Do those recent
events refute drug policy libertarianism?
The number of drug-related poisonings is up dramatically
over the past 15 years, and much of the increase appears to be attributable to
prescription opioid painkillers and benzodiazepines. Very recently, heroin
related poisonings have shot up. Very, *very* recently, fentanyl poisonings
have shot up dramatically. (Fentanyl is reflected in multiple cause of death
code T40.4, “Other Synthetic Narcotics”, a category that actually includes a
few other drugs. There’s a steady increase in T40.4 deaths over the past 15
years, then a sudden surge in the 2014.)
Supposedly these recent trends prove that we need to be tough on drug
use. If this viewpoint is correct, those recent trends refute drug policy
libertarians who believe partial or full legalization can occur with little or
no negative consequences. There are stronger and weaker versions of this
viewpoint, so I’ll deal with the stronger and better articulated version. It
goes something like the following: “The recent increase in drug poisonings is a
result of relaxing constraints on prescription opioids, along with other
potentially dangerous medicines such as benzodiazepines. This proves that
there is a very large demand response to relaxing prohibition, contrary to what
drug-libertarians believe. Prescription painkiller users can’t handle their
shit, so they pop so many pills that they overdose. We would have saved
ourselves these overdoses if we’d stuck to our guns on strict prohibition. The
taste for opioids whetted the appetite for something stronger, and in very
recent years we have seen a heroin epidemic. This refutes the
drug-libertarians’ belief that people will always stick to the
low-concentration versions of a drug when given the choice. Weak drugs are indeed
a ‘gateway’ to stronger drugs.” In this narrative, a supposedly lax policy
toward painkillers led to a huge increase in deaths, and an unforeseen
side-effect of people moving to even more dangerous drugs. There are many
assumptions and assertions in here to unpack. Overall I don’t find it a
convincing story at all. It’s not a good description of what’s happened in the
recent past.
Have constraints on prescribing
painkillers slackened recently?
The above narrative would be credible if there had been a recent
relaxation in controls on painkillers, but that’s not the case. If anything the
opposite is true. There were some very high-profile prosecutions of pain
doctors in the early 2000s, which is just around the time the increase in overdose deaths started
happening. The DEA really started going after doctors who (supposedly)
prescribed too many painkillers. These events even got the attention of the
National Association of Attorneys General, who sent a letter to the DEA in 2005
telling them to cool their jets. Still, the DEA’s actions had a cooling effect.
The early 2000s, when prescription opioid overdoses started to rise, was an era
where doctors were increasingly paranoid about prescribing painkillers.
Whatever caused the rise in painkiller use, it certainly wasn’t federal drug
policy. This is consistent with a major tenet of drug libertarianism: usage
rates increase and decrease over time of their own accord; government policy
has little effect on these trends.
One can speculate about why prescriptions
rose despite an apparent crackdown. Did pain specialists retire or stop
practicing, and naive primary care practitioners pick up the patient load? Did
primary care practitioners prescribe more recklessly? Were they more easily
manipulated by drug “seekers”? If so, than the recent rise in painkiller
prescriptions is, if anything, a negative consequence of strict drug
prohibition. In this case recent events refute strict prohibition, not drug-libertarianism.
Or maybe the DEA got slapped back so hard by the Attorneys General and doctors’
lobbies that they backed off entirely, in which case there really *was* a
slackening of government policy. But then why were painkiller overdoses rising up until 2005, when the Attorneys General sent their letter to the DEA? I’m really not sure what happened, but it
definitely looks like there was an official crackdown at exactly the time that
painkiller use started to explode.
Does the availability of
low-dose drugs satisfy or merely whet the appetite?
The other piece of the above narrative, that low-dosage painkillers
whetted the appetite for harder stuff like heroin, is highly speculative. A
major tenet of drug policy libertarianism is that users will opt for the
softer, low-dose version of a drug whenever possible. We have decades’ worth of
observations on this point, and it appears to be *mostly* true. Bolivians chew
the coca leaf, while drug smugglers prefer the more compact powdered cocaine.
People preferred beer and wine before and after alcohol prohibition in the 1920s, but they preferred hard liquor
during prohibition because its compactness made it easier to distribute. When
given the chance they stick with the leaf and the beer. They don’t inexorably
escalate to crack and bourbon. Prohibition drives people do the hard stuff;
liberalization leads people to the softer stuff. Recent events may actually
bolster this point. If the recent leveling-off of prescription painkillers is
due to a law enforcement crackdown (I confess I don’t know the real cause),
that would cause some of the former abusers to substitute toward heroin. Some
of the recent overdoses are due to fentanyl poisoning. Fentanyl is so powerful
in such low doses that people have OD’d from handling the drug in the
production process, and illegal suppliers have been spiking their heroin with
it. These overdoses are almost entirely avoidable. Quite a lot of harm
reduction, precluded by a prohibition regime, would be possible in a
legalization regime. In a legal market, doses can be specified, advertised,
regulated, standardized, titrated to the user’s tolerance, tested for
impurities (like freaking fentanyl), etc. That’s not to say there would never
be any overdoses, but there would almost surely be fewer.
Another point to consider is that our long-standing policy of drug
prohibition has pushed people toward drugs with higher toxicity, away from
drugs that aren’t very dangerous. No marijuana overdose has ever killed anybody,
a fact that is widely known by potheads and admitted even by many staunch drug
warriors. LSD, while a potent psychedelic at low doses, has no known lethal
dose. Other psychedelics are similarly non-toxic. MDMA, Ecstasy, is also very
non-toxic compared to other drugs. (No, it doesn’t cause you to burn up from a
fever or turn your brain into Swiss cheese.) Many of these are potentially
therapeutic. So while a very limited view of the past 15 years might superficially
indicate a failure of drug libertarianism, under a longer-term view drug
prohibition has pushed people toward more dangerous drugs. I’ll admit that this
is *a bit* speculative; we don’t know if recreational opioid users and
recreational pot smokers (or LSD or MDMA or psylocybin users) are the same people. But there does seem to be a great
deal of substitution; when one drug becomes unavailable people switch to
something else. Insofar as we’ve missed the opportunity to direct people to
safer, non-toxic recreational drugs, we’ve missed a chance to save lives.
Is the recent surge in overdose
deaths attributable to drug addicts and recreational users?
An implicit assumption of the “recent events refute drug
libertarianism” narrative is that most of the recent increase in painkiller use
is actually misuse by addicts or recreational users. That assumption appears to
be contradicted by the SAMSHA and Monitoring the Future
surveys, which do not show any increase in the illicit use of pharmaceuticals .
As I’ve written in previous posts, many of these deaths are accidental drug
interactions by unwary patients (perhaps encouraged by their unwary doctors)
who didn’t realize what they were doing. Surely recreational use accounts for
some of the drug poisoning deaths, but it can’t really account for the
*increase* in deaths. (Unless the surveys are completely missing an increase in
illicit use, or the increase in opioid use represents the same people taking
greater volumes of the drugs.) If the additional deaths are accidental
interactions by unwary people with legal prescriptions, then the past 15 years
don’t offer an example of relaxing drug prohibition. It’s not as though we’ve
instituted a government policy of giving addicts and recreational users free
access to their favorite drugs.
Superficially, the past 15 years look bad for drug policy libertarians.
I must admit a 3+ fold increase in overdose deaths surprises me. Most people,
drug libertarians and drug warriors alike, probably didn’t realize the problem could
get so bad. But only a shallow reading of recent history impugns drug
libertarianism. A deeper look shows that this recent trend occurred under a
regime of strict (in fact, tightening) drug prohibition. Most of the increase
is probably not attributable to recreational or compulsive use of these drugs.
The heroin overdoses were to a very large degree avoidable, as countries that
have taken a “harm reduction” approach to drug policy have seen both overdoses
and addict populations plummet. I’d like to see our country try a combination
of legalization and harm reduction. That would be a wonderful experiment, and
we’d learn a lot from it. To determine whether libertarian drug policy works or
not, we’d have to actually *try* it first.
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