Saturday, June 18, 2022

Soho Forum Debate on the Opioid Epidemic

On June 7th, the Soho forum hosted a debate between Jeff Singer and Adriane Fugh-Berman on the opioid epidemic. The resolution was “America's overdose crisis is the result of doctors over‐treating patients with opioids.” Adriane argued for the affirmative, Jeff took the negative. (I refer to Jeff by his first name because I have had several friendly conversations with him, and I refer to Adriane by her first name for symmetry.) You can watch the full event here, or most likely you can find it on your favorite podcast app. I will share my thoughts on the event below.

I won't pretend to be neutral. People who have followed me for a while know I have strong opinions on this. My most comprehensive post on this topic is here, and see here for a Cato paper that I helped with, which was authored by Jeff Miron and Laura Nicolae. I think Jeff won the debate handily. Adriane said a lot of things that are patently untrue and spins an implausible narrative of pharmaceutical companies successfully bamboozling doctors and patients. Her general story doesn't make any sense, and I think there is a very important key fact that blows apart her narrative. Jeff hits her with this crucial information, and she failed to deal with it in any material way. 

By Oxford rules the debate was a tie. But there were partisans of both sides in the audience, and they tend to pretend they're undecided at the beginning and "change their minds" later to agree with their champion. At first I thought, "How in the hell is this a tie?!", but I spoke with Jeff by phone and he explained that this often happens in Oxford-style debates. 

[Note: I tried to quote or paraphrase accurately. I apologize if something that appears in quotes isn't the exact wording they used in the debate. I made my best effort to quote verbatim, but I did not have a written transcript to work from. If there are any instances of me quote/paraphrasing and changing the meaning of what someone said, I will correct it in the post.]

Effectiveness of Opioids for Chronic Pain Relief

The most insane thing that Adriane claims is that opioids are not effective at all for chronic pain. She concedes that they are sometimes effective for acute pain and for end of life pain. But this makes no sense. If opioids can relieve cancer pain (which is chronic pain, assuming most cancer patients live for a few months or years after diagnosis), they can relieve other kinds of pain that result from, say, degrading joints or musculoskeletal issues. Adriane's story is that chronic pain patients develop a tolerance to opioids, so they stop working unless they keep increasing the dose. They can even develop "hyperalgesia", an extreme sensitivity to pain. All of that is likely true, but no doubt there are still millions of chronic pain sufferers who only get relief from opioids. Some of these patients are forced to taper off opioids because their doctors, concerned about criminal liability, become uncomfortable treating pain patients with high dose prescriptions. And sometimes these patients experience such awful pain as a consequence that they end up committing suicide. Some "pain refugees" flee across state borders to get relief. I'm tempted to believe these people when they tell us that they are getting some kind of relief from opioids. 

There is a more reasonable version of the claim Adriane is making (though it's clearly not the reasonable version she espouses). One could argue that opioids do work for chronic pain, but they don't pass the cost-benefit test because of the associated risks. In other words, a terminal cancer patient doesn't have much to lose, but someone with musculoskeletal aches and pains potentially has a long, healthy life ahead of them. There is certainly merit to this kind of argument, but Adriane is claiming that opioids don't work at all for the latter kind of pain patient. Why wouldn't the cancer patient gradually develop tolerance to the opioids until they stop working? Presumably you could have bad cancer-related pain but still survive for months or years. I think she's probably correct with respect to some kinds of chronic pain. Headaches, for example, tend to result in bad rebound pain when opioids are used for relief. But some sources of chronic pain are similar to cancer in the sense that something in the body is badly out of place and triggering the nervous system.

Jeff was reluctant to engage on this point because it was in his opinion a side-show, not necessarily germane to the resolution. But re-read the resolution's exact language, it specifies that "over-prescription" of opioids is the cause of the epidemic. I think this inserts a value judgment or clinical judgment over whether the increase in opioid prescriptions over time was justified. Jeff responded by pointing out that there is an ongoing debate among clinicians over how effective opioids are at treating chronic pain, and it's facile of Adriane to just assert that the case is closed based on some evidence that she happens to like. (In one exchange Jeff says, "Do I have to be dying to get pain relief!" to which Adriane replies, "But it doesn't work!")

This theme of the debate highlights a difference in worldviews, which I think could be it's own separate forum debate. Adriane has a technocratic worldview. If I understand correctly, she is not a practicing physician but is rather an academic researcher (still an MD, and still a valid perspective, it's just a different view of the landscape). Decisive answers can be reached using The Science ™ (my characterization, not hers). She has no respect for practicing clinicians who don't share her conclusions. (This doesn't come through strongly in the debate, but in her paid testimony in the Oklahoma opioid lawsuit she was asked a question about doctors disagreeing on this point. She responded: "Medical professionals may disagree on this, but the science on it is quite clear." Clearly she thinks she has access to ways of knowing that are superior to the mere anecdotes and inferences of her colleagues who practice medicine for a living.) She cites some randomized controlled trials and meta analyses that supposedly prove opioids aren't effective. I have not done an extensive literature review on this, but the first couple of meta studies I find in a Google search for "opioids for chronic pain meta study" seem to indicate that they are effective. (Though they also show there are some negative side effects, and sometimes non-significant improvements over NSAIDs and other pain relievers, but it's a lie to say that they don't work at all.) But let's suppose there are some really good RCTs that show no lasting benefit of opioids on chronic pain relief. Here's why that shouldn't matter.

Doing an RCT is essentially admitting that people have different physiologies, that even if the medicine "works" in some general sense, it will work for some patients but not others. In the case of opioids (codeine specifically), we actually know about genetic markers that make some people "fast" or "slow" metabolizers, the latter getting little relief and the former being incredibly sensitive to even low doses. It's easy to imagine a scenario where you run an RCT that implicitly models everyone as being the same. (It's weird how scientific studies sometimes sneak in assumptions that are bat-shit crazy if you say them out loud.) You give everyone in the treatment group the same regimen of opioids for pain relief. Some, say 1/3, get no relief, because maybe they're slow metabolizers. Another third get relief from chronic pain for the first time in their lives and are happy they've finally found a solution to their soul-crushing pain. The remaining third gets "rebound pain". Maybe they quickly metabolize the opioids and the acute withdrawal makes their pain worse. Maybe the signal from the 1/3 for whom it's effective is cancelled by the 1/3 for whom the pain is worse, or maybe it doesn't exactly cancel but the average effect gets pushed into "non-significant" territory. It's easy to imagine a scenario where you get a null result, or even a result in which you've "proved" that opioids make chronic pain worse. This approach to the truth is something that's pretending to be science, but it actually ignores most of what we know about human variability. The RCT is implicitly pretending everyone is the physiologically the same, that a treatment that objectively "works" may not work for some individuals due only to unobservable random factors, and that simply gathering enough data points to shake out the noise will yield the true signal. 

In the real world, chronic pain treatment can be a lifelong journey. The sufferer may try various remedies: physical therapy, orthopedics, over-the-counter pain medicine. If none of these work, it's perfectly appropriate to try opioids. If these chronic pain sufferers, who have already tried all the other options, suddenly and persistently get relief from opioids, my inclination is to believe them. Their physicians, who suddenly see an improvement in their patients ability to function, aren't being fooled by randomness or by an overactive pattern-matching routine running in their brains. They should not feel the need to correct their anecdotal inferences with the "hard data" coming from RCTs. What I have described above is an individualized fine-tuning of a treatment regime. For chronic conditions, including chronic pain, it looks really telling when the patient's persistent condition turns on a dime under a new treatment regimen. RCTs are nice, but in this case there are good reasons to doubt them.* Please note that this isn't a general case against RCTs. I gave specific reasons to doubt them, including known variability in our physiological ability to process opioids (in this case with known genetic variations explaining the difference), the subjectivity of the outcome, and the ability to detect effectiveness of a treatment within an individual.  

Adriane does say something about chronic pain management that I agree with. Exercise is often found to be the most powerful treatment, she cites some evidence to this effect. This makes intuitive sense to me. A lot of people have chronic pain issues from being overweight, which puts a strain on joints and the back. A combination of weight loss and (perhaps just as importantly) strength training can improve their situation by increasing the integrity of the structure while lightening the load. Three cheers for lifestyle interventions! I think there are a lot of chronic pain sufferers who would benefit from substantial lifestyle changes, and I don't just mean exercise and weight loss. There could be dietary factors contributing to inflammation (admittedly there's a lot of junk science and fad diets in this space). Maybe meditation or some kind of mindset adjustment would allow some patients to feel less anxious about their pain. At the same time, exercise is just not an option for some people who are completely immobilized by agonizing pain, or whose joints are so compromised that significant exercise is ruled out. Opioids shouldn't be dismissed for such patients. 

Addictiveness and Addiction Rates of Opioids

Adriane vastly overstates the addiction rate of prescription opioids. She makes categorical statements such as "No one is immune", "All opioids are addictive", "All opioids cause death." Her preferred estimate of the addiction rate is "8-12%", at one point saying up to 1/3 of prescription opioid users become addicted. All of this is in service of attacking the pharmaceutical companies' marketing campaign, which asserted that rates of addiction were somewhere in the area of 1%. (The pharmaceutical companies are actually in the right ballpark here, and Adriane is way off base.)

Jeff cites some much lower estimates for the rates of addiction among opioid users. He cites multiple Cochran studies that show abuse and addiction rates among opioid patients is quite low. One study found misuse rates at 0.6%. Addiction must be rarer still, given that the occasional misuser of opioids is not necessarily an addict. 

Adriane herself cites the infamous Porter and Jick paper, which found only 4 addicted patients out of 11,882 who were given a narcotic (1 case was thought to be severe), though her motive was to mock it as nonsensical. Much ink is spilt over this paper and how it was supposedly misused by pharmaceutical companies and pain doctors to "understate" the addiction risk. I insist that this paper is still telling evidence that addiction is rare. This paper comes up with a low estimate for the rate of addiction compared to other more recent papers. But if opioids had the power to pharmacologically enslave users that Adriane is insisting upon, there's no way in hell they'd get anything that low. 

What the hell is going on here? How could there be such a broad range of estimates? Who's right? My short answer is that the low estimates are right and the higher estimates are not remotely plausible. Addiction rates are low, in the ballpark of 1%. 

As I describe in a previous post, you can find this broad range of estimates within a single paper that's measuring different things and reporting different estimates. There lies the key. Here is a paper that finds addiction arising in 0.19% of cases of patients with no history of opioid abuse. Aberrant behavior occurs in 11.5% of cases, but this drops to 0.59% when pre-selecting for people with no history of abuse. I think that filtering out pre-existing abuse is what's separating the high estimates from the low estimates. (See below, Adriane is also entertaining an overly broad definition of "addiction" that conflates problematic drug use with physical dependency.) Let's insert an obvious fact here: People who are addicted to opioids prefer a steady, legal supply and try very hard to get this from their doctor. Doctors attempt to screen for this, but no sorting mechanism is 100% effective. So contra Adriane's story, it is simply not the case that opioid-naïve patients are getting addicted to their legal prescriptions in large numbers. More likely, her preferred estimates arise from the phenomenon of existing addicts seeking a supply and occasionally getting a prescription. This is really freaking important if you want to understand these numbers. If you're asking the question, "What fraction of opioid patients are addicts?" then maybe the answer shifts closer to Adriane's estimates. But if the question is, "What is the chance that an opioid-naïve patient will become an addict, given that I start them on an opioid?" the answer is closer to Jeff's estimates. The latter question is the one that's relevant to weighing the risks and trade-offs associated with starting someone on a potentially dangerous medicine, the former is a completely irrelevant exercise in dividing one number by another number. 

(Here is another paper that gets a 0.6% figure, which is the number Jeff gives in his opening statement.)

There is another reason to think that the lower figures are more plausible. We have population-level measures of addiction and misuse rates. In my Dreamland post, I do some math based on numbers from the SAMHSA surveys on drug use. There were about 97 million past-year opioid users and 2 million people who'd  had an opioid use disorder in the past year. Naively dividing one by the other gets about 2%. But (and Jeff cites this figure in his opening statement) only about 1/4 to 1/5 of opioid abusers have or ever had a legitimate medical prescription. Most are getting their supply from a dealer, friend, or family member. So it's really only about 0.5 million or so of those addicts who started off as prescription opioid users. So, taking a very crude estimate, 0.5 million over 97 million is about 0.5%, which is suspiciously close to the number found in a couple of the papers linked to above and the paper cited by Jeff. The population-level back-of-the-envelope in this paragraph is admittedly crude. There is no accounting for the journey over time to becoming an addict, as I am just using a snapshot in time based on a single year's data. But the population level numbers absolutely rule out the larger estimates that Adriane gives, unless the SAMHSA figures are off by orders of magnitude.  (I'm happy to say that a survey will miss a lot of people, say homeless people or folks without a consistent address. But is it off by a factor of ten? And anyway I have seen peddlers of the standard opioid narrative cite these figures uncritically, so presumably they don't take issues with their accuracy. If there are better estimates that attempt to correct for the shortcomings of the SAMHSA survey results, I'm happy to entertain them.)

Multi-Drug Poisonings

Jeff really hammers on the issue of multi-drug poisonings. I have written about this many times. The point here is that most "opioid overdoses" are not single-drug poisonings. The toxicology often returns multiple substances, many of which are known to have interactions with opioids. Benzodiazepines, for example, are pretty harmless by themselves (from an overdose perspective anyway), but can potentiate the effect of opioids. Jeff says: Doctors aren't prescribing cocktails of opioids, benzodiazepines, and cocaine. He points out that the "opioids pharmacologically dominate the will" story doesn't make any sense in this context. It would make sense if opioid addiction were driving people to gobble down higher and higher doses of opioids until they finally overdose. But there is no reason to think a physical dependence on opioids is going to cause you to seek out other kinds of drugs. This piece of evidence militates against the purely pharmacological account of addiction and in favor of a behavioral theory a la Unbroken Brain by Maia Szalavitz. In light of this evidence, the story of adults with bad habits and poor coping mechanisms seeking out available methods of getting high is more plausible than the story of normal, well-adjusted people getting enslaved by a chemical. 

Adriane answers (around the 37 minute mark), but not in a satisfying way. She seems to admit that benzos can potentiate opioids and it's the combination that kills you. But she also seems to say that it's the opioids that kill you, not the other drugs in the toxicology screening. ("If somebody pinches you and then shoots you, it's the bullet that kills you.") Maybe she was admitting the point about benzos but making a different assertion when it's other combinations? It was a very confused response, and she didn't seem to respond to the point that opioid addiction should not cause someone to use other recreational drugs. Jeff's point stands: Opioids are far less dangerous and have far less power to enslave the will than what Adriane is implying.

Addiction versus Physical Dependence

Jeff does his best to draw the distinction between addiction and physical dependence. Physical dependence is a physiological response to a chemical, which entails tolerance and withdrawal symptoms. Addiction is a behavioral term, which means continued use despite negative consequences. He uses the neutral example of beta blockers, which can effectively control high blood pressure in some patients. However, going off beta blockers suddenly can cause dangerously high blood pressure and potentially deadly heart rhythms. No one would characterize such a patient as an "addict", even if this patient has been treated with beta blockers for years and is completely dependent on them. And no one would impart a moral dimension to their dependence or to a sudden fatal withdrawal. 

I think Maia Szalavitz's addiction experience is relevant here, because she presents a case of addiction persisting in the absence of physical dependence. (Not mentioned during the debate.) She was arrested and forced into treatment, even being forced into a state of withdrawal by a dose of naloxone (a treatment for which she had not given informed consent). She was eventually released from jail. She came out of the experience "clean" in a physiological sense, in that the withdrawal symptoms had stopped. Her body was no longer dependent on the substance, and presumably her tolerance had returned to baseline. But she still had a psychological need for the drug. She was desperate to get back to her stash of dilaudid (an opioid) that she knew the cops hadn't found. It was a habit she'd developed, but it was not due to "chemical hooks" in the substance itself. In contrast, some people might experience withdrawal symptoms after completing a course of opioids and never even associate the symptoms with the substance. The compulsion to seek more and the physical withdrawal are distinct entities.

Adriane does her best to elide the difference. She never really concedes that these are different animals. It's not just a careless omission, either. She at times explicitly blurs the distinction. In her opening remarks around the 11 minute mark, she says that the terms "tolerance" and "dependence" were "coopted" by the pharmaceutical companies. I think this is absolute nonsense. There really was a period where doctors were afraid of opioids and they really didn't distinguish properly between problematic addiction and physiological dependence. If anyone led a campaign to correct this blind spot in their thinking, they provided an important public service. (It wasn't just pharmaceutical companies, either! There were some very concerned physicians who were worried about the undertreatment of chronic pain.) I read this as Adriane trying to dismiss an important concept that's inconvenient to her argument. There really isn't a charitable reading, in my opinion. 

I think this also might explain Adriane's higher estimate for the risk of "addiction." If you're using a definition that's so broad it encompasses things that aren't really addiction, you'll naturally get a higher figure. Probably everybody who does a course of long-term opioids experiences some kind of withdrawal when they go off. And sometimes it's quite unpleasant, I don't want to dismiss their pain. (I, for one, am not in the business of dismissing other people's serious discomfort.) But it's not the same thing as addiction, and conflating them is inexcusable. 

Disconnect Between Prescribing Rates and Addiction and Drug Overdose Rates

Jeff had some very good slides which make a point I have blogged about before. You can see them if you watch the video posted at the top, but I'll reproduce a couple of them here. The first shows a time series of addiction rates from 2002 to 2014. If you fit a regression line to the blue curve, which shows the addiction rate for prescription painkillers, you may get a mildly positive trend. But it starts at 0.6% and ends at 0.7%. In other words, it's basically flat. This kills the narrative. Adriane's story is that loose prescribing led to a growing population of addicts, and with more addicts there are naturally more overdoses. (And I'm not picking on her, this is the standard narrative peddled by opioid alarmists.) She does concede that the recent skyrocketing death rates are due to people switching from prescription pills to heroin and fentanyl, but she doesn't seem to realize this is a concession to Jeff's worldview. That is, but for prohibition, the addicts could have maintained themselves on a relatively steady, high-quality supply rather than switching to a black market with wildly, unpredictably fluctuating potency. 


Next is a chart showing the overdose death rates per 100k along with the prescription rate per 100k. Note how the overdose deaths keep climbing as the prescriptions decline. I've actually seen (somewhere) prescription rate time series going back further, and in fact this is the evidence that opioid alarmists usually seize on. There really was a period where prescriptions were rising and it seemed to correlate with increasing overdose deaths. The fallacy here is to think that public health officials have a control lever, a means of pulling back the throttle on one trendline to mechanically manipulate the other. There is a broken link in that causal chain, according to the chart above. 



A little detour to topics not discussed in the debate follows here. Maybe something was happening earlier than the beginning of this time series? The best I could do is in this post. An extremely literal reading (which is inappropriate and which I do not seriously entertain) is that misuse rates tripled between 1998 and 2003, but were flat in the preceding and after. But we still have prescription opioids rising dramatically after 2003 with no corresponding increase in addiction or abuse rates. Also, there's supposedly a doubling between 1998 and 1999, the exact year when the language on the survey changed, which looks really suspicious. I do not take a literal reading of these data seriously.

During the Q&A session (around the 1:14 mark), someone asks Adriane directly what time series evidence there is that shows an increase in addiction rates. She stammers quite badly. It's really ugly to watch. And she doesn't really answer the question. She refers to "evidence" that she cited earlier, but crucially none of it is time series data, which would show the trend that she claims exists (but does not).

I have to express my frustration with the refusal of opioid alarmists to deal with this crucial fact. I don't know if they just don't know about it, or if they (absurdly) don't see how it's relevant to their story. I guess you could dismiss them by saying something about how "people don't always tell the truth about their drug use on government surveys," which is fair enough. But that would imply a downward bias in the numbers that should be roughly constant over time. It's implausible that this bias would change over the years in a manner that exactly cancels a real trendline. Besides, I've seen German Lopez of Vox cite the SAMHSA figures for the number of opioid addicts (here for example), so some people in his camp take those figures seriously. Or maybe these people are deeply unserious about statistic, in that they uncritically and reflexively cite numbers without giving much thought to implications or whether the numbers are trustworthy. Crucially, Lopez failed to give the trend over time, which would have been readily available to him. I'm sure some of his readers would have appreciated that context, which makes other parts of his general story fall apart. (Cocaine use does appear to fall around the time that cocaine-related deaths also fall, so these surveys are definitely capturing some true signal about other controlled substances. Dismissing them out of hand is not an option.)

While we're on the topic of time series data that's inconvenient to the Adriane's narrative, here's another interesting fact, which Jeff cites. Drug overdose death rates have been increasing exponentially since at least 1979. (That's rates, as in per 100k population, not totals, so it's not a figure that's simply tracking with population growth.) Also, and this was new to me, Jeff says subsequent research shows that they've been increasing (not necessarily exponentially) since 1959. In that light, the increase in opioid-related mortality is just a continuation of a 20- to 40-year-old trend extending into the late 90s to present day. (Cocaine was the most commonly used substance in drug-related deaths up until 2006, which is well into the opioid era.) That should make us doubt that opioids are the cause of the continuing trend, in a but for sense. They were available, so that's what people were using (as Jeff points out in his closing statement). The image below is from that paper (it is not from one of Jeff's slides). 



How Gullible Are Doctors?

Adriane's worldview is incredibly cynical, bordering on paranoid. In her view, pharmaceutical companies have incredibly insidious influence over the way medicine is practiced. Their advertisements and their attempts to influence doctors are extremely powerful, and doctors don't realize they're being bamboozled. She refers to "fairytales" told by the pharmaceutical companies, specifically in reference to the lower estimates of addiction (which it turns out are correct). She even smears one of the questioners during the Q&A, Josh Bloom of the American Council on Science and Health. (She insinuates that his organization is tainted by pharmaceutical money, to which he responds "That's a lie." Epstein quickly moves on to the next question, but it's a pretty ugly encounter.)

I think this stuff is catnip for left-wing and right-wing audiences. For the left, this is an opportunity to reflexively raise a middle finger to corporate America. Their greed is so immense they don't care how many bodies they leave in their wake in pursuit of profit. For right-wingers with a puritanical bent, we have a massive drug peddler finally getting its comeuppance. Unfortunately it's all nonsense. I see Adriane as playing to her audience's knee-jerk political instincts (something we all need to stop falling for).  

Part of this story is that pharmaceutical companies are well-resourced and adept at manipulating people. Unfortunately for this narrative, it's actually really difficult to fool people consistently. If you think someone is getting one over on you, or if you sense that they have any incentive to mislead, you will instinctively discount anything they say. Even unsophisticated people who sense that someone is trying to fast-talk them can simply tune out their would-be manipulator. This places an upper limit on how convincing any argument or ad campaign can actually be, no matter how slick or well-funded. The notion of these corporate behemoths running roughshod over mindless sheep is a fantasy. Keep in mind that these are doctors! Sure, some doctors are gullible. Some may occasionally say embarrassingly foolish things in public. But most are pretty smart. They are basically the most scientifically educated class of people in society. And the people who are trying to mislead them are often drug reps with no scientific background. I say the doctors have the advantage in this encounter. (Sometimes the influencers are doctors who are paid by the pharmaceutical company to deliver lectures or "continuing education." But most drug reps are not, many have little scientific training and are basically charismatic people following a script. I know about studies showing that doctors commonly make elementary math and statistics errors, some of which are relevant to the practice of medicine. I readily concede that this is a problem. But they're mostly well equipped to resist the utter sophistry of a slick ad campaign with no actual substance behind it.) 

Jeff takes exception to Adriane's characterization of doctors as gullible. He says how implausible it is that a doctor will change their prescribing habits based on a free meal or a pen with a drug's logo on it. They're not so easily bought off or fooled, he insists. In response, Adriane again shows her technocratic side. She goes on a long, irrelevant lecture about how small gifts work better than big gifts. Smaller gifts convince the recipient that they did whatever they did for internal reasons, because nobody wants to feel like they were bought off by a trinket or a trivial sum of money. I think this is a cute description of a lab experiment, but once again it's not the real world. The subjects in the experiment she's describing presumably cooperated with the experimental design. In the real world, you can walk away from such noise. You can tune out someone who's trying to snow you, and this is exactly what we do. 

This doesn't get mentioned during the debate, but here is my write-up of a study about the supposed origins of the opioid epidemic. It attempts to blame state-by-state differences in overdose rates with Purdue Pharma's marketing campaign, which varied by state based on the paperwork burden of prescribing opioids. There are a lot of serious problems with the paper. It's interesting that this is the academic attempt to rigorously make the argument that anti-opioid crusaders are making more anecdotally, and it ultimately falls flat. Also notable, it's funny how Purdue is blamed for creating a market that is more than 10x it's own market share. They're a bit player in their own industry, following a trend but not creating it out of thin air.

Other Notable Moments

I'll end with some unconnected thoughts about a few interesting moments during the debate. 

Stanton Peele asks the first question in the Q&A, and he kind of makes an ass of himself. It's unfortunate, because I actually really like Stanton. He tries to poll the audience as to how many of them have ever taken an opioid, by a show of hands, and tries to follow it up with how many of them had a problem going off them. Jacob Sullum did the same thing in his debate with Alex Berenson a few years ago (my write-up of that debate is here, but it's worth watching the full debate too). You can't see the audience, but a very large number of people raised their hands to the "were you ever prescribed a course of opioids" question and almost nobody  raised their hands to "Did you have some problems coming off them?". (Was it exactly zero people? We didn't get an official tally.) I think the debaters can do this, but it's probably obnoxious for a questioner to do the same. Epstein, the moderator, cut him off as Peele shouts something (to someone, it's not clear who he's yelling at). I think the voters in these debates aren't necessarily just voting on who best defended their position according to the precise wording of the resolution. Sometimes they are swayed by things like demeanor, charisma, unrelated topics that are tangential to the resolution, etc.. Stanton's behavior is likely to turn away marginal voters, who look at this and say, "These guys are a bunch of crazies." We need to keep our crazy zealots in check.

During the Q&A Jeff responds to a question about a policy of over-the-counter availability for essentially any drug. I think it was meant as some kind of "gotcha", but Jeff handles it well. I don't know how this comes off to an uninitiated audience. It may be bad strategy from the standpoint of winning an Oxford-style debate. As in, the borderline voters may think you're a crazy bastard for taking an extreme position, so they may discount the rest of your arguments (even based on something that's not necessarily germane to the resolution). On the other hand, there's a "long game" to play here. This debate may have been some audience members' first exposure to libertarian ideas, or to the concept of bodily autonomy and self-ownership as moral principles. (Principles that are not universally recognized, unfortunately.) One could even lose the debate while winning the long game, because these ideas will stick in some people's minds and germinate. On this specific point, I actually think it's a moral imperative that we allow opioids to be available over the counter to anyone who asks for them. Currently we have a system of gatekeepers, doctors and pharmacists, who stand between pain sufferers and pain relief. This means that doctors can suddenly stop prescribing opioids to a pain patient who has been using them for years. Maybe the doctor is afraid of legal scrutiny, as in law enforcement deciding that they are prescribing too much. Or maybe the doctor literally gets arrested and charged, and his pain patients are left out in the cold without a provider. Something like this is happening today. It is definitely keeping chronic pain patients from getting the only treatment that works for them. 

That brings me to another point. There is some discussion of suicide among opioid patients. Adriane absurdly attributes higher rates of suicide among opioid patients to opioids themselves. It's another absurd dismissal of human agency in favor of voodoo pharmacology, as if the chemicals themselves are driving behavior. Jeff calls her out on it, saying that the causal connection isn't the one Adriane is implying. Jeff gives the more plausible reading of these numbers: chronic pain patients tend to be suicidal because chronic pain can be a living hell. It's kind of funny, because Adriane dumps on some of the studies Jeff cites as being "observational" and not sufficiently rigorous in terms of proving causation. But this is a case of her making the "correlation is causation" fallacy, even when there's a much more plausible story. 

That's the end of my commentary on the debate itself, but I really need to share this video of Adriane giving a speaker a hard time at what appears to be some kind of medical conference. I think it speaks really poorly of her character and lays bare her underlying motives. The speaker, Stephen Kertesz, presents reams of evidence of patients who have committed suicide because of a "forced taper", meaning their physicians involuntarily cutting their opioid dose. Because the government doesn't collect data on this, one has to turn to collecting anecdotes and news reports. Adriane is obviously not happy with the talk. (Do watch the whole thing, tell me if I'm being unfair.) Kertesz isn't trying to deliver a slam-dunk conclusion. He's ultimately arguing for the collection of data that would allow the government to track how much and how often this is happening. Adriane pushes back against even that modest proposal of collecting the data. She absurdly insists that there isn't evidence of a huge surge in such suicides, and the speaker quite fairly points out that this is a kind of Catch-22. As in: Yeah, there's no evidence of a huge surge because we're not collecting the data! Kertesz actually does an excellent job of collecting whatever sparse data is available, scraping news stories, interviewing spouses, social media posts and such. What kind of evidence does Adriane expect to see if official numbers aren't being tabulated? What would be the difference between a "large signal" and a "small signal", in her view, without such tabulation? Once again, it's really hard for me to interpret her behavior charitably. Adriane is a board member of PROP, the "Physicians for Responsible Opioid Prescribing". This group very likely helped write the CDC's disastrous opioid prescribing guidelines. These guidelines, while nominally just providing "guidance", in reality had the force of law behind them and were used to red-flag physicians who were overprescribing. Maximum "recommended" doses listed in the guidelines were interpreted by physicians, who were astute about reading the temperature in the room, as hard cut-offs. It led to a lot of forced tapers. Adriane is in denial about this, "Who is calling for a forced taper?" she says. It's pretty clear she's being defensive and deflecting blame.  Obviously she'd be hostile to any attempt to uncover the bodies. An honest player here would say, "Go ahead, collect the data. You'll see this is a big nothingburger, but it's worth the modest expense at data collection." Instead she's adopted this strategy of castigating her colleagues at professional conferences for bringing up the topic. Kertesz responds admirably to this abuse. My takeaway here is that Adriane is not an honest broker of the truth. She's just as compromised by a combination of financial incentives (she is a paid witness) and her partisanship in an anti-opioid crusade. Money isn't the only thing that can compromise a person's integrity. If there is any chance at all that opioid policy is torturing people to the point of suicide, then we should be incurring whatever expense is necessary to collect the data. (Does Adriane see herself as the guardian of scarce research dollars, simply guarding against profligate spending on someone's hunch? I really have a hard time reading a pure motive in this exchange.) There are some actual studies of this question using large sample sizes, by the way, so Kertesz isn't merely falling for a few emotional anecdotes. 

There was some discussion during the Q&A about why pain patients aren't more organized. I would like to hear more directly from them at events like this. I see Adriane as completely dismissing these people. She asserts that opioids don't work for chronic pain. I'd like to see the chronic pain patient who has successfully regained their functionality to approach the mic at one of these events and say, "I understand you don't believe I exist..." It doesn't have to be mean. Nobody has to shout her down, use harsh language, or make a scene. Such tactics can even be counterproductive. There's no need to even raise one's voice. I think a steady drumbeat of chronic pain suffers, each calmly recounting how their life was a living hell without opioids, would make the point just fine. My understanding is that there is adequate security at the Soho forum to avoid rowdy disruptions, so that might be why we didn't see these chronic pain sufferers screaming in Adriane's face. And I really don't want to see that. Adriane is in some sense simply serving as the avatar for a commonly believed narrative. It's important to create forums where such people can share their perspective without fear of being shouted down or drenched with spittle-laden invective. At the same time, if her perspective wins it means some chronic pain patients will be tortured to the point of suicide. I think she needs to be brought face-to-face with this. 

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*I want to run an RCT where I randomly switch out items from someone's shopping cart at a grocery store. The customer protests, "But, I love Wishbone Creamy Caesar dressing!" Scientist replies, "Sorry, but RCTs have found no improvement in general happiness comparing Caesar dressing users to over-the-counter Ranch users. Congratulations, you're in the control group of a follow up RCT! Ranch for you!" Sometimes medicine is like chemistry. It just works, and it works the same for all of us because we have roughly the same physiology. But sometimes it's more like a shopping basket, where you've built up preferences and patterns over the course of a lifetime and you've figured out what works for you. For something as subjective as pain, I think it's more like a shopping basket than a test tube. 

Saturday, March 26, 2022

Very Simple Observations on Ukraine

I don't necessarily feel the need to weigh in on the news topics of the day. There is a class of Twitter dwellers who apparently need to have an opinion about every topic. Sometimes they loudly spout the conventional wisdom while saying "expert" or "consensus" every second or third word. Some of them are contrarians for the sake of being contrarians. Some are hipster meta-contrarians, crafting clever arguments to put themselves in good standing with the consensus crowd while (more importantly) showing themselves to be more sophisticated than the contrarians. I stay out of this for most news cycles. I'm not an expert on Ukraine. I don't have anything particularly new or interesting to say. At the same time, this conflict has the potential to kill us all by setting off a nuclear Armageddon. I have opinions and feelings about that, which no "expert" has the right to deny me. So I'll offer up just a few basic observations.

First, where I'm coming from. My disposition is generally anti-war and anti-interventionist. I'm not a total pacifist, but I think armed conflict needs to be overwhelmingly justified in a way that few actual wars are. From this perspective, Russia's invasion of Ukraine is an unjustified war of aggression against a neighbor that poses no threat to it. I'm not in the camp of libertarians who reflexively blames US foreign policy for everything bad that happens in the world. The US isn't totally blameless in a causal sense. "Strategic ambiguity" may have led Ukraine to think they had a stronger backing than they did, perhaps making them more likely to flex their muscles and thumb their noses at Russia. It's truly shameful if we dangled such a promise in front of them without delivering the goods. But the moral blame falls squarely on Putin as the aggressor in this conflict. 

Some commentators are saying the US started this conflict by grooming Ukraine to join NATO. NATO is a treaty in which signatories promise to come to one another's aid in the case of invasion. Basically it was put in place to stop Russia from advancing across Europe after World War II. The only reason Russia should have a problem with Ukraine joining NATO is because they wish to preserve the option of invading them at some future date. I've heard some commentators claim that NATO members would start installing military hardware in Ukraine, missile launch silos and such. These could initially be entirely defensive (set up to, say, shoot down Russian jets or intercept missiles), but could be refit to deploy offensive weaponry pointed at Russia. I think it is beyond paranoid to think that the US or other NATO members would launch an actual invasion of Russia or start making incursions into its border. We're hesitant about getting involved in a shooting war in Ukraine because it might set of WWIII. We wouldn't literally invade Russia for the same reason. In my opinion, some of the anti-war commentators are going beyond, "Putin perceived NATO expansion as a real threat, which explains his actions" and straying into the realm of "Putin was correct that NATO expansion was a threat to Russia." If I am reading them correctly, this is ridiculous and has to stop.

Maybe these commentators are simply saying that NATO-grooming was the predictable cause of Russia's invasion. It was imprudent from the point of view of the United States, potentially incurring costs for no actual benefit, strategic or otherwise. Some have cited quotes by war hawks (Kissinger among them) warning that expansion of NATO would provoke the Russian bear. That's fine, but some are taking this too far, implying that it was immoral to expand NATO. Many cite promises by Bush Sr. to Gorbachev that NATO would not expand after the fall of the Soviet Union. I think it's morally obtuse to imply that such a promise should carry the same moral weight as a promise made between two consenting adults. I think it sucks when a nation breaks an agreement with another nation. At the same time, this was an assurance made to a desperate, collapsing empire to deter Russia from waging wars of conquest. The worthy goal here is avoiding wars of conquest that redraw the map of Europe (or other continents for that matter). Promise-keeping is nice. But this was a promise made hastily to a known killer in order to deter a killing spree in a time of great uncertainty. "We won't meddle if you go on another killing spree. We'll stay out of your affairs."  If we later say, "Actually we will stop future murderous rampages," that's a promise worth breaking. The only reason Putin should have a problem with any nation being a NATO member is that he's trying to persevere the option of launching a war of conquest. Or he has a pathetic obsession with "global influence". (Where some may see Putin as a shrewd rational actor masterfully preserving his nation's influence, I see a pathetic man-child moving action figures around on a map, occasionally making explosion noises.) The invasion of Ukraine is proof that Russia (Putin anyway) is willing to launch wars of conquest to preserve its political influence and sense of empire. 

All this said, I agree with the observation that the US is willing to "fight Russia to the last Ukrainian". I enjoy the romantic notion of a plucky but determined Ukraine halting and expelling the Russian juggernaut. But war is hell. Millions of people have had their lives disrupted, and thousands have already been killed. The Ukrainian people should not be made performers in a morality play for the consumption of US news junkies. The Ukrainians will need to decide for themselves how hard to fight and to what end. I hope nothing done by the US prolongs their suffering. I hope official US foreign policy doesn't encourage them to fight beyond what's prudent. I hope unofficial "Twitter-mob" encouragement doesn't cause them to overestimate the chances of the cavalry coming in to save the day. My not-so-hot take is that if Russia is willing to incur the losses, it can eventually take Ukraine. If that is how this ends, I hope for as few casualties as possible. Some American hawks would love to see this war be as costly as possible for Russia without a thought to the suffering incurred by the Ukrainians. I would hate to see such needless suffering just to "weaken" one of America's antagonists. Putin would still have enough nukes to end civilization, so it's not clear what strategic advantage it would be to decimate his army. (Except that maybe it would deter or make unfeasible an invasion of another former Soviet state? A good outcome no doubt, but bought at what price?)

What should have happened? I really don't know. I wish we had given a clearer signal that Ukraine wouldn't be admitted to NATO. If NATO members were unwilling to get into a shooting war with Russia, they should have made that extremely clear. At the same time, I wish we'd sold them more arms and offered more military training, and earlier. The Ukrainian military outperformed everyone's expectations. It's not unthinkable that a Ukraine with, say, ten times as many aircraft and anti-tank weapons could have completely halted the Russian war machine, or deterred it from ever crossing the border. Maybe such a military build-up would have been highly visible to the Russians an would have simply encouraged an earlier invasion? 

There is an argument that goes "Give Putin what he wants, otherwise he'll nuke the world." That's too simple. There's a counter-argument that goes, "Don't give in, otherwise Putin will smell weakness and expand without limit." That's also too simple. You can't give in to unreasonable demands just because some madman has a nuclear arsenal, but you also can't draw lines in the sand everywhere. Scott Alexander said it best in a recent post:

I think this is where the lines-in-the-sand come in again. Imagine Russia declared a “no-sanctions zone” across the entire world, where if any corporation stopped doing business with them, they would bomb that corporation’s headquarters (even if the corporation was headquartered in eg the US). While this might give some corporations pause, a lot of Americans would feel honor-bound not to comply - it would be “giving into terrorism”.

The line between common-sense “don’t provoke a nuclear power” and “if we went along with this, it would be giving into terrorism” is set by international law, diplomatic norms, and various fuzzy rules of war. They say that some things are allowed, and other things are bullying and if someone threatens them you need to call their bluff. The silly “no-sanctions zone” idea would be the latter. And so would a no-fly zone.

Some among the anti-war commentariat (I'm thinking in particular of a very recent speech by Scott Horton) have been making too much of the fact that Russia has nukes, as if any provocation whatsoever will cause total annihilation. Standing up to a nuclear power certainly requires caution and prudence. I don't think we should get into any shooting fights with the Russian army, and establishing a no fly zone would be unwise. (A no fly zone is essentially a promise to shoot down Russian planes. If enforced, that starts a shooting war. If not, it destroys our credibility.) 

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There is a "that's not my problem" mentality among some of the anti-war libertarians, which I consider morally obtuse. (It's a real shame, too, because I typically count myself as a member of that group.) As in, "Sorry about the terrible invasion, but that's not America's problem." And then it feels like there's some kind of bullet-biting contest where they insist on total American neutrality even in the face of the worst atrocities. It's weird, because these are the same people who will quite correctly point out that war is immoral because it kills lots of non-American civilians. My reaction to this is "Really? Even if an extremely delicate and circumscribed use of force could, say, stop a massacre? Even if there's a 99.9% chance a show of force, without actual force, would halt the advance of a genocidal death squad?" Of course, hawks tend to badly miscalculate the odds of something like this succeeding. Restraint and humility are wise when considering the use of force. But I don't sign on to this notion that it's "not my problem" if a large nation commits an atrocity against a smaller nation, or a nation commits atrocities against their own citizens. The US should at the very least be welcoming their refugees. If the lives of foreigners have value (and I would insist they have just as much intrinsic value and dignity as American lives), we should regard aggression against them as a problem that needs to be addressed. If a delicate projection of power could save thousands of lives, that shouldn't be off the table because we're biting the bullet on some kind of moral "principle". (Scare quotes because it's difficult to articulate what this principle is, not because I'm against being constrained by moral principles. Is this a "principle" that results in more aggression in the world? Does the same principle say we can't use force to stop private aggression within the US? Or is it specific to nations? Is it permissible under this principle for private individuals or private militias go abroad and help Ukraine or a similarly situated nation? Is the objection to being conscripted, through taxation and use of your resources without your consent, to participate in a war? Even if it's a just war?)

Wednesday, February 9, 2022

Comparisons to the Flu are Relevant

There is a type of person who becomes apoplectic if you try to compare covid to the flu. I noticed this from the very beginning of the pandemic and I thought it was completely nuts. To be fair, there were some commentators making inappropriate speculation, saying that covid would be like a "bad flu season." Obviously it turned out to be much worse than that, but it was intrinsically reasonable to compare it to something we understood and lived with. 

The infection fatality rate for covid, averaged across the population, is somewhere around 0.2%. If you infect a million random people, ~2000 will die from it. Obviously this varies wildly by age and other risk factors (see discussion below), but this is a good place to start. "If you get covid, you're about X times more likely to die than if you got the flu." This anchors the risk to something we're familiar with. Whatever precautions we typically take to avoid getting the flu, we should scale them up accordingly. That's not to say proportionally. If your risks are 10x that of dying from flu, you may be willing to spend more than 10x the cost in avoiding it. People tend to be risk averse. Still, it's a good starting point to adjust from, not some utterly alien concept demanding an arbitrarily large up-scaling of precaution measures. It makes sense to ground those decisions in something we're familiar with, and the flu is a good place to start.

The other piece to consider is your risk of getting infected. Obviously covid is much more transmissible than the flu. Looking at some data at this CDC page, it looks like there are ~30 million flu cases in a typical year. Let's suppose covid is so transmissible that nearly all Americans are going to get it under a "business as usual" regime, call it 300 million covid infections (about 90% of the US population). That's another useful piece of information. "Covid is like the flu, but you're 10x as likely to get it." (Or whatever the multiplier is, I'm not wedded to any particular point estimate.) 

There's a philosophical question about whether I should care about the second piece of information, the likelihood of transmission. I generally don't scale up or down my caution with differing flu seasons. It's just something I'm inured to. Though possibly this is just because flu is below a threshold for risk that I can just rationally ignore. Maybe I would respond if there were a flu season where the active strain that year is 3x or 5x as transmissible? Or maybe I'm appropriately applying a heuristic that "Getting sick is part of life, mitigation measures aren't that effective. I'm inured to these kinds of risks, and I won't change that unless something truly deadly comes along." The notion of scaling up and down my precaution for very active versus less active flu seasons seems weird to me. But maybe it's actually rational to do this and I'm bad at updating my behavior. I'd probably be more likely to get a flu shot if experts were projecting a truly bad flu season. (If I didn't, my wife, who is in health care, would gently nudge me to get the shot.) But I don't see myself socially distancing or masking up for a "bad flu season." 

The most relevant piece of information is the extreme age stratification. "It's kind of like the flu in terms of overall symptoms and infection fatality rate, but it basically doesn't cause problems in children below age 12, it's similar to the flu for ages (say) 20-40, and above age 65 it poses a serious risk of death." Add in some caveats about specific risk factors like obesity, diabetes, pre-existing lung disease, etc. This is something that really would affect my behavior. "I'm basically fine, I shouldn't undergo any particular precautions for my own benefit. But I should avoid elderly or infirm members of my family, or at least take some precautions, until the pandemic subsides." Many years ago, my wife and I were picking up an elderly member of the family for a family gathering. She lived in an old folks home, and there was a sign at the door warning that anyone with flu symptoms should stay away. I kept that thought with me. It made me aware that a mild illness for me could be a fatal infection for someone who's not so healthy. It was probably worth scaling up this sense of precaution by a factor of ten or more as a response to Covid, whatever that entails. But it made little sense for young people who are mostly encountering other young people to scale up their precautions. As I pointed out in a prior post, young people vastly overestimated their risk from covid, presumably causing them to take irrational precautions to avoid the virus. 

We are, as a collective, utterly incapable of rational risk calculation. Dominant media narratives and messaging from "public health" institutions fail to put the panic porn into perspective. We become totally inured to significant risks, like automobile accidents, but obsess over insignificant risks, like an opioid prescription turning us or our neighbors into mindless drug addicts. We obsess over determinants of health that don't matter, like economic barriers to health care, but fail to take simple, inexpensive steps that would improve our health and longevity, like exercise and improved diet. Our experience with covid over the past two years has really driven this home for me. 

Note that there are two determinants in the "how much should I worry/take precautions" calculus. One is the magnitude of overall risk (assuming the problem is unmitigated). If covid had the mortality rate of small pox, I'd be singing a very different tune. The other determinant is "How effective are mitigation measures?" (There are some things you can't do anything about.) I think people are badly overestimating on both fronts, so it's leading to costly interventions that don't stop the spread. Studies on the benefits of masking are at best inconsistent. (Read the first few studies on this question that Google returns. That's studies, not opinion pieces or news columns. I see a lot of very wide confidence intervals on the odds ratios that surround 1.0, implying the statistical tests can't tell if masking is helpful or harmful.*) The supreme confidence in their efficacy is not warranted, neither is the outrage directed at people who refuse to mask up. Likewise, the closing of schools was never warranted, nor was the closing of outdoor spaces. It was well known early on that children were unlikely to be harmed by the virus and also quite unlikely to transmit it. It was also known that the virus did not transmit effectively outdoors. No matter how dangerous the virus is, it makes little sense to conduct ineffective hygiene theatre out of a misguided sense of "do-something-ism". 

The almost daily references to the total body count are totally irrelevant. (I also wouldn't mind if people stopped converting the body-count to "9/11s". As in, "This is like having three 9/11s each week!") What matters is the plausible counterfactual, where cost-justified interventions were taken. Maybe some commentators are thinking that most of the deaths were avoidable (something I think isn't remotely plausible), so it's okay to cite the raw total as an order of magnitude estimate? I wish they'd be clearer about their assumptions. An earlier rollout of the vaccine may have cut the deaths by some large percent, though it's clear now that new variants are evolving to evade the narrowly-tailored mRNA vaccines. It's possible that an earlier vaccine rollout would have simply driven the evolution of new variants to an earlier point on the timeline. Then again, the vaccines appear to protect against extreme illness and death, even if they're losing their effectiveness against preventing infection full stop. "It's a lot like the flu, except it keeps evolving to evade available vaccines. Also, that's not really different from the flu. It's something we're familiar with." 

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* On the masking question, people will sometimes acknowledge (or brush aside as "underpowered") the studies that show weak or null effects of masking. They'll then retreat to an a priori explanation of why they should work. "A mask filters x% of incoming air, so it's at least x% effective" or the contrary "The virus is too small to be blocked by the matrix of cloth in a mask, and there's adequate airflow around the mask anyway." Or even, "A mask blocks outgoing droplets, but then you're breathing and blowing on it for the next hour or so. This generates more aerosolized virus than if you just went maskless." Whether masks are slightly helpful, benign, or hurtful is an open question. Again, see the lower confidence intervals on some of the studies that Google returns. 

Wednesday, December 29, 2021

Against “Kinder, Gentler” Socialism

There have been some recent attempts to resuscitate and rejuvenate the dead ideas of socialism. Despite its having been thoroughly refuted by the experience of the 20th century, advocates are always appealing to some slight variation on the basic concept that's "never been tried." You can read some of my recent posts as pushing back against these attempts to redeem a fundamentally misguided idea. 

In this post on worker ownership of the firm, I'm arguing against a thread of socialism that downplays state control of production and endorses worker ownership of the firm. As I read it, this position is actually a substantial retreat from socialism as it was initially conceived, an attempt to "moderate." Or perhaps it's just and attempt by crypto-communists appear moderate to onlookers. It's as if they recognize socialism in actual practice (as in literal state control of the means of production) has a horrendous track record. "No, no, we're not endorsing that." Ben Burgis and Richard Wolff are attempting to achieve as much socialism as possible through voluntary arrangements, while still not shying away from using the machinery of the state to mold the world toward their imagined utopia. I think their vision of an economy dominated by worker co-ops is extremely unlikely. Apparently the workers agree; the vast majority of workers in free economies are wage and salary employees. Very few workers get a substantial share of their income from residual claims against their employer's revenue (like you would as a partial owner). Even this kinder, gentler, warmer, fuzzier variant on socialism is a terrible idea.

In this post I explore the experience of the Israeli Kibbutzim. This was an institution of private socialism that started strong at their initial founding and began to decline. The critiques of such a system that a basic econ 101 analysis would warn you about began to materialize and take a bite. If "kinder, gentler" socialism were a viable option, they would have grown rather than shrank. The obvious incentive problems and brain drain took their toll. Despite reforming themselves in a pro-market, pro-property direction (hiring outside firms to run their commissaries, giving members the right to own more private property and leave the Kibbutz with it, etc.), life outside the Kibbutzim was more attractive. 

I see people like Burgis and Wolff as misstating the historical record, or simply not dealing with it. They subscribe to a vision of the world that I don't recognize, where companies have "power" over employees and customers. (They don't have "power." They can only offer a thing for a price, which the customers and workers can freely take or leave.) They fail to recognize the massive improvements in living standards over the last two centuries, or at any rate they fail to attribute those improvements to private enterprise. So they end up inventing solutions in search of problems.

Mao and Stalin were mass murderers. I'm glad that today's defenders of socialism at least see a need to distance themselves from them and say their program is a different thing. This is a kind of progress. But the problem isn't just that these people were big meanies. State socialism failed to deliver the goods. If the problem were merely that corrupt, evil people took over the machinery of the state, we still should have observed superior economic growth (with the proceeds going to the corrupt rulers rather than the workers more generally). No, the problem with socialism is the incentive problem. People treat communal property like trash (compared to how they treat their private property). People don't work so hard when their salary doesn't depend on their productivity. Those problems don't go away when you retreat to a gentler, more voluntary form of socialism. I'm happy to see experiments in communal living arrangements, and I think some version of this can succeed in a tightly knit community of very dedicated individuals. (The Kibbutzim falls just shy of this realization, but comes close.) I don't want to over-analyze the motives of modern defenders of socialism, but I see them as not willing to let go of something when history has given us a clear verdict. I detect a desperate clutching to whatever variant of this idea remains "untried." They've retreated to a superficially defensible enclave of idea-space. But they're trying to defend something that's fundamentally indefensible. 

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I want to apply a "line in the sand" test to some of these people. As in: Is there a line they won't cross, where the economy becomes "too socialist" or the government exerts too much control over markets? Is there theoretically a point where they would say, "Nope, this is too much socialism. We need more economic freedom and private incentives." If not, they are crypto-communists masquerading as sensible moderates. They want whatever amount of socialism that they can get away with. If they got what they asked for, they would simply push it further in the same direction. I often sense that there is no limiting principle. (Not just w.r.t. socialists pushing socialism. The answers to questions like "How much should we tax cigarettes?" or "How much should we pay school teachers?" always seems to be "more", without reference to the current level or recent trendlines.) Maybe most of these gentlefolk have a limit in mind, and I'm being paranoid for entertaining this hypothetical at all. 

Study on the Origins of the Opioid Crisis Published

 Almost two years ago, I wrote this post describing a pre-print paper on the origins of the opioid crisis. It was an interesting attempt, but I think it was fundamentally confused. For example, it supposedly finds that differences between states in opioid overdoses are driven (in part) by law differences. (So called "triplicate states" required doctors to fill out forms in triplicate when prescribing narcotics, other states did not.) Their punchline is that it's not the law difference itself that's driving the difference, but rather Purdue's response to the law. Specifically Purdue's decision not to market as enthusiastically in triplicate states caused the difference, according to their analysis. If triplicate states would have gotten the same results in overdose deaths if Purdue had decided to give them equivalent marketing attention, then what are the policy implications? The paper tries to suggest that other states should have had triplicate laws, but their own argument suggests that that strategy would have had limited success. Suppose all states were triplicate states. Doesn't that just mean Purdue would have said "Screw it, we're going to market just as hard everywhere."? Their causal story might be true, but their attempt to draw policy conclusions from it is hopelessly confused. 

There are other major problems with the paper, which I outlined in my earlier post. I have never seen any of the opioid alarmists grapple with the fact that there is no trend whatsoever in the number of users or addicts. An important link is broken in their chain of causation leading from opioid marketing to opioid overdoses. And they never seem to acknowledge that the "opioid epidemic" is just a continuation of a pre-existing trendline stretching back to 1979, at least. Also, by all accounts Purdue had a tiny market share of total opioids prescribed. So it's weird to single them out for blame.

I can't seem to find the published version of the paper online, so I can't see if the final version addressed my concerns. If I manage to get my hands on it, I'll do a follow-up post pointing out that my criticisms were answered. 

Wednesday, October 20, 2021

Overall Mortality and Drug-Related Mortality by Age, 1999-2018

With Covid-19 hitting the world in mid-2020, I was having a lot of thoughts about how to measure public health crises. Covid deaths were numerous enough to show up in the all-cause mortality figures. This basically ruled out the possibility that Covid was far less severe or far less common than the official statistics implied. Cause of death misattributions could conceivably overstate deaths in one category while understating those in another, but they couldn't drive an upward trend in overall mortality. The excess deaths look particularly stark if you break down the analysis by demographic and look at those groups especially hard-hit by the virus. The all-cause mortality figures ruled out a lot of kooky conspiracy theories and narratives that minimized the severity of the virus. 

I thought this fixation on all-cause mortality could be useful in other contexts. Of particular interest to me was drug-related mortality. I believe that there is a huge misattribution problem in drug-related causes of death, particularly with regard to prescription opioids. If someone dies with a syringe in his arm, maybe the cause of death is unambiguous in that case. But millions of people are walking around with blood levels of opioids that would kill a naïve drug user. Surely these people sometimes drop dead of unrelated causes, like a sudden fatal heart arrhythmia, and the medical examiner wrongly marks it as a drug overdose. If drug overdoses (as marked on the death certificate) are a large proportion of these deaths, but the all cause mortality doesn't change much, it raises suspicions. Of course, other causes of death could be falling at the same rate that drug overdoses are rising. It's certainly possible. But it would look really suspicious. 

I downloaded the all-cause mortality by year, age, race, and gender from the CDC website here. I appended total drug deaths based on my decoding of the large cause of death file (which I've reported on for several years, see my work up of the data for 2016, 2017, and 2018) . Since the opioid epidemic is disproportionately a white male phenomenon, I limited the analysis to that demographic. (Males have something like double the drug-related mortality of females, so the effect of an opioid crisis in their all-cause mortality will pop out more if we limit the analysis to them.) Keep that in mind for all charts and numbers below, the dataset is being filtered for white males. Many of my observations stand without doing this filtering; I did the analysis both with and without. I'm sharing the filtered version in this post. 

Another thing to keep in mind is that prescription opioid deaths dominated the trends in drug-related deaths from 1999 to about 2010. After 2010, heroin and synthetic narcotics like fentanyl began to dominate the trends in drug deaths, and prescription opioid deaths tended to flatten out. I will refer to these periods below and try to justify my claim that these are two different epochs. 

First I want to get a feel for the age distribution of drug-related mortality. Below is a density plot, which basically shows the distribution of deaths in each of three years. It looks like the distribution shifted to slightly older between 2000 and 2010, then younger in 2018. The average (not shown) bounces around between 40 and 42.5 over this time period, which doesn't sound like much. But the distributional shift kind of maps onto a story of prescription opioid use rising in the 2000 to 2010 period, being more pronounced in the 40+ demographic (the modal drug poisoning is just shy of age 50 in 2010!). Then the use of recreational heroin and fentanyl rises in the 2010-present period, hitting younger users harder. Modal age of deaths is around 30 in 2018, but do note the fatter tail, extending more into older ages than in 2000 or 2010. The mode can shift a lot without the overall average budging much. Anyway, the story of pills being an older phenomenon and street drugs being a younger phenomenon makes intuitive sense to me and is consistent with what I know generally about drug use patterns.


Next I want to show what drug-related mortality is doing by age group over this time period. Below I am showing drug mortality per 100k for ages 20 through 59. It definitely looks like there is an upward march. Here I am not making a distinction that I usually make, in which I break out suicides and unintentional overdoses. I am simply including all deaths in which a drug was mentioned on the death certificate (so this actually includes some car accidents, drownings, and some other deaths that generally aren't counted in studies of the overdose epidemic, but which can plausibly be blamed on drug use.) Some show a more consistent upward trend over the period, others show some temporary plateaus. Between, say, ages 25 and 50, there is an evident spike in the 2010+ period, a very clear break in the trendline. This is obviously related to the explosion of fentanyl-related poisonings over the period. (The grey box on top of each plot shows the age of the decedent.) 


So what is happening to all-cause mortality over the same period? Here is what those numbers look like.


I found this odd. A major cause of death is rising, and yet it's only evident in the all-cause mortality numbers for, say, ages 25 through 40. The heroin/fenanyl epidemic is evident in the all-cause trends at ages ~25 to 45. Every age in this range is showing an increase at least in the last few years (say, 2015-2018). Some are showing an increase over the 2010 to 2018 period, which matches with the period over which heroin/fentanyl deaths were really exploding. The all-cause mortality patterns basically validate the idea that there's a serious illicit drug problem in the 2010 to present period. 

What about the period from 1999 to 2010? This is a time when overdose deaths were dominated by prescription pills rather than illicit opioids. The only ages for which there is an obvious upward trend over this period (granting some substantial reversals and plateaus) are maybe ages 24 to 32 (not that any of these endpoints are exact). At ages 20 and 21, there is actually a decline in overall mortality. For people in their mid-30s, the trend looks pretty flat. For ages 36 to 49 the trendlines slope downward for this period. This is weird. Something is apparently offsetting the drug-related mortality over this period in some of the hardest-hit demographics.

It's not like the drug-related deaths are just a rounding error, either. Many analyses (in particular I'm thinking of Angus Deaton's recent work) have suggested that drug-related mortality is causing an overall decline in life expectancy, which would imply that they're a substantial fraction of overall deaths. Indeed they are. Let's look at the actual numbers. 


Supposedly, drug-related mortality rises from ~5% of deaths to ~15% of deaths for 20 year olds over the 1999-2010 period. And yet there is no evidence of this in their all-cause mortality figures? For 33 year olds it rises from ~10% to ~20% of overall deaths, and yet the all-cause trend is flat? People in their 40s are mostly seeing improvements in mortality over this period, and yet they're also seeing substantial percentage-point increases here. Either something is offsetting the "opioid epidemic" (at least up until 2010), or the trend in drug-related deaths is spurious (misattributing deaths of other causes to opioids, say). Given the substantial fraction of deaths that are supposedly attributable to drug-related causes, something should be evident in the all-cause mortality for basically all age categories. But that's not what we're seeing.

I only have the foggiest notion of how to do a proper "excess death" calculation.* The exercise is particularly fraught when you have a moving target like this, with very different trends at different ages. I don't even think "excess deaths" is a well defined concept in this kind of statistical environment, where you expect deaths to fluctuate wildly due to unpredictable social trends. So I did something much simpler. I built an "actual versus counterfactual" comparison. The actual lines are the same as the all-cause mortality figures above, the counterfactuals are what we would have seen if everything else had stayed the same. In other words, what does it look like if non-drug deaths were locked in at their 1999 values and the only driver of overall mortality were changes in drug-mortality? Red is the true trendline, blue is the counterfactual that I have just described. 


There are a few lessons here. First of all, even if you're 100% credulous of the overdose numbers collected by the CDC (and sometimes broadcast by the merchants of moral panic in the media), your dire storytelling should be tempered by good news. "Of course, despite this horrible epidemic, of addiction, overall mortality is flat or declining for most demographics." Is it so hard to inform your readers and viewers of the bottom line impact on overall mortality? Second lesson, you shouldn't be 100% credulous of the CDC's numbers. You should concede that there is something to the notion that deaths are being systematically misattributed to drugs. The only demographics for which the opioid epidemic narrative fits for the 1999-2010 period are folks in their mid-20s up to about age 32. For all other ages, it is clear that something other than drug poisonings are driving all-cause mortality trends. A third lesson: disaggregate your data. There's a deeper story than what the overall population statistics are telling you.  

Next we'll take a look at very broad causes of death. Internal causes of death are things like cancer and various kinds of organ failure. "Natural causes." External causes of death are things like automobile accidents, drowning, suicide, homicide, and drug overdoses. Obviously this is a more general category than "drug related mortality," but trends in overdoses should be reflected in the trendlines for external causes. I was looking for evidence of misattribution. If the rise in reported overdose deaths is due to deaths from other causes being falsely attributed to drug poisonings, we would expect to see some cause of death that is falling while drug overdoses are rising. That's to say, we should expect that drug poisonings are "stealing" from some other category. I was looking for a set of trends that were mirror images of each other. Since it is abundantly clear that the increase in overdoses in the 2010 - present period is quite real, I will fixate on the 1999-2010 period when prescription opioids dominate the drug mortality trends. 

[Note that you can query the CDC's Wonder database for more or less granular causes of death. In this case I'm getting stats by the broadest categories: external causes, heart-related, lung-related, digestive system-related, cancer, and infectious disease. Then I'm grouping these into two very broad categories: internal and external causes of death.]

Below I have plotted the change in mortality by age between years 1999 and 2010 for two broad categories, internal and external causes of death. (Above zero means mortality increased over the time period, below zero means a decrease.) I am not seeing the mirroring that I was looking for. So there is no tidy story that, for example, "heart attacks are being systematically mislabeled as drug overdoses." At least not according to this view. 


Maybe a simple comparison between two end-points is glossing over a trend? Maybe we'll see something different if we look at the full range of years? To check for this, I plotted the internal and external mortality for the full 1999-2010 period, for each of several ages. 


Again, I'm not seeing any "mirroring" in which one trend is rising at the same rate as the other is falling. (For ages 45-55, it's true that the external trend is rising while the internal trend is falling, but not with matching slopes.) For ages 25 - 35 it looks like external causes of mortality are rising, which is in line with the opioid epidemic story. But this looks a little bit weird. The external cause trendline is flat for 40-year-olds? For 20-year-olds external causes are actually declining a little, even though (see above) drug-related deaths are apparently increasing? Are other external causes of death falling for them while drug overdoses are rising? 

What I have not done yet is look at a "drug-related" versus "external but non-drug-related" trend comparison. If those trends show the mirroring I was looking for, I think that will be a point scored in favor of Sam Peltzman's concept of risk homeostasis. That is, when people have opportunities to engage in risky behavior, they don't simply pile risk on top of risk on top of risk. They have an overall appetite for total risk. So as they engage in more risky behaviors in one domain, they hit the brakes in others. At least that's the hypothesis, at least on average and at the population level. (Of course I wouldn't claim that every single individual is such a Mr. Spock with perfect rationality and actuarially sound calibration of risks. But it makes sense that drug users might decrease their use of some drugs as they increase use of others, or avoid hazardous environments when they know they are going to be inebriated.) 

Something that struck me here was the degree to which external causes of death dominate at young ages while internal causes of death dominate at older ages. You can see from these charts how external causes dominate up to just after age 30, but internal causes are dominant by age 35. I knew that there was a very sharp gradient in all-cause mortality by age, but I hadn't before appreciated this break-out by cause of death category. 

Whatever you think about the quality of our nation's vital statistics, there is some good news here that doesn't depend on accurate labeling or reporting or cause-of-death attribution. All-cause mortality is falling for most demographics, probably driven by a combination of improvements in medical technology and (more speculatively) changes in lifestyle. Had you realized that mortality improved so much over the past 20 years? I suppose that's a silver lining, that even when something terrible is happening (like a raging heroin/fentanyl epidemic that is unambiguously killing tens of thousands of people), favorable trends can more than offset it. All this is prior to Covid, of course. Including 2020 in this picture would pretty drastically change the rightmost end point. That aside, we've endured about ten or fifteen years of panic porn about the opioid epidemic with almost nobody pausing to point out that overall trends were pretty favorable. 

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*I'm assuming you compute some kind of Poisson frequency based on the number of deaths, then use that to compute the confidence interval, then look at a different period to see if the number of deaths observed is outside that confidence interval. How many deaths are "excess"? Observed minus the top of the confidence interval? Observed  minus the expected number? Is this "expected deaths", the midpoint of the distribution, even defined if you know that it jack-knifes over a ten year period?