Opioids and The War On Pain Treatment

08 Friday Mar 2019

Posted by Nuetzel in Prohibition, War On Drugs

Tags

Annals of Internal Medicine, CATO Institute, Chronic Pain, Dr. Ted Noel, FDA, Fentanyl, Geraldo Rivera, Heroin, Imported Opioids, Jacob Sullum, Jeffrey Miron, Opioid Addiction, Opioid Deaths, Opioid Prescription, Opioid Production Quotas, OxyContin, PDMPs, Portugal Decriminalization, Prescription Drug Monitoring Programs, Prohibition, Purdue Pharma, Scientific American

I repeatedly hear the bogus claim that prescription pain killers are a primary cause of opioid addiction. Twice this week I heard Geraldo Rivera prattling about it, blaming the drug companies for the opioid epidemic, expressing his view of the righteousness of the many lawsuits faced by Purdue Pharma and other firms. But these cases are hardly sure wins for the plaintiffs, and for good reason. The idea that pharmaceutical companies misleadingly promoted the effectiveness of drugs like Oxycontin for pain relief, and minimized their addictive potential, might appear credible, but there are a number of factors that argue strongly against these claims. Of course, opioids are legal prescription drugs, approved for pain relief by the FDA, and are generally marketed by drug companies under guidelines established by the FDA at the time of approval. And sadly, the narrative promoted by Rivera and many others is at tension with the needs of patients suffering from chronic pain.

In fact, opioids are effective for temporary and chronic pain relief, and they have been used for those purposes for many decades. In “The Other Opioid Problem“, anesthesiologist Dr. Ted Noel asserts that few chronic pain patients have overdosed or been killed by ODs. According to Scientific American:

“A Cochrane review of opioid prescribing for chronic pain found that less than one percent of those who were well-screened for drug problems developed new addictions during pain care; a less rigorous, but more recent review put the rate of addiction among people taking opioids for chronic pain at 8-12 percent [but less than 1% abuse].”

Those prescribed opioids for temporary relief after an injury or surgical procedure are even less likely to develop an addiction. The large majority of addicts are self-selected out of a population of individuals who want to get high. And most of them feed their addictions on opioids obtained illegally, often from imported heroin and fentanyl. Yes, opioids are stolen from legitimate patients, pharmacies, or elsewhere, and sometimes they are prescribed illegally by unscrupulous physicians. That might be the way many addicts get started, but most of the illegal opioid supply in the U.S. is imported heroin and fentanyl.

A causal linkage between opioid prescriptions, addiction and opioid deaths would imply a strong, positive correlation between prescription and death rates. However, Jacob Sullum reports that there is no correlation across states between prescription rates and death rates from opioids. As Sullum notes, this result offers “more reason to doubt that pain pill restrictions will save lives”.

In fact, in a separate article, Sullum writes of other evidence strongly suggesting that those restrictions may have counterproductive effects on opioid deaths, in addition to denying some patients access to the pain pills they legitimately need for treatment. According to Sullum, all 50 states have Prescription Drug Monitoring Programs (PDMPs) that monitor controlled substances and keep tabs on prescribers and pharmacies. These have succeeded in discouraging opioid prescriptions, but research appearing in the Annals of Internal Medicine suggests that the programs might be doing more harm than good:

“Fink et al found six studies that included heroin overdoses, half of which reported a statistically significant association between adoption of PDMPs and increases in such incidents. … To the extent that PDMPs succeed in making pain pills harder to obtain, they encourage nonmedical users to seek black-market substitutes. ‘Changes to either the supply or cost of prescription opioids after a PDMP is instituted,’ Fink et al. observe, ‘might reasonably drive opioid-dependent persons to substitute their preferred prescription opioid with heroin or nonpharmaceutical fentanyl.’

The FDA has enforced quotas on the production of legal opioids. According to the CATO Institute:

“The tight quotas on opioid production contributed to the acute shortage of injectable opioids being felt in hospitals across the nation. It is not only making patients suffer needlessly but places them at increased risk for adverse drug reactions or overdose.”

The FDA’s restrictions were eased somewhat after complaints from the medical community, but the harm continues. At the time of CATO’s report, opioid prescriptions had declined by 41% since 2010, while the overdose rate continued to escalate.

This pattern is all too familiar to those who have been arguing against drug prohibition for years. The flood of fentanyl into the country, and into what is sold as street heroin, is a direct consequence of prohibitions on supplies of legal heroin and other narcotics. But breaking through the puritanical and bumptious mentality of drug warriors is almost impossible. The worse the situation gets, the tighter they turn the screws, doubling down on the policies that have repeatedly failed in the past. Here I repeat the concluding paragraph of a Sacred Cow Chips post from January 2018 on the opioid epidemic:

“There are solutions to the deadly nature of the opioid epidemic, but prohibition is not one of them and never will be. If anything, prohibition in varying degrees has aggravated the dangers of opioids. To truly solve the problem, we should eliminate restrictions on the production and distribution of legal opioids for pain management, legalize heroin, and stop interfering in markets. That would be merciful for patients in real pain, make recreational use of opioids dramatically safer, and put an end to the gangland violence associated with underground competition. Second, redirect those resources into … harm reduction programs. [Jeffrey] Miron notes that legalization has worked in other countries, like Portugal and France, to reduce overdoses and opioid deaths. As a political matter, however, these steps might not be feasible unless we get over the cultural bias stigmatizing recreational opioid use as ‘evil’, and the idea that laws and enforcement can actually prevent people from trying to get high.

Portugal’s Successful Détente With Drug Users

14 Thursday Jun 2018

Posted by Nuetzel in Liberty, Prohibition, War On Drugs

≈ 1 Comment

Tags

Addiction, Drug Legalization, Drug Policy, Drug Prohibition, Drug Treatment Programs, European Monitoring Centre for Drugs and Addiction, Needle Exchanges, Portugal, Portugal Decriminalization, Recreational Drugs, Rehabilition, War on Drugs

The U.S. wastes vast quantities of resources on the War on Drugs with nothing to show for it but counterproductive results. Drug use today is as commonplace as ever, despite the cumulative expenditure of many billions of dollars on law enforcement and judicial costs. We have ceded drug markets to organized crime, tolerated corruption of public officials, incurred the human and economic costs of millions of life-years wasted behind bars, and subjected users to impure and dangerous forms of contraband. And in the process, we have encouraged addiction, disease and death while dedicating relatively few resources to programs that might have helped these troubled souls.

Contrast that with Portugal’s approach to drug policy. The country’s decriminalization of drug use as well as harm reduction and treatment programs both deserve consideration in this context. Decriminalization took place in 2001: drugs are still illegal, but the penalties are very light. Treatment programs include a system of needle exchanges beginning in the early 1990s as well as various forms of outreach instituted in 2003-2005. Before the advent of these policies, Portugal had an extremely high rate of drug abuse; many feared that decriminalization would lead to further degeneracy, but no increase in drug use transpired, and the liberalized policies are credited with a drastic reduction in drug deaths and other tragic fallout. Consider the following:

a dramatic decline in the number of people who died from using an illicit drug to a rate of drug-induced death well below the EU average;
newly-diagnosed HIV cases among intravenous drug users fell by more than 95%;
drug-offenses declined by about 2/3;
the proportion of offenders imprisoned for offenses under the influence of drugs fell in half;
With the exception of cannabis, estimates of drug use among 15-34 year-olds have decreased, with lifetime and recent use rates below EU averages;

These facts are taken from this discussion of the effects of Portugal’s drug policies, this Wikipedia entry, and the 2018 Portugal Country Drug Report from the European Monitoring Centre for Drugs and Drug Addiction.

As a fiscal matter, some of the strongest objections to Portuguese drug policy have to do with the granting of public aid to drug addicts, who usually have themselves to blame for their predicament. And in fact, decriminalization was accompanied by a decision to transfer funds associated with enforcing drug laws and punishing offenders into treatment and rehabilitation of addicts. This includes subsidized housing and jobs as well as loans for certain productive efforts. These strike me as better uses of public funds than a drug war, and by all accounts the programs have been successful. And to the extent that recovered addicts are able to lead productive lives, they add to the strength of Portugal’s economy. In an ideal, classically-liberal order, privately-funded lifetime insurability would avoid the need for public funding of these programs, but that is a reform for another day.

Like any prohibition of activity in which a plurality engages, laws against drug use are generally ineffective and counterproductive (also see here). Portugal’s enlightened approach to drug policy is praiseworthy, sets a great example for other countries, and might be more politically feasible than full legalization. However, as long as there are any penalties for drug possession, there will be a wedge through which rents can be extracted by the underworld. Full legalization would do the most to attenuate crime and other risks associated with drug use, and it would also maximize the resources available to address problems faced by addicts and drug-dependents.

Note: the poster above is from 2014… the numbers are larger now!

Our Homicidal Drug War

17 Tuesday Oct 2017

Posted by Nuetzel in Prohibition, War On Drugs

≈ 4 Comments

Tags

Britigne Shaffer, CATO Institute, Controlled Substances Act, Dan Kahan, DEA, Donald Trump, Drug War, Jeff Sessions, Jeffrey Miron, Mandatory Minimum Sentences, Michael Owen, Milton Friedman, On the Banks, Prohibition, Scott Sumner

Drug prohibition and the war on drugs are destructive policies and most burdensome to communities that can least afford it: impoverished and often minority neighborhoods. Drug laws and their enforcement likely account for the bulk of homicides that occur there, directly or indirectly. A post on SacredCowChips last week discussed the violence that frequently beleaguers communities that are home to unassimilated minorities. Drug prohibition compounds the tragedy in several ways: deadly rivalry among supplier organizations; violent confrontations with law enforcement; user criminality; drug-related incarceration; degraded user productivity; and tainted supplies that exacerbate health risks for users.

Ultimately, bad laws are distinguished by their failure to achieve broad compliance. The thing is, people who want to do drugs will do so regardless of their legality. Most recreational users are sufficiently imbued with a survival instinct and the self-control to govern their use effectively, without ostensible harm. Nearly all recreational users believe they are engaging in a harmless activity, and most of them are right. That is, quite simply, why the drug war just doesn’t work, and it won’t ever work. It doesn’t work for pot, LSD, cocaine, or anything else, including opioids and heroin. (Also see this.)

Prohibition, however, delivers the drug trade into the hands of gangs and mobsters. The supply side of the business attracts individuals having few legitimate market opportunities, who happen to be concentrated in economically depressed neighborhoods. The drug trade’s illegality transforms it into a risky and violent enterprise, and efforts to enforce prohibition magnify those dangers and expose law enforcement to great risk as well. Then, there are the effects of mass incarceration on individuals and their home communities. The situation is self-reinforcing, adding to the instability of these struggling areas.

There is ample evidence that drug prohibition is a driver of crime and responsible for a large number of homicides in the U.S. A Chicago prosecutor was quoted by HuffPo in 2013 as saying that 80% of homicides in the city were gang-related, and therefore primarily drug-related. Economist Jeffrey Miron has linked drug prohibition to international differences in violent crime rates. Scott Sumner has this take on the drug war and crime rates, including a brief analysis of the drop in homicides (40%) after alcohol prohibition was repealed. In 1991, Milton Friedman stated that the repeal of drug laws would eliminate about 10,000 U.S. homicides every year, which at the time would have been about a 40% reduction. And here is Yale’s Dan Kahan on the subject of drug laws and homicide:

“The weight of the evidence pretty convincingly shows that drug-related homicides generated as a consequence of drug prohibition are tremendously high and account for much of the difference in the homicide rates in the U.S. and those in comparable liberal market societies.“

In my last post on the U.S. homicide rate, I drew on Britigne Shaffer’s On the Banks blog post entitled “Michael Owen Nails the Gun Debate“. As log as we have prohibition and a drug war, the U.S. homicide rate is likely to exceed most other industrialized countries:

“We have a system in place where the government subsidizes poverty in urban areas, imposes economic blight in those same areas through heavy taxes and regulations, renders the residents permanently unemployable via the ‘criminal justice’ (sic) system, and creates a lucrative black market in drugs by restricting supply (not to mention increasing demand as people are desperate to escape their circumstances by getting high), meaning the only game in town is often entering the drug trade. The drug trade is violent because those in it have no access to courts to settle disputes. Powerful industries lobby to keep the drug war going; the top spenders are law enforcement unions, the prison industry, big alcohol, tobacco, and pharma.“

The CATO Institute‘s Handbook for Policymakers, Issue #23, advocates the following: repeal of the Controlled Substances Act; allowing states to pursue their own initiatives without federal interference; complete repeal of mandatory minimum sentences; and termination of the Drug Enforcement Administration (DEA). These actions would allow the federal government to focus its resources on real threats, rather than fighting an unending war with an underworld empowered by those very laws, and with Americans who wish to exercise freedom over their use of drugs for medicinal or recreational use. From the CATO Handbook:

“Repeal of prohibition would take the astronomical profits out of the drug business and destroy the drug kingpins who terrorize parts of our cities. It would reduce crime even more dramatically than did the repeal of alcohol prohibition. Not only would there be less crime: reform would also free federal agents to concentrate on terrorism and espionage and would free local police agents to concentrate on robbery, burglary, and violent crime. … The war on drugs has lasted longer than Prohibition, longer than the Vietnam War. Prohibition has failed, again, and should be repealed, again.”

Despite the destructive effects of prohibition, a great many Americans—and politicians—base their opinions about drug laws on flawed moral reasoning that somehow it is more “wrong” or more “dangerous” to do drugs than to drink alcohol, itself a drug posing great danger to abusers, but a legal one. Responsible drug use, like responsible drinking, is a victimless act, or would be without the engagement of underworld suppliers. But it’s clear that President Donald Trump and Attorney General Jeff Sessions are committed to a continuation of the failed drug war, as are a majority of both Democrats and Republicans in Congress. The drug-related killings will continue, as will the ongoing damage to so many American families and communities. The refusal to end the drug war is a tragedy of many tragedies past and future.

Wanna Help People? End the Drug War!

03 Tuesday Nov 2015

Posted by Nuetzel in War On Drugs

≈ Leave a comment

Tags

Black Markets, Colorado Legalization, Colorado Pot Legalization, Drug Abuse, Drug Cartels, Gangland Violence, Individual Liberty, Jacob Sullum, Milton Friedman, Prohibition, Prostitution, Victimless Crimes, War on Drugs

We’re taught that illegal drugs are a scourge on humanity, that their use is immoral and that legalization is out of the question. Yet far more of us, our friends, and our loved ones have been intimate with the destructive effects of alcohol and dependency on legal drugs than on illegal drugs. Pharmacologically, the “worst effects” of illegal drugs are no worse than the well-known effects of alcohol abuse. In fact, the “worst effects” have more to do with prohibition than with the illegal drugs themselves.

Rules are codified into law successfully when widespread agreement exists among the citizenry that a rule is sensible. This should trouble drug prohibitionists: a substantial proportion of the population has used illegal drugs as adults, indicating a strong lack of consensus that recreational drugs should be illegal. For this reason alone, drug prohibition is and always will be ineffectual.

The great economist Milton Friedman was a long-time critic of the drug war. Several of his articles on the topic are linked at this site. One of the links is this interview from 1992, which is lengthy but sticks primarily to the issue of the drug war. I’m not sure that all of the facts Friedman cites have held up over time, especially with respect to trends in alcohol consumption. Nevertheless, it is a great interview:

“There are [sic] an enormous number of innocent victims now. You’ve got the people whose purses are stolen, who are bashed over the head by people trying to get enough money for their next fix. You’ve got the people killed in the random drug wars. You’ve got the corruption of the legal establishment. You’ve got the innocent victims who are taxpayers who have to pay for more and more prisons, and more and more prisoners, and more and more police. You’ve got the rest of us who don’t get decent law enforcement because all the law enforcement officials are busy trying to do the impossible.“

Here is a brief list of the pernicious effects of drug prohibition:

Prices are driven upward by the legal risk inherent in black market trade;
High prices lead to more crime as heavy users seek means of payment;
Impure and more dangerous variants are traded in attempts to stretch quantities and increase potency;
Dealers advance “samples” to gain trust and cultivate dependency among users;
Addiction is stubbornly resistant to legal barriers;
Unnecessary deaths from impure and excessively potent drug varieties;
Black market trade leads to violent crime as underworld elements seek to control markets and enforce discipline in their organizations;
Unnecessary deaths from gangland violence;
Arrest, imprisonment and ruined lives for victimless crimes;
A huge burden on taxpayers;
A huge burden on the criminal justice system;
Inevitable corruption in law enforcement as officials face hefty rewards for protecting the drug trade;
Innocent people become casualties of violence instigated by gangs and sometimes by police actions.

A fascinating dynamic of the black market in drugs is the tendency toward monopolization at the top: Large cartels dominate the importation of supplies due to the risk and expense of such operations. As Friedman noted, the war on drugs contributes to the difficulty of entering into competition with established players. At the same time, the drug war guarantees huge rewards to the cartels by inflating drug prices:

“What more could a monopolist want? He’s got a government who makes it very hard for all his competitors and who keeps the price of his products high.“

The drug war creates greater danger for users. In “Prohibition Kills“, Jacob Sullum discusses four recent examples of more dangerous and even deadly drug variants that have been developed as a direct consequence of prohibition. Friedman is often quoted as saying that crack cocaine was a direct consequence of the drug war. Sullum asks whether this could be an intentional strategy by drug warriors for discouraging consumption. I’m not convinced they are quite so nefarious, but it’s something to ponder.

More dangerous varieties of drugs would not vanish overnight if drugs were legalized, though the incentive to develop them would diminish. Of course, if legalization brings prices and risks down, as we’d expect, it would encourage greater recreational use. That should not be viewed as a “bad” any more than better access to cocktails at happy hour. Abuse is unlikely to increase because problem users tend to be undeterred by prohibition. And as unsavory as an increase in recreational drug use might seem to the temperance faction, it would still represent only a small fraction of the real costs of ruined lives imposed by prohibition and the drug war.

Legalization would bring other complexities, as Colorado’s experience with marijuana shows. For example, rules with respect to driving under the influence must be updated, as well as laws prohibiting possession by minors. Colorado went so far as to regulate packaging, and tax treatment of the drug trade will stoke debate, as governments will hope for something of a tax bonanza. But the more that government attempts to regulate and tax drugs, the more that problems similar to those associated with drug prohibition will persist, albeit on a smaller scale.

Economically, legalization should eliminate a burden on taxpayers. It would free up law enforcement resources to battle real crime and should make more funds available for treatment programs. It would also help to improve lives and safety in inner cities and other areas ravaged by black market drug trade and the violence it foments. And of course, legalization would put an end to the ruin of lives caused by the arrest of individuals for victimless crimes.

Prohibition of drugs belongs to a larger class of social problems brought on by efforts to bring the police power of government to bear on private behavior. I already mentioned that alcohol prohibition had similar consequences. To lesser degrees, similar harmful consequences are associated with laws against prostitution, large soft drink containers, sugary foods, and practicing almost any commercial art without a license. The same can be said for price regulations like rent control and the minimum wage. The former has led to the destruction of vast quantities of housing; the latter harms low-skilled workers along non-wage dimensions and makes it difficult for unskilled workers to gain valuable experience in the job market. Government interference with individual liberty might well restrain certain activities deemed “undesirable” by busybodies, but it it also leads to higher prices, greater risk, black market activity, violence, unnecessary legal actions against individuals, and greater expense for society.