The Criminalization of Gays in the United States

I recently read two books that detail the history of mistreatment of homosexuals in the United States. Secret City: The Hidden History of Gay Washington by James Kirchick is focused on the implications of being a homosexual for one's career in government. Vice Patrol by Anna Lvovsky is more focused on the tactics used by municipal police departments to entrap gay men. Both are worth reading if you want to know more about the official government oppression of gays in the 20th century. This was a topic I knew existed, but I'd never seen a proper book-length treatment of it before. The closest to it was a chapter Norm Stamper gave to it in his book Breaking Rank. Stamper is a former police officer (former chief of police of Seattle in fact), and he's old enough to have been part of a vice squad. He recounts a few grossly homophobic jokes by the director of the squad, which gives a flavor of the scene he was working in. Secret City and Vice Patrol give me a fuller view of this world. 

Gays were essentially barred from serving in government. The ostensible reason for the prohibition being that gays, having a dirty secret to hide, would be easy to blackmail. If a homosexual were in a role that involved handling sensitive information and a foreign agent figured this out, that person would be a security risk. It's superficially plausible, but Kirchick points out that this is a self-fulfilling prophecy. A gay person's career is in constant peril because of the official policy of "no gays in government." Codifying this policy (which was already in play in the cultural layer of society before it was ever officially codified) makes it easier to blackmail them. Kirchick tells the story of a gay government employee who gets outed. He makes no effort to deny or cover up who he is, he simply tries to argue, "There's nothing to blackmail me over. My status as a gay man is known to everyone." This didn't work, he was fired anyway. There was something else at play beyond the official rationale for the prohibition, probably that people in that time just thought "Those people are gross" and didn't feel any remorse for openly discriminating against them. Kirchick finds there was little to no evidence that blackmailed homosexuals were responsible for any security leaks. 

It's regrettable that this is how Washington worked in the 20th century. But what really revolted me is the level of "due diligence" that the government went through to root out gays in their midst. Government employees often faced rigorous background checks by serious FBI agents. It might not have bothered me quite as much if there was some kind of "don't ask, don't tell" policy, where everyone was notionally against homosexuality but they didn't bother too hard to uncover it. But they invested serious resources into these background checks. Bachelors were automatically suspect and got extra scrutiny. Interviews with friends and acquaintances often turned up minor clues. A background-checker who was a decent human being, who recognized he was conducting a witch hunt, would have simply declined to overturn every stone he found. The FBI agents who conducted these inquisitions must have seriously believed they were fighting a righteous war against the wicked, because they went to great lengths to track down every 2nd and 3rd-hand clue about someone's past. Secret City describes several instances of these investigations discovering a homosexual past, sometimes turning up an incident that was decades old. Those days are basically behind us, and I'm generally one to accept progress for what it is and let the past be the past. But the FBI's hunt for homosexuals reaches a high bar of depravity. I think there should be some kind of reckoning. At least a public naming and shaming of some higher-ups who were complicit in these investigations. It doesn't rise to the level of "Nazi prison guard". But it's still in the realm of, "This is sufficiently wicked that you should have recognized it at the time. You ruined people's lives over nothing." It would be interesting to hear someone try to justify their complicity in this kind of inquisition. I feel like some kind of message has to be sent that "just following orders" is not sufficient cover for wrongdoing. You have a responsibility to resign if you're ordered to do something unconscionable, at the very least to refuse the orders. I'm not saying we should go doxing these by-now senior citizens, who (assuming any are left) are probably living out their remaining years in some kind of quiet dignity. But some kind of cross-generational line in the sand has to be drawn against this kind of domestic persecution. (Maybe we wait until we're pretty sure they're all gone and unseal the relevant files? Similar to the unveiling of the Stasi files after the fall of East Germany, which revealed the wrongdoings of Stasi agents and their informants. Or maybe we get a few of them, who truly had regrets and a change of heart, to step forward and renounce what they did? I feel like there needs to be some kind of clearing of the air. The State Department has issued an apology for the so-called Lavender Scare, which is a start at least.) 

Secret City is mostly about the career implications of being outed as a gay person, specifically in the federal government. Vice Patrol gets into the weeds of anti-gay law enforcement at the municipal level. Again, I was shocked by the amount of manpower and resources that went into persecuting homosexuals. Vice patrols used different tools than the FBI background checkers and had a different motive. The FBI wasn't concerned with criminal prosecution or capturing someone in the act. They merely wanted to establish someone's status as a homosexual. Anti-gay vice cops, on the other hand, were primarily motivated to get convictions. This usually did entail catching someone in the act, which implied the need for subterfuge and hidden surveillance. Homosexual behavior (of the kind the vice squad is concerned with) is consensual, so the police needed to trick gays into revealing themselves. (Victims of crimes generally come forward willingly, so less subterfuge is necessary to identify and apprehend the criminals.) Some vice cops would dress as gay men and hang around in gay bars or public restrooms that were known to be frequented by gay men. If someone made too direct a proposition, they would be arrested and charged. Responding to this environment, gay men had indirect, often non-verbal cues to coordinate with others. The book recounts an exchange in which a vice cop tries to get a (presumably) gay man to make an explicit proposition, and the (very wise) gay man repeatedly declines to oblige him. They both grow frustrated with the exchange and part company. 

This legal ecosystem of cat-and-mouse games created a lot of borderline prosecutions, in which it wasn't totally clear to an objective third party whether a proposition had been made. A gay man caught in this trap could often successfully argue in court that no proposition had been made and it was all a misunderstanding. The police had to resort to arguing that they had special expertise in recognizing gays and gay behavior. Some gay stereotypes may be easily described in objective terms, things like "tight pants" or "speaks with a lisp". Other traits might defy description. Some series of subtle cues might have set off the vice cop's "gaydar," though explaining this to a judge may be impossible. (Quick, look at some images of a man's face and a woman's face, explain in terms of objective measurements how you know one from the other. "Well the nose is kind of...and the ears are slightly..." It's hard to describe in words, yet somehow you can tell the difference with near certainty in most cases. It seems plausible that some people have this kind of tacit classification mechanism when it comes to identifying gay people.) This actually created a kind of legal tension, a contradiction of legal arguments. The police would often insist that they had expertise in identifying homosexuals. At the same time, they often targeted gay bars, whose owners would plead ignorance, arguing that they have no way of knowing what a gay person looks like. How are they supposed to know the sexual proclivities of their clientele? The police could turn around and insist that it's obvious when someone is gay, but that would undermine their claim to have a special skill in this area. 

The book also gets into the topic of liquor licensing boards. The boards would target gay bars, attempting to remove their liquor license. But obviously in a world where homosexuality is against the law, no bars were advertising their status as a gay bar. Owners would simply deny that they could distinguish gay customers from straight customers, so they had no way of strictly maintaining a straight clientele. Licensing boards couldn't just issue a summary judgment and revoke a license on a suspicion. Owners of (allegedly) gay bars had legal recourse. There was some kind of due process that generally worked in their favor. 

What revolted me most about this book was the surveillance of public restrooms. Once again, these were consensual acts between adults, so the authorities must resort to morally questionable behaviors to catch and prosecute them. That meant entrapping someone in a sting operation or staking out and spying on the bathroom's users. Some vice cops would sit in an adjacent stall and give some kind of cue (like tapping their foot). If a person in the adjacent stall fell for it, they'd be arrested and prosecuted. The police would also install video cameras and listening devices, or observe through binoculars from some perch (through a hole in the wall or a tiny window that was hard to notice). It's hard for me to fathom the rationale for this. If people (gay or straight!) were wantonly having sex in public restrooms (without availing themselves the cover of a bathroom stall), it would be easy enough to catch them without entrapping or surveilling anyone. An occasional random check-in would catch a couple in the act, and they could be arrested for public indecency. It would not take much of this to discourage the practice, and thrill-seekers would be more discrete about their dalliances. 

No, the effort that vice cops put into prosecuting gays suggests they thought they were on the side of the angels, fighting a crusade against sinfulness. Surveilling these mostly innocent restroom users truly crosses a line. And this isn't just the moral clarity of a distant generation talking, not a case of "moral hindsight is 20/20". Some judges who presided over these prosecutions offered the same misgivings. A bathroom stall, some judges argued, was a strictly private space. There was never a state interest in snooping on the occupants, and doing so inherently runs afoul of 4th amendment protections. Judges also felt that some of the arrestees had been entrapped. They may have had no inclination toward homosexual conduct if the police hadn't enticed them with suggestive conduct. That's hardly an enlightened attitude toward the gay community by today's standards, but it's clear that the judiciary provided pushback against the excesses of vice enforcement.  

Once again, I think there should be some kind of reckoning for the police officers and officials who were complicit in this culture of actively persecuting homosexuals. It was long enough ago that most of these people would be retired or gone, so there wouldn't be much in the way of career consequences. But some kind of naming and shaming is in order for anyone who played a part in this regime. This isn't a case of, "Moral standards shifted unpredictably over a couple of generations, so it wouldn't be fair to judge them by the new standards." It's not an instance of "They have audio of me saying a word that later became a no-no, so now I'm cancelled." It's not merely, "I failed to stand up for what's right in a wicked world". I think the actions of vice cops were morally revolting in a way that was obvious at the time. And they zealously pursued their targets, selecting the persecution of a despised minority as a career. (In an interview that I can't locate now, I heard Anna Lvovsky describe her experience interviewing an instructor of a vice squad. This was the man who taught young cops how to successfully persecute gays. She honorably played the part of the impartial scribe, and we have an excellent book because of it. I don't think I could have remained so calm in her situation. Bless her.) Norm Stamper has set a phenomenal example here. He dedicated a chapter of Breaking Rank to his time as a vice cop. He apologizes for being late to the party on gay rights issues, though he was decades ahead of his colleagues. We could start with a few more voluntary about-faces and apologies by former vice patrolmen, maybe involuntary naming-and-shaming for truly egregious examples of anti-gay policing. 

I haven't done justice to either book, and obviously I'm adding my own reactions of moral outrage. Secret City is over 800 pages, Vice Patrol just shy of 300 pages of actual text. This post barely scrapes the surface. I'm merely trying to paint the basic historical landscape and contrast it to present enlightened views of gay rights. I think it's worth offering a few observations from a libertarian perspective. 

It's worth noting that extra-legal persecution of homosexuals would probably have been happening even absent the vice squads and federal rules banning them from government posts. Politics is downstream of culture. That is to say, government is for the most part constrained by what the general population finds acceptable. Official policy is often the codification of something that's already happening in private society. This is something that libertarians need to struggle with. The "gays are easy targets for blackmail" rationale may be bogus for the reasons given above, but it's still the case that publicly outing someone could have destroyed their life. This was probably true up until the very latest part of the 20th century. Persecution of minorities can happen without the government lifting a finger. This kind of thing can run on the cultural layer of society if a social consensus forms that "homosexuality is icky." There is a school of thought that insists on libertarianism as being a strictly political philosophy, which shouldn't be offering commentary (not speaking as libertarians anyway) on these kinds of cultural issues. Assuming there is a free labor market, homophobic employers could fire gay people. Landlords could discriminate against gay tenants in a free market for housing, etc. And this could be the norm rather than an isolated act of bigotry. Worse, it could be the case that homophobic tenants and employees are the ones insisting on being in a gay-free environment, so even enlightened gay-positive employers or landlords may feel pressured to discriminate by the less enlightened mobs they serve. It's a little bit weird to see society coordinate to discriminate against a minority group and insist that libertarianism has nothing to say about it. It's not exactly "government", but it's still a kind of coordinated power being directed against a relatively powerless minority group. I think most libertarians don't subscribe to this strict separation of political and cultural prescriptions, but the ones who do should squirm a little at this thought. Anti-discrimination laws, as a general tool, don't solve the problem in this kind of society, because such laws would reflect the general public's understanding of who should and shouldn't be a protected class. I'm still a radical advocate for freedom of association, up to and including the right of bigoted shopkeepers or employers to exclude whoever they don't like for any reason. I think in today's society such bigots wouldn't survive the first flex of their "right to discriminate." They'd be boycotted and shamed out of existence. But 50 years ago? I'm not so sure. Discriminating against despised minorities may have helped rather than harmed their bottom line. We should keep in mind that in less enlightened parts of the world, there are still bloody race riots. Resented minorities are often beaten, raped, or murdered. Violent pogroms are carried out by mobs. Sometimes governments are complicit in such racial violence, but often these are impromptu lynch mobs composed of "normal" people. These are incredibly powerful social forces, projecting power and initiating violence. It makes little sense for libertarians to build this wall of separation between strictly political philosophy and social philosophy that condemns extra-judicial violence, as if the latter were not part of our mission. Race riots happen in some cases because of anocracy, a lack of sufficient government, or a failure by existing governments to enforce the law (though it could do so if it were inclined to). Sometimes governments protect unpopular minorities from a society that would initiate violence against them; this thought should make libertarians of the anarchist persuasion (and I am one by the way) squirm a little. Sometimes a big, central government secures the rights of minorities against smaller state and local governments; this thought should make secessionists and extreme federalists uncomfortable. There is plenty to squirm about here. (To statists I would say, sometimes the government simply reinforces and codifies the bigotry of the surrounding society, see the contents of this post for numerous examples. So "government prohibits bigotry" isn't such a straightforward answer to the problem, either.)

It's also worth reflecting on the difference between the gay lifestyle today and the one that was practiced in the 20th century, when it was considered illicit. Neither of the above mentioned books discusses gay relationships as long-term bonding between a loving couple (or if they did, it was so brief I missed it, sorry). Surely there were some long-term gay couples, though they must have gone to great lengths to disguise their relationship. Two men cohabiting for a long period of time would have raised eyebrows, eventually attracting the attention of family members, landlords, employers, and possibly the authorities. No, most of the homosexual encounters described in both books were "hook ups." These were one-time dalliances between two people who would most likely never meet again. (John Kennedy was propositioned by a man who, to his great credit, he remained a life-long friend with. Presumably such propositions sometimes paid off, which would result in two acquaintances knowing one another to be gay. I'm sure this led to some repeat encounters, if not actual cohabitation or long-term relationships.) What am I driving at? In this kind of environment, homosexuality really does seem illicit. People are engaging in subterfuge, trying to evade the law, possibly lying to cover their tracks. And what they're covering up is not a loving, long-term relationship, but (to onlookers in the mid-20th century) a form of sexual depravity. In the present day, a gay identity really does mean long-term relationships. It means introducing your friends and family to your partner. It's perfectly wholesome. In the early to mid 20th century, it meant late night hookups in public parks or bathrooms. There is a generalization here, which is that criminalizing something makes it seem sleazy, even if it isn't inherently so. The obvious analogy is drug prohibition. Under a prohibition regime, drug dealers really are sleazy people. They use violence to silence witnesses or settle disputes. They hire drug mules to swallow condoms filled with dangerous powders and cross borders with them, which sometimes results in the condom failing and causing a fatal overdose. They sometimes use minors as delivery boys. The chemical processes they use to manufacture some drugs are toxic enough to make the property they're done in uninhabitable. When a drug cop busts a drug dealer, they're likely apprehending someone who has murdered a rival or cooked up a batch of bad dope that killed one of his customers. They end up thinking they're fighting a holy war because the people they arrest really do engage in destructive behavior. These cops mostly lack the imagination to see what the counterfactual is: the world in which drug commerce is legal. Markets that are above board aren't generally associated with these sleazy behaviors. The guy who sells me beer at the liquor store (or the grocery store) has no inclination to second-guess my motives, to pat me down in search of a wire, to shoot me if he finds one. Likewise, a vice cop in the mid-20th century who apprehends a homosexual is catching someone in the middle of an act that society deems morally revolting.* He doesn't see the counterfactual world that has only come to light in the past 30 or 40 years, where openly gay couples have long-term, loving relationships. To explain is not to forgive. Obviously I'm not trying to justify the criminalization of homosexuality or of drugs. But we owe it to ourselves to get into the heads of people who prosecute these government orchestrated wars on vice. They think legalizing the vice means "Without the deterrent of the legal prohibition, there would be lot more of the ugly stuff we see on our jobs." They often lack the imagination or the inclination to see the counterfactual. They can't see that they're creating their own dragons to slay.

I was looking for a book in the libertarian canon that handled these topics, but I now don't think one is needed. Secret City and Vice Patrol lay out the historical details matter-of-factly with little editorializing or moralizing. To a modern reader, none is needed. The moral commentary writes itself in the reader's head. In this light, libertarian commentary on the history is kind of redundant. (Should someone write the same book from the libertarian perspective, offering the same history and factual details but pausing occasionally to say, "This is bad, because it violates the non aggression principle"?) At best, I think some libertarian editorializing is possible with regard to how to the moral arc is bending. Government prohibitions on drugs, prostitution, and gambling are analogous to the prohibition of homosexuality.** Driving an activity underground forces practitioners to engage in "sleazy" behaviors to cover their tracks. This causes onlookers (typical members of the broader society) to associate unseemly behaviors with the prohibited activity, even when there's nothing inherently wrong with it. There's something almost wholesome about drinking a few beers at a family barbecue. When you encounter the median beer drinker "in the act", there's nothing inherently sleazy about it. In most cases there wouldn't even be noticeable intoxication. But when the activity is illegal, the responsible practice of it stays hidden. It only becomes uncovered when something dangerous happens. Like someone crashing into a tree after snorting too much coke or discovering someone is an opioid addict when they fatally overdose.  There is certainly a "libertarian take" on this history that puts it into the context of other violations of our liberties. But I wouldn't want to supplant these two fine volumes with a libertarian version. I would simply add these books, exactly as they are, to any libertarian bookshelf (or any bookshelf for that matter) and leave it at "The libertarian editorializing writes itself." 

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I apologize for slipping into using the language of earlier times for parts of this post. It's not cool to refer to gays as "homosexuals" (even though it seems like a scientific, Latinized word for the people who engage in the behavior, it sounds wrong). I hope it's obvious when I'm giving voice to a person living two to four generations ago versus when I'm using my own language. 

*Imagine a vice patrol kicking down the door of an elderly gay couple, shouting "Freeze, police!" and barking orders. The couple would appear as harmless, decent folk who'd been needlessly terrified. I could imagine at least some of these cops having second thoughts about their mission after a few of these. This is a different mindset than someone who regularly catches homosexuals in the middle of the act in a public place. The undercover vice cop who routinely has a man proposition him by running a hand up his leg probably feels a sense of moral disgust. A more domestic gay lifestyle just isn't part of his world, so he never sees it.

**With an important difference. I think "gay" as an identity is possible if it's legalized in a way that it's not when homosexuality was criminalized. I don't know if "drug user" or "gambler" can or should become parts of your identity in the same way.  

Financing the Purchase of a Box Containing One Million Dollars

Suppose you have an opportunity to purchase a box containing a million dollars. It's not actually cash, but a series of IOUs that are only redeemable by you. Because the box is only valuable to you, the current owner has no other buyers. He's willing to sell for, say, $50k. 

A very confused onlooker observes this situation and says, "But, you don't have $50k. You can't afford to purchase this box!" I hope we can all agree that this is silly. Obviously you can finance the purchase of the box out based on your expected future windfall. You don't have $50k yet, but if you can credibly prove that you'll make good on your investment, you can borrow some money at a reasonable rate and pay back the loan out of your profits. (Most obviously, you can say, "Let me have the box and I'll immediately open it and give you $50k", and you and the current owner can then part ways.")

Change the example a little bit. Now it's not one big IOU for a million dollars. It's a series of IOUs that reach maturity at different times, stretching indefinitely into the future. The net present value, discounting future cash flows, is one million dollars. But really that's summing up your increased income over a lifetime. It would still be incredibly silly to say that you "can't afford" to purchase the box. It's worth just as much. The different maturities change the timing of your loan payback, but it's still overwhelmingly a good deal. 

Change the example a little more. Now it's not a series of IOUs, but rather a collection of extremely rare seeds that only you know how to cultivate. The resulting crop will be extremely valuable. The expected payoff is still a million dollars over the course of a lifetime, but making good on that requires some planting and nurturing. It's not something that will be your full-time job, but once you learn the craft it'll be a light hobby that pays off handsomely. Or maybe the box is full of a kind of cryptocurrency that requires solving some math or logic problems by hand. (Only solutions worked out by you will unlock the crypto, it somehow knows.) Given consistent effort, these math problems will definitely pay off. You will never get stuck on any one problem indefinitely. You can skip some of them if you truly get flummoxed, but there are enough such problems to solve that the expected net present value is still $1 million. All you have to do is put in the time. It's probably still worth purchasing this box. In this latest scenario, it would still be incredibly silly for someone to come along and say you "can't afford" to buy the box. It would be equally silly to take a look at your finances at some time before your loan was paid off and say you need financial help. It's still the case that you can finance the purchase of the box out of your expected future earnings, and still make an absurdly high rate of return on your purchase. 

This arrangement is starting to look more and more like a college education. The later examples change the timing and certainty of the payoff and the element of labor required to make the investment worthwhile. College isn't equivalent to a box full of ready cash, but it is a really good deal if you make good on it. It pays for itself several times over. You can finance a college education out of the expected increase in your future earnings. You can make those expected future earnings more certain by choosing a remunerative major (STEM or pre-professional) and working hard while in school (versus slacking off and getting bad grades, which I saw a lot of in my college days). 

Looking up some quick figures, a college degree pays off to the tune of around $1 million over a lifetime. (Obviously this is an average that glosses over several relevant variables, like choice of major.) The average cost of tuition is about $10k per year for in-state, $20k per year for out-of-state. (Once again, glossing over some relevant variables. A prospective student has a lot of choices s/he can make to lower or raise this figure.) The figures I used in the "magic box" example are roughly in the same ballpark. A student making the right decisions can make this a really good deal. They don't need help. It's true that some students overpay to go to fancy private schools or get worthless degrees. Some pay exorbitant tuition for elite private schools. They are essentially deciding to buy an overpriced status good, possibly seeing it as their key to elite positions in government. They don't really deserve our sympathy and they certainly don't need help. Some drift aimlessly in college and eventually decide they don't want to finish. That's unfortunate. I wish I could counsel some of these people before they made an impertinent life choice or talk them into sticking it out for a couple more years. But I don't think they deserve our help. This is someone who is declining to pick up a million dollar bill on the sidewalk. 

The recent chatter about the proposal to cancel student debt has been maddening. It's obvious that this is a middle-class and upper-class entitlement. The benefit of this debt forgiveness accrues to those people who are reaping that $1 million boost in lifetime earnings (on average). The cost, assuming the government eventually pays for it, is being spread to everyone. This means people who don't go to college are, on net, paying for the people who do. 

The Quantified Self

I've recently subscribed to the Oura ring and 23andMe. The goal is to learn a little bit more about myself. I would describe the results as mostly, "Confirming stuff I already knew and getting almost no actionable information." 

The Oura ring tracks a few vital signs, such as heart rate, respiratory rate, pulse ox, and body temperature. It also tracks movement, so it can tell if you're moving around or not. My interest was in tracking my sleep quality. The Oura ring guesses what phase of sleep you're in based on the various bio markers it can measure. You actually need the proper equipment (as in electrodes connected to the head) and brain-wave detection to measure which phase of sleep you're in, but the Oura ring makes a best guess based on movement, heart rate, etc. Its estimates leave room for improvement. See this paper comparing the ring to a proper polysomnography: 

From EBE analysis, ŌURA ring had a 96% sensitivity to detect sleep,and agreement of 65%, 51%, and 61%, in detecting “light sleep” (N1+N2), “deep sleep” (N3),and REM sleep, respectively.

That's not great. See also this video by a professional sleep researcher, who compared the measurements from his ring to what he got from professional-grade equipment. He got an overall accuracy just shy of 60% on phase-of-sleep detection. My own measurements usually show that I get around one hour of deep sleep. But sometimes it (alarmingly) tells me I only got about 20 minutes worth. I tend to average 1.5-2 hours of REM sleep, the remainder being light sleep. But I don't really believe it. My subjective well-being after a night's sleep is pretty uncorrelated with my Oura ring's sleep score. I wish it gave a lot more caveats and warnings to the user that "this is just an estimate", perhaps giving some kind of confidence interval. It was easy enough to find online reviews of the Oura ring, but I would worry about some users becoming needlessly anxious about their sleep quality based on the ring's inaccuracy. (See also this review by a doctor, who was not impressed.) 

The one thing that I did find useful is that it shows how your heart rate decreases over the course of the night. I have a resting heart rate in the 60s, which is normal. I previously had no way of knowing what my heart rate was while I slept. I now see that it tends to fall over the night and dips down into the 50s or even the high 40s. It also may be useful to know if your sleeping heart rate stabilizes early or late during your sleep. If it stabilizes late, that could mean you're over-training and need to take a break from physical activity. 

I'll give the Oura ring credit for highlighting a recurring pattern in my sleep. I routinely wake up feeling like garbage on Wednesday morning (specifically Wednesdays). My best guess is that it's due to eating a late meal Tuesday nights. I go to jiujitsu Tuesday evenings and get home at around 8:30, usually eating around 9 or later. If you eat a large meal too close to bed time, it can affect your sleep and lead to a late stabilization of your heart rate. I hadn't put this together, but I may experiment with smaller meals Tuesday evenings.

The other handy thing is tracking my average oxygen saturation. I sometimes snore, and I wanted to know if this was just annoying or if it could be full-blown sleep apnea. It runs in my family, so I have a reason to be worried.  I'm in better shape than some of my snoring family members, so maybe it's not a problem. (I don't snore as often or as loudly as my parents or brother, so something that I'm doing is probably working.) My Oura ring almost never detects a problem here. It's reading consistently at 98%. On an occasional night of cruddy sleep, I get a reading of 97% (never lower than that) and a message saying that it detected interruptions in breathing. Flawed as the Oura ring is, I think it's useful to flag potential issues. If it flags too many nights as having had breathing interruptions, I'll do a proper sleep study. (Likewise, if it fails to detect these, but my wife tells me my snoring is getting worse or I'm suffering excessive daytime sleepiness, I'll throw out my Oura ring and get a proper sleep study done.)

The Oura ring also tracks movement, so it can tell you if you move around a lot at night. This is interesting, but not really actionable. I get varying stats on different measures of my sleep score (time in deep sleep, REM sleep, etc.), but I consistently get poor marks for "restlessness." I do have to wake up an reposition myself a few times during the night, but the Oura ring is tracking a lot of tiny movements that don't rise to this level. I don't know what I'm supposed to do with this information. If I went to bed earlier and gave myself longer time to sleep, presumably I'd still be a restless sleeper. 

The information I got from 23andMe was likewise interesting but unsurprising. And none of it was actionable (though in theory it could have been). You get various reports telling you that you are more or less likely than average to experience IBS, sleep apnea, restless leg syndrome, and a host of other conditions. My issue with most of these is that you know from your subjective experience whether you're suffering from them or not. The information that your genes predispose you to it isn't useful. (Perhaps their test counter-indicates the condition, though you have it anyway. A false negative test on a question you already know the answer to.) I think many of these are polygenic tests. That is, they aren't testing for one or two specific genes that vastly change your probability of having the condition. They're based on an analysis of hundreds or thousands of genes, detecting correlations to various conditions. But there are also tests for certain "variants", genes that do have a well-understood connection to various diseases. (Examples are Cystic Fibrosis, Tay-Sachs Disease, and a bunch of conditions I've never heard of.) I was negative for all variants, so it didn't affect me. But I could see how someone would find this information actionable. You'd at least want to follow up with a doctor or work out some kind of monitoring plan. If you and your partner both tested positive for a given variant, it could spark a conversation with a genetics counselor about the potential affect on children. 

23andMe also provides some limited information about ancestry. My ancestry composition was pretty boring and predictable for an American of European ancestry. It pegs me as northwestern European, mostly English/Irish and German. My surname is German, my mother's maiden name is Irish, and both sides have a lot of Irish and German surnames going back generations. I also have a Swedish great great grandmother, though my 23andMe test pegs me as ~2% Finnish and 0% for the other Nordic states. I don't know if the genetic test is inaccurate or if perhaps my Swedish ancestors were recent transplant from Finland before they came to the United States. The breakdown of the British/Irish ancestry was leaning toward the English side, whereas I'd always thought of my ancestry as being more Irish. Maybe my Irish ancestors were also recent transplants from elsewhere in the UK? There was nothing I'd call "exotic". It apparently detected a small trace of Ashkenazi Jewish ancestry, which was intriguing to me. It reads as 0.1%, which comes out to one relative about ten generations ago. (I desperately wish to know more about this person, assuming s/he is real!) But it's hard to know what this means. Should I round it off to zero because it's within some margin of error? But then, why is the test yielding zero percent exactly for Italian, Spanish, East Asian, South Asian, etc., rather than a smattering of 0.1%s all over the place? 

23andMe can also connect you to other people who use the service, though you have to opt in to make yourself "discoverable." It pointed me to a number of distant cousins, only one of whose name I recognized. And it incorrectly marked him as a second cousin, whereas he's really a first cousin, once removed. It's still impressive, given that it's inferring these relationships based on a small market penetration. If, say, 10-20% of the US market used 23andMe, the family trees would be fuller and the connections would be made with more accuracy and greater confidence. 

A neighbor of mine was adopted as a baby. He recently discovered some of his birth siblings because his daughter was a 23andMe subscriber. Apparently they didn't know about him, the birth mother having died without revealing any details, so it's hard to imagine they would have met each other any other way. I think it's wonderful that a consumer service can make such discoveries for us. I don't know exactly what I was hoping for. Like, some forgotten branch of the family tree that nobody knows about. A "Grampa's little secret". (My paternal grandfather did have an out-of-wedlock son, but it's not a family secret.) 

I have heard people say they don't want to do a genetic test because it might conceivably affect their insurance rates. Perhaps the 23andMe data becomes discoverable by insurance underwriters, and they use the information to price or deny disability, life, or health insurance. I actually think this is nuts. You should want as much information as you can get that's relevant to your long-term planning. If there's information in your genes that suggests you're only going to live to, say your mid 50s, it's worth knowing that for planning your future. You probably won't want to have a kid in your 40s, for example. (Though you still may! Maybe you're a raging natalist, bless you, and you care about your hypothetical child's future whether you're around to enjoy it or not.) You might want to save more of your earnings to take care of your spouse and children, or (alternatively) you may decide to spend down your existing savings knowing that you won't be needing it. You may decide to drop some of those nagging health habits that will only pay off in your 70s and 80s. A lot of these decisions could actually go either way. What's weird to me is making this pact with your future insurers: "I won't peek if you don't." For most kinds of insurance, it's irrelevant anyway. Typically you get health insurance through your employer. They basically have to issue you the policy, they can't deny or change rates based on health status. So unless you're buying health insurance on the open market (hardly a "market"), you're fine. For life insurance, typically you'd have a term policy with a rate that was locked in when you bought it (hopefully when you were young). Say you buy a 30-year term life policy when you're 30. It's ten years later, you're curious about what you'll find in a genetic test, so you do 23andMe. Well, your term life policy is locked in. They can't cancel based on new information. It'll cover you until you're 60. At that point, maybe you want another policy and there's some adverse information in your genetic test. (Why, though? A life insurance policy is meant to cover the lost earnings of a breadwinner. By age 60, you've had time to accumulate savings and are usually an empty-nester, so this is less of an issue.) Okay, but if you get the genetic test at age 40 you still have 20 years to plan for that. That's 20 years worth of savings and compounding interest. If I'm genetically predisposed to dying early, I think I'd rather have that information and be able to plan with it, rather than preserving this option of buying cheaper life insurance at age 60. (And wouldn't the life insurer's underwriting discover whatever conditions you have by then? Wouldn't such a condition have started to manifest and leave a trace in your medical history?)

Two Books on the Trump Administration from the Inside

 I recently read two books about the internal workings of the Trump administration from people I respect. Casey Mulligan's You're Hired and Scott Atlas's A Plague Upon Our House are both very good. They offer a different lens through which to view an administration that's usually portrayed as oafish and arbitrary. I'm no fan of Mr. Trump. He generally had a terrible policy agenda and the way he conducted himself in office (particularly on the way out!) was atrocious. At the same time, the media's derangement at him (a literal syndrome) often led to an inaccurate picture of his administration. Seriously, it's like some of his detractors think his staff were a bunch of morons wandering aimlessly around the White House saying "Duh. Duh." to each other. Not that they were all great minds, but they were mostly professional, honorable people who wanted to serve their country. I'm sure they had intelligent conversations about policy including discussions of various considerations (if not full blown cost-benefit analyses). It's likely most of them were not particularly big fans of Mr. Trump but saw an opportunity to steer the beast. 

I've known about Scott Atlas for years. I was introduced to him by an Econtalk episode, which led me to read his earlier book In Excellent Health. I thought the media treatment of him was shitty, and people I know recited talking-points about him to me. These were mostly know-nothing, NPC-style recitations on topics they had no background information on. I sometimes had the energy to push back and say I knew something about him. Atlas is clearly a knowledgeable person on public health issues in addition to being an honorable person. 

Atlas was the "anti-Fauci". Anthony Fauci and Deborah Birx were two of the other advisers to Trump's pandemic policy. Atlas paints them as being reflexively pro-lockdown, favoring anything that might plausibly reduce Covid numbers and ignoring any costs of such policies. Atlas was an important counter-weight to the establishment faction. It was a virtual guarantee that the establishment/alarmist position would be represented among Trump's advisors. Someone had to be in the White House to offer the non-catastrophizing take on Covid policy. We were lucky to have had someone like Atlas, who had the president's trust and respect. Fauci and Birx are depicted as not really having their bags packed, so to speak. They had at best passing familiarity with literature on, for example, the effectiveness of masking. (When Atlas asked Birx for the evidence that convinced her of the effectiveness of masking, Atlas explains that he'd read the same paper and found it unconvincing. It was not exactly an RCT.) They were more concerned about consistent, simple messaging than they were about how those messages mapped on to the underlying reality. That's a dangerous play for a prominent figure in public health. The risk is that you cling tenaciously to a dangerous falsehood even as discrediting information comes in, or that your lack of nuance turns off citizens who are paying close attention. Atlas was a wink at those more observant citizens, as if to say to them, "Yes, we know that slogan-length public health messaging is oversimplified and often wrong. The president knows that they are picking which actions they want you to take, then back-fitting the messaging to get you to do it."

In You're Hired, Mulligan paints an interesting picture of the internal workings of the White House. Trump's tweets are often depicted as impulsive, as if he pounded out stray thoughts with his thumbs before rolling over and going to bed. Mulligan describes a more deliberate approach. Trump himself was not the author of most of those tweets. They were crafted by a team, often with some internal A/B testing or informal focus grouping. These tweets were often used to take the public's temperature, rather than to cram a half-baked policy down their throats. The intent was often to gauge the public's reaction. In describing this, I'm not opining on the morality of his approach to the public. There is something creepy about a president behaving this way. But Mulligan's narrative does contrast with the dominant media narrative of the Trump White House. 

A couple of things bothered me about Mulligan's book. He had an entire chapter on the "opioid epidemic". He basically recited the standard narrative, that a bunch of irresponsible doctors, encouraged by greedy pharmaceutical companies, overprescribed opioids. And this supposedly created a new class of addicts. There are serious problems with this narrative. He even blamed "lax drug policy" for the increase in overdose deaths, specifically calling out Eric Holder for his memo encouraging some laxness in applying harsh statutory sentencing. He suggests (I can't recall if implicitly or explicitly) that we could have kept fentanyl from hitting the drug market through stricter enforcement. The opposite is true; there never would have been demand for recreational fentanyl in a legal market. (This is really absurd. The sheer potency of fentanyl makes it impossible to interdict.) People need to seriously stop pretending like we've been trying libertarian drug policy for the last 20 years. Nothing could be further from the truth. The Holder memo might have had some tiny marginal effect on drug trafficking, but blaming it for an already-existing trend in rising overdose deaths is pretty dubious. I have to give Mulligan a strike or two for getting this one wrong, because I think it's one of the greatest injustices of American domestic policy. This is a massive moral blind-spot for him. Interestingly, he repeatedly plugs some kind of software algorithm called "theory guru". Supposedly this algorithm can automatically check if your economic assumptions are consistent with each other. He should have turned this loose on his musings about drug policy. If you place any credence at all on economics as a way of thinking, you will come to the conclusion that drug prohibition is an utter contradiction. Mulligan is using a very simple analysis, "If you raise the cost of doing something, you get less of it." Okay, but you "raise the cost" by gratuitously hurting people. Most people who think about this clearly will say that demand for drug use is inelastic, so a 1% increase in the "price" (monetary and non-monetary, including harms from the legal system etc.) will yield less  than a corresponding 1% drop in drug use. This is a losing game. The harm to remaining users is necessarily greater than the "savings" to those who are successfully deterred. I like Mulligan, but it feels like he seriously fell down on this one. 

The other thing I didn't care for was Mulligan's qualified defense of populism. He has some righteous anger at technocrats. I understand the sentiment. Technocrats can get things badly wrong, and people get hurt because of it. But the alternative is to basically yield to popular demands, which can be even worse. Seriously, he had me reaching for Bryan Caplan's The Myth of the Rational Voter to serve as an antidote.  Maybe his point was merely that DC technocrat-types are out of touch and don't care about the same issues as the median American (whatever that means). But it's a confusing message for a mostly free-market style economist like Mulligan. He has some harsh words for Peter Navarro, who is basically the public face of Trump's idiotic protectionism. I feel like he needed to grapple a little more with the fact that Trump's protectionism has broad popular appeal. Voters are mistaken about the effects of such economic policies, and it's his job as an economist to push back and correct their errors. If voters have a tendency to be authoritarian and to impose bad laws on their neighbors, I say technocrats can serve as a useful counterweight. I don't want to be ruled by either a populist mob or an academic technocracy, but I can see a useful role of each as a check on the other.  

I don't intent to write a comprehensive review of either book. I did want to share a slightly more coherent view of the Trump administration. If nothing else, these books offered some mild assurances that there's an adult in the room, even if the president is an idiot. There's usually someone around to say, "That's a terrible idea," or "Um, the president can't do that, sir." 

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.