"But even though the concentration in Appalachia does suggest some vaguely Case-Deaton-y conclusions, the rest of the regional pattern does not.... Maryland is the richest state in the union."
Gotta stop you there. You may be right that the opioid crisis is not primarily driven by poverty. But pointing to the wealth of Maryland is a total red herring. Maryland has extremes of wealth, and extremes of poverty. Maryland has Chevy Chase, and Maryland has Prince Georges County. And, famously, Maryland has Baltimore. They made a good tv show about it, once.
If you want to make your case about poverty not being a driver, then drill down to the county-level or finer. States like MD and CT have huge disparities of wealth within them. Talking about the wealth of the state as a whole is a disservice to your argument and to your readers.
My little brother died 2 weeks ago of a heroine overdose. Got started on oxy when he was 16 after an intense chest surgery. It was a decade of pain, struggle, lies, theft, rehab, false hope, and finally an end that none of us wanted but all knew was likely coming.
We come from an upper-middle class family in Houston, though my folks are now broke from all the rehab and we all had to chip in to pay for the cremation. I had my own struggles with addiction. Was an alcoholic for about a decade, though I was able to recover with the support of my immediate family and am 3 years sober. The dividing line between me and my little brother is very thin and blurry. We are separated only by a few simple decisions and a lot of luck. Common between us is that we were both ASD and both suffered from depression and anxiety before the introduction of any substances. I, eventually, learned how to manage and get my head over those, for the most part. He did not.
Former oxycontin/heroin addict here. The right way to think about addiction treatment is as a lottery. Each time you send an addict to treatment they have an x% probability of recovering. That x% is mostly correlated with *length* of stay in a treatment facility. And when I say "stay" I mean inpatient, because all outpatient addiction treatment is bullshit, at least for the acute phase. Effectively zero people have ever quit using opioids from outpatient treatment alone.
The most important thing you can do is physically separate the person from the drugs - by force. This means we need to retain the threat of prison on the books for these crimes, but we shouldn't be using it. We should be giving people a stark choice "go to prison or go to treatment" and in that treatment center, they will be held, by force if necessary. Each time you do this to someone, you get an x% probability of them not going back to using. 'x' is probably not super high, but it is correlated primarily with *length* of stay, and almost nothing else. Different treatment modalities probably help at the margin, but we don't really know what's best and that barely matters anyway.
What works is physical separation by force. Force someone to stop using, and you get some chance that they won't go back. The best we can really do is keep cycling addicts through this system each time they're caught. But the key piece here that I really want to emphasize is "force". The state just paying for their treatment is not enough. They need to be put there and held there at the point of a gun if necessary. Actually exercising the state's power to compel people who've broken the law is what's necessary here.
Ironically the solution here is a middle path between conservatism and liberalism. You need force and coercion, but it needs to be used in a compassionate, not punitive way. I suspect this is why we've made less progress than we otherwise might. Conservatives just want to punish. Liberals just want to tolerate. Those willing to use coercion aren't using it in a useful way.
Unpopular opinion- we could to a certain extent give up? We could decriminalize possession of small amounts of hard drugs (as I believe Oregon is doing), and continue to prosecute dealing. Along with decriminalization, we could mandate that an officer confiscate any drugs they see in public view- enough to motivate addicts to not shoot up right on the street (no one wants to lose their drugs).
Most importantly, we could offer treatment options *to those who want it*, but we could move away from judges mandating rehab (which would be a non-issue with possession decriminalized anyways). Rehab is expensive, lots of pro-rehab legislation is just a front for shady treatment centers, addicts have to go through 7-10+ times in their life for it to 'work', and most importantly- forcing someone to go to rehab who isn't self-motivated is a complete waste of everyone's time, including the taxpayer who's paying for it. One thing that's difficult to get the left-leaning 50% of the population to understand is that lots of addicts are perfectly happy with their lifestyle- or, not unhappy enough to change. You can't force large-scale behavioral changes on the unwilling. Some people, unfortunately, just can't be saved.
If your response is 'well drug addicts stealing/panhandling/camping on the streets is bad', I have no objection to enforcing laws against that- and now police officers will have more time and more resources to go after those petty crimes, when they're not wasting time arresting folks just for possession.
We don't have to have a magic solution for drug addiction- we could simply stop wasting law enforcement time & resources on arresting people for simple possession. Arrest dealers, make supply more difficult as Matt mentions, and offer treatment to those who are self-motivated. If you disagree, tell me what society is doing to force the enormous number of alcoholics in the US to change their behavior. The answer is, if they don't break any other laws, nothing- we can't make them save themselves
"Michael Shellenberger and other Bay Area critics of Chesa Boudin argue that bad progressive policy is responsible for drug addiction, and drug addiction is responsible for San Francisco’s homelessness problem. I think this is pretty clearly mistaken."
This strawman's Shellenberger and others quite a bit. He doesn't argue that the policy of SF is responsible for drug addiction, but that it exacerbates it, concentrates it, & on the margins makes it easier to remain an addict (ignoring the crime aspects).
I don’t know enough about the science or policy to know how effective this would be, but it seems like it should help a bit if it works and becomes widely used.
You don’t mention the most obvious solution: suboxone. There are drugs that allow opioid addicts to safely take the opioids and stay off heroin. They’re highly effective. But they’re very difficult to prescribe. As a doctor I can write for Oxycodone with just a regular DEA permit, but writing for Suboxone or methadone requires a special waiver and hours of training that’s a pain in the ass to get done. As a result it takes addicts forever to get into a doctor who can prescribe the meds to help them. Very bad situation that the DEA is not doing anything to fix
It was nice to see Matt engaging with the points that Shellenberger makes.
I still don’t think that he has the homeless and its relationship to drug abuse correct. And that’s because there is bad data out there. As I’ve said before there’s a visible homeless population which probably is related to drugs. And then there is a unseen invisible homeless problem which is related to housing. Homeless activist like to hide these numbers just as they like to avoid talking about whether the homeless in San Francisco were from San Francisco, from the Bay Area, or just became homeless there and were raised someplace else.
Anyway, it’s probably old-school conservative of me, but I think that marriage and jobs are what men need to keep them off drugs. Or at least help.
One possible solution worth looking into IMO is Kratom. I've personally only ever tried it once back during my days as a drug addict, but as far as I understand it has effects that directly substitute for opiate pain relief but without the respiratory depression that makes overdosing on opiates so deadly. Experience tells me that most drug addicts are not going to quit using substances. People turn to substances for reasons. It could be chronic pain, or it could be something emotional/mental, but either way those reasons aren't going to go away because you quit taking heroin. So one (uncomfortable!) underexplored solution is encouraging healthier substitutions. Cannabis is an obvious one that other commenters have discussed, but to be frank, it is a pale imitation of the power opiates have to relieve all forms of suffering, whether emotional or physical. It can definitely substitute for some people.
Another possibility, again somewhat uncomfortable but worth exploring, is perhaps the US government should be heavily investing in trying to discover the drug that OxyContin was *supposed* to be, i.e. a pain medication that is abuse-resistant and unlikely to kill you if you do abuse it.
The curves have been bad for a while. But the spike in 2020 affected both sexes, all regions and all races. I suspect the data for 2021 will show another significant increase.
Now, I'm not a social scientist and the studies aren't done yet. But. It isn't a large leap of faith to think the interventions to deal with COVID are a large contributing factor. Joblessness, kids out of school and disrupted lives add stress and pain. We've seen the increases in alcohol abuse and mental health issues in kids. I believe opioid deaths are related.
Our response to the COVID pandemic has resulted in a particularly tragic tradeoff. COVID kills (mostly) very old people. The unintended consequences of our societal response will result in the deaths of (mostly) younger people.
The solution that really needs more focus is aggressively getting Buprenorphine out there. It's the closest thing to a silver bullet we have, and we make it harder to access than it needs to be in most states.
I have a close friend who does social work in San Francisco, helping transition people out of prison who struggle with mental illness and addiction. He is very much left of center but hates Chesa Boudin with a passion. He says that addicts will never voluntarily agree to enter rehab without the threat of incarceration. So Chesa’s decision not to prosecute low-level offenses basically makes his job impossible. Meanwhile, overdose deaths in San Francisco have tripled since 2018. The arrival of fentanyl deserves the vast majority of the blame for this, but Chesa isn’t helping.
I think advocates of supply side solutions fail to grasp that previous drug war efforts have made drugs stronger. The US focused on coke trafficking in the 80's; cocaine use went down, but meth use went up. Congress made it harder to make meth by regulating precursors and putting pseudoephedrine behind the counter. So cartels switched to a different formulation of meth, which could be made in larger batches at higher levels of purity. They went after pill doctors, and pill mills sprang up. They went after pill mills, and people turned to heroin. Now fentanyl is overtaking heroin. Cracking down on supply just seems to push addicts higher up the ladder.
“You cannot look at this in a fair-minded way and decide it’s Chesa Boudin’s fault.”
That’s because it’s a very misleading map:
“The U.S. Centers for Disease Control data shows that in 2010, San Francisco’s overdose death rate was at about 13 per 100,000 people, compared with 49 in 2020.“
The best answer to the opiate crisis is legal marijuana. No, it isn’t kale, it has side effects and you might get lung cancer if you smoke it long enough, but marijuana is a lot safer than opiates. It helps manage chronic pain. The states that have had dispensaries for a while (CO, WA, CA for medical) have relatively low opiate death rates. Furthermore, government has more credibility to say “opiates can kill you” when it isn’t peddling reefer madness alarmism.
It's nice to see the acknowledgement here that not every problem can be solved via technocratic means.
On this though:
"Michael Shellenberger and other Bay Area critics of Chesa Boudin argue that bad progressive policy is responsible for drug addiction, and drug addiction is responsible for San Francisco’s homelessness problem. I think this is pretty clearly mistaken. "
I don't know about progressive policy in the Bay Area, but it definitely is true that the homeless population has a much, much higher rate of drug and alcohol addiction and that is a driver of a significant portion of homelessness.
I have an example from my own family where my brother-in-law went from a successful upper-middle class business owner to living in the streets because of his alcoholism, which eventually killed him. No government program and not even his own robust and supportive network of family and friends prevented it, despite many attempts at intervention.
"But even though the concentration in Appalachia does suggest some vaguely Case-Deaton-y conclusions, the rest of the regional pattern does not.... Maryland is the richest state in the union."
Gotta stop you there. You may be right that the opioid crisis is not primarily driven by poverty. But pointing to the wealth of Maryland is a total red herring. Maryland has extremes of wealth, and extremes of poverty. Maryland has Chevy Chase, and Maryland has Prince Georges County. And, famously, Maryland has Baltimore. They made a good tv show about it, once.
If you want to make your case about poverty not being a driver, then drill down to the county-level or finer. States like MD and CT have huge disparities of wealth within them. Talking about the wealth of the state as a whole is a disservice to your argument and to your readers.
My little brother died 2 weeks ago of a heroine overdose. Got started on oxy when he was 16 after an intense chest surgery. It was a decade of pain, struggle, lies, theft, rehab, false hope, and finally an end that none of us wanted but all knew was likely coming.
We come from an upper-middle class family in Houston, though my folks are now broke from all the rehab and we all had to chip in to pay for the cremation. I had my own struggles with addiction. Was an alcoholic for about a decade, though I was able to recover with the support of my immediate family and am 3 years sober. The dividing line between me and my little brother is very thin and blurry. We are separated only by a few simple decisions and a lot of luck. Common between us is that we were both ASD and both suffered from depression and anxiety before the introduction of any substances. I, eventually, learned how to manage and get my head over those, for the most part. He did not.
Former oxycontin/heroin addict here. The right way to think about addiction treatment is as a lottery. Each time you send an addict to treatment they have an x% probability of recovering. That x% is mostly correlated with *length* of stay in a treatment facility. And when I say "stay" I mean inpatient, because all outpatient addiction treatment is bullshit, at least for the acute phase. Effectively zero people have ever quit using opioids from outpatient treatment alone.
The most important thing you can do is physically separate the person from the drugs - by force. This means we need to retain the threat of prison on the books for these crimes, but we shouldn't be using it. We should be giving people a stark choice "go to prison or go to treatment" and in that treatment center, they will be held, by force if necessary. Each time you do this to someone, you get an x% probability of them not going back to using. 'x' is probably not super high, but it is correlated primarily with *length* of stay, and almost nothing else. Different treatment modalities probably help at the margin, but we don't really know what's best and that barely matters anyway.
What works is physical separation by force. Force someone to stop using, and you get some chance that they won't go back. The best we can really do is keep cycling addicts through this system each time they're caught. But the key piece here that I really want to emphasize is "force". The state just paying for their treatment is not enough. They need to be put there and held there at the point of a gun if necessary. Actually exercising the state's power to compel people who've broken the law is what's necessary here.
Ironically the solution here is a middle path between conservatism and liberalism. You need force and coercion, but it needs to be used in a compassionate, not punitive way. I suspect this is why we've made less progress than we otherwise might. Conservatives just want to punish. Liberals just want to tolerate. Those willing to use coercion aren't using it in a useful way.
Unpopular opinion- we could to a certain extent give up? We could decriminalize possession of small amounts of hard drugs (as I believe Oregon is doing), and continue to prosecute dealing. Along with decriminalization, we could mandate that an officer confiscate any drugs they see in public view- enough to motivate addicts to not shoot up right on the street (no one wants to lose their drugs).
Most importantly, we could offer treatment options *to those who want it*, but we could move away from judges mandating rehab (which would be a non-issue with possession decriminalized anyways). Rehab is expensive, lots of pro-rehab legislation is just a front for shady treatment centers, addicts have to go through 7-10+ times in their life for it to 'work', and most importantly- forcing someone to go to rehab who isn't self-motivated is a complete waste of everyone's time, including the taxpayer who's paying for it. One thing that's difficult to get the left-leaning 50% of the population to understand is that lots of addicts are perfectly happy with their lifestyle- or, not unhappy enough to change. You can't force large-scale behavioral changes on the unwilling. Some people, unfortunately, just can't be saved.
If your response is 'well drug addicts stealing/panhandling/camping on the streets is bad', I have no objection to enforcing laws against that- and now police officers will have more time and more resources to go after those petty crimes, when they're not wasting time arresting folks just for possession.
We don't have to have a magic solution for drug addiction- we could simply stop wasting law enforcement time & resources on arresting people for simple possession. Arrest dealers, make supply more difficult as Matt mentions, and offer treatment to those who are self-motivated. If you disagree, tell me what society is doing to force the enormous number of alcoholics in the US to change their behavior. The answer is, if they don't break any other laws, nothing- we can't make them save themselves
"Michael Shellenberger and other Bay Area critics of Chesa Boudin argue that bad progressive policy is responsible for drug addiction, and drug addiction is responsible for San Francisco’s homelessness problem. I think this is pretty clearly mistaken."
This strawman's Shellenberger and others quite a bit. He doesn't argue that the policy of SF is responsible for drug addiction, but that it exacerbates it, concentrates it, & on the margins makes it easier to remain an addict (ignoring the crime aspects).
Opioid vaccines could be an interesting solution. They make people unable to get high, forcing them to quit. Example: https://www.cuimc.columbia.edu/news/experimental-opioid-vaccine-being-tested-columbia
I don’t know enough about the science or policy to know how effective this would be, but it seems like it should help a bit if it works and becomes widely used.
You don’t mention the most obvious solution: suboxone. There are drugs that allow opioid addicts to safely take the opioids and stay off heroin. They’re highly effective. But they’re very difficult to prescribe. As a doctor I can write for Oxycodone with just a regular DEA permit, but writing for Suboxone or methadone requires a special waiver and hours of training that’s a pain in the ass to get done. As a result it takes addicts forever to get into a doctor who can prescribe the meds to help them. Very bad situation that the DEA is not doing anything to fix
It was nice to see Matt engaging with the points that Shellenberger makes.
I still don’t think that he has the homeless and its relationship to drug abuse correct. And that’s because there is bad data out there. As I’ve said before there’s a visible homeless population which probably is related to drugs. And then there is a unseen invisible homeless problem which is related to housing. Homeless activist like to hide these numbers just as they like to avoid talking about whether the homeless in San Francisco were from San Francisco, from the Bay Area, or just became homeless there and were raised someplace else.
Anyway, it’s probably old-school conservative of me, but I think that marriage and jobs are what men need to keep them off drugs. Or at least help.
One possible solution worth looking into IMO is Kratom. I've personally only ever tried it once back during my days as a drug addict, but as far as I understand it has effects that directly substitute for opiate pain relief but without the respiratory depression that makes overdosing on opiates so deadly. Experience tells me that most drug addicts are not going to quit using substances. People turn to substances for reasons. It could be chronic pain, or it could be something emotional/mental, but either way those reasons aren't going to go away because you quit taking heroin. So one (uncomfortable!) underexplored solution is encouraging healthier substitutions. Cannabis is an obvious one that other commenters have discussed, but to be frank, it is a pale imitation of the power opiates have to relieve all forms of suffering, whether emotional or physical. It can definitely substitute for some people.
Another possibility, again somewhat uncomfortable but worth exploring, is perhaps the US government should be heavily investing in trying to discover the drug that OxyContin was *supposed* to be, i.e. a pain medication that is abuse-resistant and unlikely to kill you if you do abuse it.
The curves have been bad for a while. But the spike in 2020 affected both sexes, all regions and all races. I suspect the data for 2021 will show another significant increase.
Now, I'm not a social scientist and the studies aren't done yet. But. It isn't a large leap of faith to think the interventions to deal with COVID are a large contributing factor. Joblessness, kids out of school and disrupted lives add stress and pain. We've seen the increases in alcohol abuse and mental health issues in kids. I believe opioid deaths are related.
Our response to the COVID pandemic has resulted in a particularly tragic tradeoff. COVID kills (mostly) very old people. The unintended consequences of our societal response will result in the deaths of (mostly) younger people.
The solution that really needs more focus is aggressively getting Buprenorphine out there. It's the closest thing to a silver bullet we have, and we make it harder to access than it needs to be in most states.
https://www.pewtrusts.org/research-and-analysis/issue-briefs/2021/05/policies-should-promote-access-to-buprenorphine-for-opioid-use-disorder
I have a close friend who does social work in San Francisco, helping transition people out of prison who struggle with mental illness and addiction. He is very much left of center but hates Chesa Boudin with a passion. He says that addicts will never voluntarily agree to enter rehab without the threat of incarceration. So Chesa’s decision not to prosecute low-level offenses basically makes his job impossible. Meanwhile, overdose deaths in San Francisco have tripled since 2018. The arrival of fentanyl deserves the vast majority of the blame for this, but Chesa isn’t helping.
I think advocates of supply side solutions fail to grasp that previous drug war efforts have made drugs stronger. The US focused on coke trafficking in the 80's; cocaine use went down, but meth use went up. Congress made it harder to make meth by regulating precursors and putting pseudoephedrine behind the counter. So cartels switched to a different formulation of meth, which could be made in larger batches at higher levels of purity. They went after pill doctors, and pill mills sprang up. They went after pill mills, and people turned to heroin. Now fentanyl is overtaking heroin. Cracking down on supply just seems to push addicts higher up the ladder.
“You cannot look at this in a fair-minded way and decide it’s Chesa Boudin’s fault.”
That’s because it’s a very misleading map:
“The U.S. Centers for Disease Control data shows that in 2010, San Francisco’s overdose death rate was at about 13 per 100,000 people, compared with 49 in 2020.“
That’s as bad as West Virginia.
https://www.sfchronicle.com/projects/2021/san-francisco-drug-overdoses-map/
The best answer to the opiate crisis is legal marijuana. No, it isn’t kale, it has side effects and you might get lung cancer if you smoke it long enough, but marijuana is a lot safer than opiates. It helps manage chronic pain. The states that have had dispensaries for a while (CO, WA, CA for medical) have relatively low opiate death rates. Furthermore, government has more credibility to say “opiates can kill you” when it isn’t peddling reefer madness alarmism.
It's nice to see the acknowledgement here that not every problem can be solved via technocratic means.
On this though:
"Michael Shellenberger and other Bay Area critics of Chesa Boudin argue that bad progressive policy is responsible for drug addiction, and drug addiction is responsible for San Francisco’s homelessness problem. I think this is pretty clearly mistaken. "
I don't know about progressive policy in the Bay Area, but it definitely is true that the homeless population has a much, much higher rate of drug and alcohol addiction and that is a driver of a significant portion of homelessness.
I have an example from my own family where my brother-in-law went from a successful upper-middle class business owner to living in the streets because of his alcoholism, which eventually killed him. No government program and not even his own robust and supportive network of family and friends prevented it, despite many attempts at intervention.