with jail time or punitive taxes. But the harshest punishments and most enforcement resources fall on suppliers. Illegal drug production usually triggers severe mandatory minimum sentences, measured in years or decades of incarceration. Transporting or merely possessing large amounts of drugs usually triggers similar penalties. The above analysis still applies. Supply interdiction doesn't mean that drugs disappear from the marketplace. It simply means that the market price is higher than it would otherwise be. We can think of supply interdiction as just another means of raising the price faced by the drug user, similar to a tax or a penalty faced directly by the user. Or you can redo the above analysis by shifting both the supply curve and the demand curve. The basic result does not change. (The supply curve will shift leftward to reflect the fact that suppliers will produce less at any given price. The intersection with the demand curve will occur at a higher price and lower quantity, which are the predictable effects of banning something.)

In this article by Benjamin Powell at the Library of Economics and Liberty, there is an excellent explanation of what happens when you try to shift the supply curve for a good with very inelastic demand. See the figure here in the middle of the page. Note the very small reduction in the quantity of drugs consumed compared to the extremely large increase in price. This isn't some trick of drawing the axes on different scales. It is an inevitable consequence of inelastic demand. As Powell explains, hammering drug suppliers harder actually increases their revenue:
The main effect of a supply-side drug war is a large increase in the price of drugs. Revenues of drug dealers equal the price of the drugs times the quantity sold. Because the drug war increases price more than it decreases quantity, the remaining drug dealers have more revenue as a result of the drug war. In the above figure, the drug war costs suppliers the revenue in the blue box, but suppliers gain the revenue in the larger red box. They can use this increased revenue to buy better technology to smuggle drugs into the United States, to buy more and better weapons to fight law enforcement, or to corrupt more judges and police officers.
Of course revenue isn't profit, but this should still be a worrying result for anyone who is pro-drug war.

At his blog The Big Questions, Steven Landsburg explains here and here why it's futile to deter suppliers with penalties. He presents an little economic formalism to explain what happens when you try to prohibit something.

Gary Becker Made Similar Arguments

In a paper titled The Economic Theory of Illegal Goods: The Case of Drugs by Gary Becker, Kevin Murphy, and Paul Grossman, the authors make essentially the same argument I make above. They use more formalism but come to similar conclusions. They also make many other points I haven't touched on. So I'm pretty sure I'm basically on the right track, even if I might have goofed on a detail here or there. I wrote about it at some length here. Basic common-sense economics gets you to the conclusion that drug prohibition is overwhelmingly likely to fail, and some guys who are smarter and more thorough than me got to this conclusion well before I did. I recommend reading the whole paper, or if you don't have time for that my post summarizing it (both linked to above). Some excerpts:
Optimal public expenditures on apprehension and conviction of illegal suppliers obviously depend on the extent of the difference between the social and private value of consumption of illegal goods, but they also depend crucially on the elasticity of demand for these goods. In particular, when demand is inelastic, it does not pay to enforce any prohibition unless the social value is negative and not merely less than the private value.
We show that a monetary tax on a legal good could cause a greater reduction in output and increase in price than would optimal enforcement, even recognizing that producers may want to go underground to try to avoid a monetary tax. This means that fighting a war on drugs by legalizing drug use and taxing consumption may be more effective than continuing to prohibit the legal use of drugs.
…when demand for drugs is inelastic, total resources spent by drug traffickers will increase as the war increases in severity, and consumption falls. With inelastic demand, resources are actually drawn into the drug business as enforcement reduces drug consumption.
I found the following passage absolutely stunning:
The conclusion that with positive marginal social willingness to pay-no matter how small-inelastic demand, and punishment to traffickers, the optimal social decision would be to leave the free market output unchanged does not assume the government is inefficient, or that enforcement of these taxes is costly. Indeed, the conclusion holds in the case we just discussed where governments are assumed to catch violators easily and with no cost to themselves, but costs to traffickers…The optimal social decision is clearly then to do nothing, even if consumption imposes significant external costs on others.
They aren't stacking the deck by making some weird libertarian assumption about inefficient government or massive negative side effects (assumptions which accurately describe the actual real-world war on drugs). And yet they reach the conclusion that drug prohibition almost certainly isn't worth pursuing. There's more. They relax the "inelastic demand" assumption and still find the verdict to be quite firmly against prohibition:
Even if demand is elastic, it may not be socially optimal to reduced output if consumption of the good has positive marginal social value…[some technical details, elasticity conditions, etc.]… It takes very low social values of consumption, or very high demand elasticities, to justify intervention, even with negligible enforcement costs.

…when demand is inelastic, total production costs rise as consumption falls, and enforcement costs rise more rapidly. With inelastic demand, a war to reduce consumption would be justified only when marginal social value is very negative. Even then, such a war will absorb a lot of resources.
Using more formalism than I do above, they also discover the solution of a tax beating a ban:
Our analysis shows, moreover, that using a monetary tax to discourage legal drug production could reduce drug consumption by more than even an efficient war on drugs. The market price of legal drugs with a monetary excise tax could be greater than the price induced by an optimal war on drugs, even when producers could ignore the monetary tax and consider producing in the underground economy…With these assumptions, the level of consumption that maximizes social welfare would be smaller if drugs were legalized and taxed optimally instead of the present policy of trying to enforce a ban on drugs.
There are a lot of other details to that one could discuss here. Several large volumes could be written on how drug policing corrupts political institutions and the police, in a few countries leading to a failed state. Or one could discuss the knock-on effects of incarcerating large fractions of prime-age males in inner city communities and the absolute havoc this wreaks on traditional life cycles and social norms. A related point, volumes could be written about the systemic racial disparities, which are real and have real effects whether they are intentional or not, whether they are motivated by explicit racism or not. Or we could discuss at length how drug policing degrades trust between police and the communities they serve even when they show up to perform a legitimate policing function, like solving a property crime or a murder. Or someone could write several long papers about how black markets encourage violence because they don't have legal means of resolving disputes, and that this violence is a significant fraction of the total violence in our society (at least in the United States; Jeffrey Miron and Paul Goldstein have done some excellent work on this subject). Someone could write a book about how the war on drugs eviscerated our constitutional rights by constantly carving out "drug war exceptions" to the Bill of Rights (Radly Balko's Rise of the Warrior Cop does exactly this). All of these are very important and deserve a serious treatment. What is surprising is that we reach a strong verdict of "drug prohibition fails" without ever considering these very serious problems. Some basic economic reasoning counter-indicates drug prohibition, without even diving into these other topics.