I won’t summarize it, but you can read the essay to get some
context. To me it’s just the standard narrative of the opioid epidemic: we
loosened prescribing practices on opioids, which in turn created new addicts,
which in turn led to lots of drug overdoses. I posted a debunking of this story
here.
In that piece I tried to refute the narrative that
VerBruggen is selling to his readers. I could just post a link to that piece and say, “Moving
on.” But it might be more constructive to respond specifically to his piece.
The very first sentence of the essay gets us off to a bad
start:
America has seen a veritable explosion of serious drug abuse over the past two decades.
Not it has not. Opioid abuse has been flat since at least 2002, even declining
in recent years. Heroin use has increased in very recent years (we’ll get back
to that later), but as I have pointed out repeatedly these are two different
trends and should be treated very differently. It makes little sense to combine heroin/fentanyl
overdoses (a big risk applied to a small population) and prescription opioid
overdoses (a small risk applied to a very large population) and call it “the opioid epidemic.”
Maybe VerBruggen would take issue with the government
statistics on prescription opioid abuse and addiction. Maybe there’s some kind
of reporting bias that’s masking the trend or something. I’m fine with playing
the “let’s doubt official government statistics because they might not be
accurate” game. In fact, let’s play that game with the drug overdose
statistics.
I argue here and here that it’s difficult to actually assign a cause of death to an
individual body. I suspect that a lot of medical examiners are writing down “drug
overdose” because it’s a handy explanation in some cases where the actual cause
might be harder to discover (or inherently ambiguous). But don’t take my word
for it. Do pick up a copy of the Karch’s
Pathology of Drug Abuse textbook. I provide several excerpts in which he
cautions the reader as to just how hard this problem is. In fact, I had to pare down my list of
quotes for those posts because it was getting very long.
I have scoured the drug overdose data in great detail. It’s the same dataset
from the CDC that VerBruggen is getting his numbers from. I find a lot of
irregularities and a lot of indications of a spurious trend. “A body is a body, so there can’t be a spurious trend in
death counts” one might be tempted to say. But the assigned cause of that death is malleable
and subject to various guesses, mistakes and reporting biases. I think that is part of
the story. Opioid prescriptions did something like triple from 1999 to 2015. If
three times as many people are walking around with opioids in their
bloodstreams, that’s three times as many opportunities for a cardiac arrhythmia
or other mysterious sudden death to get marked down as a drug overdose. Or perhaps the death isn't "mysterious" in the sense of lacking an obvious cause, but rather has many contributing causes competing for the top spot of "underlying cause." Indeed, a typical drug decedent is sick and old, compared to the average user who is much younger and healthier. These CDC death records can list up to 20 contributing causes of death; if any of those are drug-related it is almost always labeled a "drug poisoning." You rarely see it going the other way, where "sleep apnea" is listed as the main/underlying cause with "other opioids" as a mere "contributing cause of death." I’m not
literally claiming that the full rise is explained by miscoding deaths, but
some large fraction likely is. I point out in this post that there were zero
drug overdoses in certain states in 1999 (based on my filtering/counting which I think is defensible; see post for details). That seems implausible to me. It
looks a lot more like they just weren’t looking for those things, until more
recently when people (specifically medical examiners) caught on that this was happening. (Death codes changed over from the ICD-9 to the ICD-10 codes in 1999, which plausibly kicked off a spurious trend. As in, "Oh, there's a code for that now!")
VerBruggen takes the same approach that I criticized in a
German Lopez piece: He starts with the total number of drug overdose deaths (“over
50,000”) and then tells his readers that 2/3rds involve some kind of opioids.
Why start with an over-count, then force your readers to pull out a calculator
(or open an Excel workbook) and multiply by 0.67? I suppose he sort of
justifies this by saying, “In the official statistics that year, nearly
two-thirds of drug overdoses involved an opioid of some kind—an undercount
since many overdoses are not properly coded as opioid-related.” Alright, so
miscoding causes of death is a problem? I agree. It’s throwing off official
death statistics? I agree. But let’s count errors in both directions, or if we
can’t estimate those errors admit to a little more skepticism.
By the way, the "over 50,000" thing is kind of a pet peeve of mine and it screams "sloppy." You can only get to "over 50,000" if you count suicides. See my workup of the 2015 data here. If we only count unintentional overdoses, the number is more like 44,000. About 15% are either suicides (mostly) or "undetermined intent" (a smaller proportion), assuming once again that the medical examiner was correct. Fifteen percent isn't a huge correction, but adding in ~8,000 deaths that have nothing to do with the problem you're writing about is hard to defend. You could tell a story such as "These suicides happened because the decedent was a miserable addict and couldn't take the shame anymore," but this is getting speculative. You don't get to count suicides as part of "the opioid epidemic" just because the physical/chemical cause of death was the same. Anyway, this is all slightly pedantic, because unintentional opioid overdoses are clearly high and rising.
By the way, the "over 50,000" thing is kind of a pet peeve of mine and it screams "sloppy." You can only get to "over 50,000" if you count suicides. See my workup of the 2015 data here. If we only count unintentional overdoses, the number is more like 44,000. About 15% are either suicides (mostly) or "undetermined intent" (a smaller proportion), assuming once again that the medical examiner was correct. Fifteen percent isn't a huge correction, but adding in ~8,000 deaths that have nothing to do with the problem you're writing about is hard to defend. You could tell a story such as "These suicides happened because the decedent was a miserable addict and couldn't take the shame anymore," but this is getting speculative. You don't get to count suicides as part of "the opioid epidemic" just because the physical/chemical cause of death was the same. Anyway, this is all slightly pedantic, because unintentional opioid overdoses are clearly high and rising.
VerBruggen introduces the book Dreamland by Sam Quinones, which is another presentation of the
standard narrative (this time in book-length form). I found Dreamland to be frustrating and mostly
useless for all the reasons my regular readers will be familiar with.
[I]f, by contrast, the abusers of opioids are mainly individuals who abused them from the beginning, then the epidemic is a strong indicator of the consequences of entirely legalizing drugs. It is a demonstration of what happens when drugs are in full supply, safely manufactured, and easily available to those seeking a high and at risk of addiction.
I’m sorry, but this is just wrong. The past 20 or 30 years
are not an example of drug legalization. It’s not an example of relaxing
prohibition, even on a specific class of drugs. Does anyone think they could
just ask their doctor for opioids and get them? Of course not. Doctors are
extremely suspicious of people who come to their offices complaining about
pain, more so people directly requesting opioids. I hear media accounts of “pill
mills” handing out too many pain pills with little oversight, but this is
mostly a fringe phenomenon. Considering the number of severe chronic pain
patients who can’t get opioids (some of whom commit suicide), considering that Cato was writing about an
anti-opioid crack-down as early as 2005, considering that Jacob Sullum was
writing about this paranoia as early as 1997, I think
I’m on solid ground saying that obtaining opioids was never easy. (Sure, you could pick nits about how these are "libertarian" sources, but 1) the underlying information is still relevant and still stands and 2) who else would you expect to be writing about this kind of government overreach?) VerBruggen's presentation of the recent decades as a slackening of legal restrictions on recreational use of opioids is just wrong. Sure, the sheer tonnage prescribed increased by a factor of 3 or so. That doesn't mean it's easy to get your hands on some.
(Anecdote: I was in the E.R. in a Columbus, OH hospital in 2006. There was a lady in the waiting room complaining vaguely about pain, presumably trying to get a prescription of opioids. This isn't much of an anecdote really, because everyone in medicine knows this kind of thing happens all the time. Are most of these people successful? If opioids are so freely available, why do they go to so much trouble?)
(Anecdote: I was in the E.R. in a Columbus, OH hospital in 2006. There was a lady in the waiting room complaining vaguely about pain, presumably trying to get a prescription of opioids. This isn't much of an anecdote really, because everyone in medicine knows this kind of thing happens all the time. Are most of these people successful? If opioids are so freely available, why do they go to so much trouble?)
Much of the recent increase in opioid prescriptions is for
acute pain after a surgery or after an accident. Maybe this mildly increases the number
of “pills in circulation” (a term I’ve heard used to describe the passage of
pills from legitimate patients to the black market). But what’s going on here? These
unused pills are very dispersed, sitting a few per bottle in separate medicine
cabinets in separate homes. Do a large fraction of these really make it into
the hands of addicts? Do the patients themselves sell them? Do addicts have
access to enough dispersed medicine cabinets to support a habit? (As in, can they visit the homes of enough friends and relatives, get access to their master bathrooms, and steal enough opioids to support a habit?) I’d like
someone to better fill in this part of the story, because it seems pretty
implausible to me.
As to this: “…then the epidemic is a strong indicator of the
consequences of entirely legalizing drugs.” No, of course it’s not. There is a
long list of essentially harmless drugs that we could legalize. If there is any
amount of substitution away from alcohol, tobacco, opioids, and cocaine (the
biggest killers), it is worth legalizing those. I’m not sure to what extend “potential
opioid users” and “potential psychedelic” or “potential dissociative anesthetic”
users overlap, but there would surely be some people who are satisfied with the
harmless substances and would thus not bother with more dangerous highs. I don’t
understand how this sentence even made it into his essay, because in the very next
part he begins to discuss marijuana legalization. This should have been an
opportunity to pause and reflect on ways to divert people away from opioids by reducing
the cost of other options. It is
unlikely that total intoxication would rise in a society of full legalization;
rather people would choose the least
costly forms of intoxication (least costly as measured in health and time costs as well
as dollar costs).
[T]hose opposed to even the legalization of marijuana at this point have to admit that the public is not on their side. Support for marijuana legalization has crossed the 50 percent threshold...When it comes to legalizing hard drugs, the case is otherwise: Very few Americans are in favor.
Such surveys aren’t much good if people are constantly being
misled by sensationalist drug journalism. Read Dan Baum's Smoke and Mirrors for a full account of this history. Every new drug "epidemic" turns into an overblown moral panic, usually before there are any vital statistics or any kind of hard data supporting it. VerBruggen is careful and mild-mannered in his approach. He's hardly a sensationalist himself, and he has looked into the numbers. But his reporting on this story is still misleading.
VerBruggen has two paragraphs on a cultural change in medicine regarding the treatment of pain, which led to the rise in opioid prescriptions. Thank goodness this happened. Some severe chronic pain sufferers have tried every option, and the only thing that works for them is high-dose opioids. VerBruggen to his credit gives a nod to this:
Few would deny that for many patients, pain is real and can devastate their quality of life.What I think he fails to address (perhaps doesn't realize) is that any attempt to restrict opioid use will condemn some of these chronic pain patients to a life of uncontrolled pain. The false positive/false negative trade-off is fundamental. It is a sheer statistical fact. There is no way to side-step it. I wish that people in the opioid alarmist camp would state more clearly how comfortable they are with letting chronic pain patients suffer. It doesn't work to just say "Do better screening." We already have the most educated people in society (doctors!) making the decisions regarding who gets what medicine, based on detailed medical histories. Even if we're willing to spend a lot more of society's resources coming up with a better screening mechanism for sorting out addicts, we're already way past the point of diminishing marginal returns. There are two possible ways to reduce "unnecessary" opioid prescriptions: better screening ("our algorithm for predicting who's a pain patient vs. who's an addict is more accurate"), or a stricter cut-off ("for a given level of accuracy, change the threshold by which we label people 'true pain patients' vs 'recreational users faking it'"). The first is unlikely to work at all or to scale up if there even exists a better screening algorithm; the second cuts off more legitimate pain patients. My challenge for opioid alarmists: acknowledge the trade-off, and describe how comfortable you are with cutting off pain patients who are actually suffering. (Some people in high places are disturbingly comfortable with cutting off pain patients and making them "tough it out.")
VerBruggen cites a letter published in the New England Journal of Medicine that supposedly kicked off the change in attitudes toward opioids. Dreamland by Sam Quinones also makes repeated references to this letter, asserting or implying that the message in it was wrong. The letter states that only 4 out of 11,882 patients with no prior history of addiction got hooked on opioids after being administered. "We conclude that despite the widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction." Dreamland repeatedly presents this letter as some sort of mistake (VerBruggen's piece simply cites it without necessarily saying it was wrong, though that is the overall tilt of his essay). The sample wasn't representative, it was from a time when opioids weren't readily available on the streets (really?), most of these patients were administered far milder doses than what's given today, etc. But guess what? The conclusion holds up extremely well. Only about 1% of opioid-naive post-surgery patients show any sign of misuse after being administered opioids; presumably the rate of addiction is far lower than this.
VerBruggen cites a crackdown on pill mills in Florida circa 2010, supposedly leading to a decrease in opioid overdoses. Again, I find this implausible given all the accounts of crack-downs on prominent, legitimate pain doctors going all the way back to the early 2000s. By what objective metrics was there a "crack-down", and when did it start, and what was the level of enforcement before the crack-down? Regression analysis? VerBruggen knows about these. It's an appropriate tool for quantifying the response to policy.
He has two paragraphs concerning the rise in heroin overdoses circa 2010 and the tainting with fentanyl, an extremely potent synthetic opioid (~50 times stronger than heroin). He does here point out that it's a very tiny fraction of former opioid users who switch to heroin, and that a heroin habit is much deadlier. Indeed, I've calculated that a heroin habit has an annual mortality rate of about 4% per year (admittedly this is based on probably imprecise or biased information about how many users there are and how many of them die). This again would have been a nice place for VerBruggen to insert some doubt about his proposal to keep drug prohibition in place. There is basically no market demand for fentanyl. Heroin users avoid it if they can, but in a black market it's impossible for them to know what they are getting. Jeff Miron makes this point in his Law and Liberty forum essay, but VerBruggen offers a pretty weak non-response to this point. Like I said in my response to Caulkins, this is absolutely the fault of drug prohibition. There is simply no way such a dangerous product would be sold, unlabeled and at such a dangerously high dosage, in a legal market. Prohibition advocates are responsible, but they keep trying to take a pass on this.
On the age distribution:
Opioid deaths have long been concentrated among the middle-aged but, in the past few years, young adults have been catching up thanks to heroin.
And now we arrive at the key question: Are we talking here about pain patients—those who have inadvertently become addicted, so much so that they eventually take a fatal dose? Or are these folks non-medical users, who got hooked through deliberate misuse?This is an excellent question, and kudos to VerBruggen for asking it. Again, though, the policy implications are very different depending on how you answer this key question. Suppose it's the former. Well, as stated above it is a very tiny fraction of pain patients who even misuse their prescriptions, let alone become addicted or overdose. Are we willing to let 100 people suffer because one of them might take the drug recreationally? Or if we put it on the basis of avoiding a single incidence of addiction, are we willing to make even more people suffer (say, about 500 if these proportions are correct) to avoid a single addiction?
Or suppose it's the latter: prescriptions don't turn people into addicts, but existing addicts get a hold of loose pills from legitimate prescriptions and "doctor shop". In this case, restricting access to opioids seems even more deranged. "I'm sorry, you can't have the opioids that would spare you a few days or weeks (or months or years) searing pain, because someone who enjoys taking them might get a hold of them." I don't think such a policy would be fair or moral, and, make no mistake, fairness and morality are important considerations. I sometimes see this technocratic, quantitative-without-theory "public health" approach to the opioid issue that seems to want to decrease the body count at all costs. I don't think that's a worthy goal. You need some way of measuring and quantifying these costs, which requires a bit of theorizing.
He follows up that passage with a discussion of literature, suggesting that most drug abusers start out having had a legitimate prescription. None of the studies he cites establish causation, though admittedly some may be suggestive. Presumably most of these people started out having tried alcohol or coffee or marijuana, too. With something like ~85 million past-year users of legitimately prescribed opioids (the lifetime number would be much higher) and ~36 million people having abused prescription opioids at some point in their lifetime, these are huge populations.
To be absolutely clear, 41 percent of addicts’ having started out as medical patients with legitimate prescriptions is hardly a small percentage...
Doctors must prescribe these pills less often without denying relief to people who really do suffer from extreme pain, as they have already started doing.Once again, this is simply not possible. The false positives/false negatives trade-off is real. Let's draw out the curve and restrictionists can tell us what part of the curve they feel comfortable with. But let's stop pretending there is no trade-off to be negotiated. (Amusingly, VerBruggen lectures Miron about trade-offs regarding alcohol legalization in the follow-up essay, which we'll explore later.)
But since so much of the problem stems from blatantly illegal behavior rather than the misuse of legitimately prescribed drugs...I'm actually not so sure. Once again, by several different measures there are no more opioid abusers, despite something like a tripling of prescriptions. An alternative explanation is that, of the 85 million or so legitimate opioid patients, some extremely tiny fraction of them occasionally slips up and mixes medications. Now, clearly many of these overdoses are from addicts or even non-addicted recreational users, but we don't know for sure in what proportions. This is another distinction that has important policy implications. If the rise in opioid deaths is mostly coming from legitimate pain patients, then what we're seeing is a roughly fixed risk (again, a tiny risk) of overdose simply being applied to a larger population. I don't think that's worrying, and should not spur a moral panic about drug use. It would be like worrying that there are "three times as many back surgery deaths" in an era when back surgery expands three-fold (or suppose driving or trampolines or ATVs or some other activity with a low-but-real risk expands three-fold). Anyway, the "much of" part in that phrase is a hedge, so I'll let it slide as technically true.
He launches into an exposition about "how the drug war works."
The federal system holds very few drug prisoners who weren’t involved in trafficking; in state prisons, only about one-quarter of drug prisoners were sentenced for possession...I see a lot of this kind of stuff in drug reform debates, downplaying the number of people in prison. It's still a very large number of people whose lives are ruined for no good reason. Even if it's a small percentage of the total population of prisoners, it's still big. I see a lot of people poo-pooing this as "not the solution to mass incarceration". Fair enough, but it would be a big step.
In fact, arrests related to possession are more than quadruple those related to dealing.He says this in the context of denying that mere drug users are imprisoned at significant rates, but in fact this shows that these people are indeed harassed by our legal system. More so than incarceration statistics would show. Let's count this harassment in our calculus of whether the war on drugs is worthwhile. It is a cost. Let's add to it all the people who are needlessly harassed without getting arrested, and let's account for the forms of harassment that are far more severe than imprisonment.
VerBruggen seems favorable to marijuana legalization, though he raises some unnecessary notes of caution about a harmless substance.
Marijuana legalization is not consequence-free, to be sure. It drains users of their initiative and, notwithstanding its reputation, it is habit-forming.Citation, please? "Habit-forming" is a weasel phrase. It's not chemically addictive in the sense that opioids are, or in the (quite different!) sense that cocaine is. Anything can technically be "habit-forming."
It is not as addictive as opioids and seldom if ever kills those who smoke it.Ugh. Just say "never." Sorry for seeming confrontational on something where he and I agree on the policy, but half-hearted endorsements of policies that are obviously good still bother me. If someone is overstating the costs of a policy, I'm going to correct them even if they still reach the same conclusion as I do.
Regarding treatment, we should have no illusions. Many addicts refuse help. We know of no treatment that is effective more than about half the time. And treatment is expensive.I mean this next part earnestly: Bravo, Robert! I've said something similar. Let's not pretend that "more money for treatment" will magically cure all addicts. I think his statement implicitly recognizes free will; an addict who "refuses help" is actively choosing to remain an addict. I think we should all admit that some large fraction of drug addicts are like this, in addition to there being a large population of addicts who desperately want to recover. By the way, VerBruggen should read Maia Szalavitz's book Unbroken Brain for a sort of contrarian take on addiction (I say "contrarian" but it's ultimately more plausible than the "drugs dominate the will" model of addiction).
In the same section a couple of paragraphs later, he seems favorable to drug courts. I am skeptical. See the link above to my post on "Drug Courts and Drug Treatment." Drug courts may be a (somewhat more) humane alternative to incarceration, but they are still oppressive and infantilizing to the people who attend them. Assuming we legalize substances that aren't inherently dangerous and limit drug courts to serious addicts who are actually causing problems (a tiny minority of drug users), I'm okay with them.
Addiction medications have proven to be highly effective, if far from 100 percent so. These include methadone, buprenorphine, and naltrexone.
He also seems favorable to needle exchanges and safe injection facilities, and I applaud him for this. But how about we take these things out of the legal grey-zone they are stuck in? Just legalize them and put them in the plain light of day. The main driver of heroin overdoses is once again the fact that the user doesn't know what they are taking. (Also, recent release from prison is a huge risk factor; this is yet another way in which prohibition exacerbates the drug overdose problem.) Now, it's probably wise to direct heroin users to some kind of supervised facility even in a legal market in case they imprudently take more than they intended to. But this risk would be much lower in a fully legalized market, in which people buy their heroin from a pharmacist rather than a high-school drop out who doesn't even know what he's selling.
He ends his essay with the following flourish:
In short, the opioid epidemic has dispelled a lot of myths and quashed a lot of hopes regarding the War on Drugs. Legalizing drugs looks much less wise than it once did and, in any event, has little chance of gaining public support. A much narrower, but still powerful, set of reforms is in order.
Jeffrey Miron replies, and VerBruggen shoots back.
He invites us to turn back the clock a decade or two and ask a legalization advocate (his younger self-for example) what would happen if we dramatically expanded opioid prescriptions. He points out, probably correctly, that such an advocate probably would not have predicted the increase in mortality. He accuses Miron of issuing "a post hoc attempt to rationalize away the unexpected result of a disturbing national experiment." Experiment indeed, but once again the past 20 years was not even remotely an experimentation with drug legalization, for all the various reasons described above.
I don't quite understand VerBruggen's point with his hypothetical interrogation of a naive drug reformer. "He would have made a bad prediction, so we know his understanding of the world is totally wrong." Is that what he's implying? Let's play that game with VerBruggen. Given your narrative, wouldn't you predict that the number of prescription opioid users and addicts has increased dramatically in recent years? Does your narrative's failure to predict a completely flat trendline mean it's wrong? Not necessarily. But we should certainly bring all evidence to light and do a full appraisal of all competing theories, rather than place the spotlight on any one bad (hypothetical) prediction of one of the several competing narratives. Wouldn't his narrative imply that a crackdown would have reduced opioid-related deaths, when in fact they increased? Is his point about "new addicts versus populations of existing addicts" (stocks versus flows) the same kind of after-the-fact rationalizing that he criticizes?
Miron further writes that the U.S.’s experiences before 1914 (when opioids were legal) and during Prohibition support his point. Regarding the former, we don’t have good vital-statistics data from a century ago or more, and we also didn’t have as much disposable income to spend on drugs back then, so the comparison is limited. But it’s worth noting that the nation enacted drug restrictions at that time specifically because addiction was becoming a problem, dating back to morphine abuse following the Civil War and opium dens frequented by Chinese railroad workers around the same time.
The reality of Prohibition is rather messy, too. It certainly had plenty of bad effects, but recent research suggests it significantly reduced alcohol consumption and liver-cirrhosis deaths. It’s quite possible it saved lives on balance.
Want to talk about the quality of vital statistics? Let's get into it! In the book Drug War Heresies, the authors discuss the inconsistent (or just consistently awful) quality of drug overdose and abuse statistics across the developed world. It's often hard or impossible to do inter-country comparisons. There is a long discussion of drug policy shifting in Italy, from a lax policy to a crack down with a law enforcement approach and back to a lax policy with a treatment/harm-reduction approach. But all of this was done based on shifting political powers and ideologies; there was virtually no good data supporting these movements. For that matter, are vital statistics any good in the United States in the present day? I have serious reservations, which I discuss at length above. Once again, our survey data seem to indicate that you can triple the amount of opioids prescribed without increasing the number of addicts or the number of non-addicted casual users. If these data are accurate, they significantly refute VerBruggen's whole narrative. If they are not, then we need to adopt a skeptical stance toward the statistics and admit that the policy implications are unclear.
Even for solid, unimpeachable data, the policy implications for some measured trend are usually ambiguous. They depend on your assumptions about what is generating those data, your value system, how much weight you put on various costs, etc. VerBruggen is taking the sheer, brute fact of a rising death rate and trying to draw policy implications from this. You can't get an ought from an is.
What about the fact that efforts to control prescription-pill abuse since 2010 seem to have backfired, driving addicts to dangerous alternatives like heroin and Fentanyl? This is something I discussed in my original piece. It does illuminate the need to consider current addicts when introducing new controls, but it doesn’t suggest loosening controls to begin with is a good idea. By 2010, prescription-opioid overdoses had roughly quadrupled in a decade, the clear result of increased, not limited, supply.
Drug Interactions: Something VerBruggen Misses Entirely
Something else I've written about at length, but which VerBruggen misses entirely, is the degree to which these "drug overdoses" are actually multi-drug interactions. I have detailed stats on this for the figures from 2014, 2015, and 2016. I actually think it's quite misleading to call these "drug overdoses" because such a small proportion of them are single-drug overdoses. Most involve multiple substances. From 2016 (the most recent year for which this detailed data are available), about a third of these involved benzodiazepines. About 13% involved alcohol. About 9% involved antidepressants. Only about 14% of prescription opioid overdoses involved only a single substance. This is a big deal, because once again it illuminates a specific risk factor for policy to target, rather than suggesting blanket prohibition. Once again, prohibition removes a lever of control over this specific problem, but legalization would restore this control. A drug user who has to stand before a pharmacist and ask for recreation-grade opioids could receive a lecture about mixing. The pharmacist could spot someone purchasing multiple potentially interacting substances and warn them against mixing, or (with a little bit of corporate or government intervention) perhaps they could cross-reference their current purchase with recent purchases. Or perhaps they could issue "do not mix" warnings as a matter of policy and print warning labels and recommended dosages on the packaging. VerBruggen mentions "harm reduction" in a favorable light, but supply-side prohibition takes most of the obvious solutions off the table.
Opioid Alarmists Have Under-Theorized the Problem
VerBruggen is side-stepping philosophy. He is trying to derive policy implications from brute facts: Opioid prescriptions tripled, and then opioid-related mortality tripled (or perhaps quadrupled or more). But I don't think it's possible to avoid these sticky questions of moral philosophy. Even ducking that, the exact policy prescription depends on the exact mechanism that is causing the death statistics to rise.
VerBruggen tells us that the death rate due to opioids rose from six per 100,000 in 1999 to 16 per 100,000 in 2015. Okay. Is 16 per 100,000 a lot? Is it too much? Was six per 100,000 acceptable? Did going from 0.00006 to 0.00016 cross some threshold at which drug prohibition suddenly becomes a good idea? I don't know, and VerBruggen doesn't really tell us. Alarmists like to present the numbers in a way that makes them look big and scary, but every time I've seen these numbers presented as a risk, as some kind of rate per user, they don't look scary at all. Sixteen per 100k of total population? This number would be only very slightly bigger if you divided by the number of total prescriptions in the U.S.; last I checked there were something like 200 million prescriptions annually (compared to ~330 million total people). When I try to place a dollar estimate on this risk, it seems comparable to what a rational person might pay to avoid a week or so of nagging pain. Even supposing that you divide by a much smaller number, like the number of recreational opioid users or the number of opioid addicts, it doesn't look so bad. It's nothing like the ~4% per year mortality rate for heroin users (from that cause of death alone!).
Even the act of dividing by total users and expressing this ratio as the risk per user raises sticky philosophical questions, and I address these in my response to Caulkins. If, say, 15 out of every 100,000 people has a gene sequence that will cause them to drop dead if they ingest opioids (and supposing it's impossible to test for this, thus making it a true risk rather than a known quantity), then such a risk calculation represents something meaningful. Then again, if you can choose whether to indulge a foolish impulse to snort or inject your Oxycontin (and, more to the point, do so repeatedly until you have an unmanageable addiction), then dividing by total users is a pointless mathematical exercise. Risk is about unknown possibilities happening by random chance. People can choose by their own free will whether they are exposed to a fatal drug interaction or overdose. (At the very least they can initially choose, and even without this caveat there is some element of choice in the decision to continue using or to abstain.)
By what standard should we judge the rise in death rates? From a pure libertarian standard, anything that anyone does with their freedom, so long as they are only harming themselves, is acceptable. From an economic rationality standard, rational actors weigh the costs and benefits of their actions using the best information available to them (they rationally acquire new information until the cost of acquiring more information becomes prohibitive). Thus any action taken is justified according to the actor's own cost-benefit calculus (ignoring externalities, or assuming these are somehow internalized).These both give similar results. Under the libertarian standard, people are morally at liberty to do whatever self-harm they choose to indulge. Under the economic rationality standard, any action taken is recommended by the person's own cost-benefit calculus, and we should be reluctant to second-guess this because third parties cannot observe the person's preferences. You don't have to accept either standard to conclude that prohibition is a good idea, but I should point out that these are the standards that most people apply to most realms of life: choosing a romantic partner, choosing friends, choosing a church, choosing what to read, choosing what to eat, etc.
Perhaps a slightly paternalistic standard is appropriate, or even a harshly paternalistic standard: people aren't fully rational, because they underestimate certain costs. We are justified in using force to stop them. The economics on this are pretty clear. Absent making heroic and stilted assumptions, it is essentially impossible to deter self-harm in a way that produces a net benefit to society. The harder you hammer self-harmers, the greater the total harm to society. The penalty you impose (either directly on users or indirectly by targeting suppliers) grows much faster than the benefit gained by successfully deterring users. (Don't take my word for it. Take Gary Becker's word for it. Or better yet, read his actual argument.)
What about a "fairness" standard of judgment? Suppose restricting access to opioids means that people who really need them can't get them. I think this is terribly unfair. You'd have to be able to deter a lot of abusers for every legitimate pain patient to make this worthwhile, and by all accounts it's the other way around. (See above, regarding the very small proportion of legitimate patients who go on to become abusers.)
What about a "personal responsibility" standard? Is it fair to punish manufacturers and dealers because some of their customers do stupid things and kill themselves? (Again, it's become too easy to accidentally overdose because of the fentanyl phenomenon, which is a product of prohibition. That aside, it takes some phenomenally stupid patterns of drug use to actually kill yourself.) I don't think so.
How about a "public health" standard, where any increase in illness or mortality is bad and should be decreased at any price, no matter how high. I said above that this is a deranged and immoral standard, but as far as I can tell it's the only one that's consistent with VerBruggen's ultimate policy recommendation to continue supply-side prohibition. (And even then, only given his assumptions about the effectiveness of supply-side prohibition, which are pretty implausible.)
What about a utilitarian standard? What counts in our calculus of costs and benefits? Surely pleasure counts. The notion that people use these substances and continue to use them because they enjoy them is totally lost on drug warriors. How do we begin to count the costs imposed on people involved in the supply chain? Inconvenienced motorists who are stopped and harassed by police. Terrifying SWAT raids on residences, which more often than not turn out to be innocent. Multi-decade prison sentences, often for low-level dealers. Lopsided gender ratios in heavily-policed neighborhoods, leading to a breakdown of family structure. Not to mention the budgetary cost of employing law enforcement and imprisoning drug dealers. The human cost is truly enormous, even if we set aside our moral revulsion and adopt a strict cost-benefit calculus, even if we convert "man-years languishing in prison" to a bland dollar figure. VerBruggen wants it to continue, so apparently he thinks it's worth it. I wish he'd tell us how he got to this answer, because I'm stumped.
And Andrew I. Cohen made a more philosophical case against continuing the War on Drugs, even if it’s focused on dealers rather than users, emphasizing the seriousness of deploying state power and writing that I have “not quite shown us why such a stark measure is justified here.” On that we can agree to disagree; the incredible rise of opioid-involved fatalities that ensued when we loosened controls on opioids shows, to me, that the state does need to be involved here. And while we can have a discussion about how to treat low-level dealers, I believe criminal sanctions and not just civil fines are certainly needed to deter high-quantity traffickers.Apparently he's endorsing all the horrible things we currently do to drug dealers? I'm left scratching my head here. Nothing in his main essay or his response comes anywhere close to justifying current policy.
I was hoping that this forum would lead me to the crux of my disagreement with these "thoughtful prohibitionists." Unfortunately, I'm still confused. Prohibition of any kind does not appear to survive any kind of cost-benefit analysis, based on any serious attempt to quantify and weigh costs and benefits. VerBruggen seems like an incredibly thoughtful journalist. I hope he will reconsider his support for supply-side prohibition. Despite his arriving at good policy prescriptions in a lot of areas specifically regarding drug policy, I think he is deeply misguided on this point.
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