History versus Data: How Much Do We Know About Past Drug Epidemics?

More to the point, how much is it possible to know about an "epidemic" that happened prior to modern record-keeping? How much do we trust accounts that were assembled prior to the existence of a modern public health bureaucracy?

I recently saw a snarky comment on Facebook linked to a story on the Chinese Opium Wars. The comment mocked the standard drug legalization stance, that most of the problems of drug use are a result of prohibition. To the poster, this was an obvious case of a drug epidemic wreaking havoc without the assistance of bad government policy.

But I read his comment and thought, "The modern United States has a pretty decent public health bureaucracy, collects data on every single death and it's causes, and collects data on drug use rates, and we still don't know what the hell is going on!" I've argued repeatedly that we don't really know how many "drug overdose deaths" are actually drug overdoses versus some unrelated cause. I think plainly deaths, from opioids and particularly heroin and fenatnyl sold has heroin, have increased in recent years. But nobody know the exact counts because nobody actually knows for sure how many of these are real overdoses versus deaths from other causes miscoded as overdoses.

Am I just trying to shade the issue with bland skepticism? Not really. Read a book called Drug War Heresies by MacCoun and Reuter. There is a long section about how the tracking of drug abuse rates and overdose deaths is not very good, even in modern times in European countries. Italy saw a regime change, from a relaxed policy to a harsh one, then back to a relaxed one, based on rhetorical flourishes by politicians about the nation's "drug problem." But there was no good data underlying any of these claims about Italy's drug policy working or not working. No country really had data that was detailed or high-quality enough to assess their drug problem, much less measure the effects of various drug policies, except in the very roughest sense.

I anticipate a reaction to this post that goes something like, "Data schmeta! We have testimonials and descriptions of the problem by contemporaries who witnessed it. They knew a problem when they saw one." We should certainly acknowledge these kinds of testimonials and take them seriously, but with a grain of salt. Remember the guy who got high on bath salts and ate someone's face? And then it turned out he wasn't actually high on bath salts? Someone who watched a lot of news in the 80s might have gotten the mistaken impression that there was a cocaine epidemic destroying our country. But this "epidemic" was grossly exaggerated, like so many drug scares. Most people who used cocaine never had a problem. People tend to exaggerate scary new social problems, and new drugs are especially ripe for this treatment. Read Smoke and Mirrors by Dan Baum for a detailed account of the media totally flubbing its coverage of drug stories and politicians crafting policy based on these misleading accounts.

I'm also tempted to dismiss the accounts of someone who routinely sees a lot of dysfunctional adults and thinks they have a special insight into the cause of the problem. Someone can have a career that allows them to rack up a lot of "plural anecdotes", but that person still lacks the data to analyze the problem. What's missing from their sample is the very large number of people who don't ever have problems with their drug habits.

See a critical take on the Opium Wars by Jeffrey Miron here.

Thus, the evidence suggests China's opium prohibition had a minimal impact on opium consumption.

Here is the full text of their conclusions section:

 This paper has demonstrated that Chinaís legalization of opium in 1858 was not associated with a perceptible increase in opium consumption. This conclusion is subject to several caveats, most importantly that it rests on data for opium exports from India to China, not on direct observation of Chinese opium consumption. Nevertheless, the export data fail to provide even a hint that prohibition had reduced consumption.

The other main caveat is that this conclusion may not apply to other prohibitions. Beyond the obvious differences in time and place, there is little evidence the Chinese government expended substantial resources attempting to enforce opium prohibition, despite its ample rhetoric. Thus, it is not surprising the prohibition had minimal impact. This episode nevertheless raises a cautionary note about the impact of weakly enforced prohibitions, and the abundant evasion and corruption spawned by Chinaís opium prohibition are reminders of the constraints faced by any prohibition, even one with significant enforcement.

There is much more of interest in the paper.