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"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.

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Everything west of Hagerstown (or arguably Frederick) is Appalachia, too.

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And the Eastern Shore might as well be a different country.

Yup. Maryland is a land of many contrasts.

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Which is why I (very lightly) think Maryland should be the first state in the presidential primary calendar

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If the parties were smart, they'd order there primaries by margin of victory in the previous election year. The first primaries of 2020 would have been Michigan, New Hampshire, Pennsylvania. The first 3 of 2024 would be Georgia, Arizona, Wisconsin.

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That's a good suggestion. The other good way to do it would be to start from the states that are closest to various medians (in income, racial composition, education etc) and then work out toward the outliers.

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The interesting thing is both of our proposals would arrive at very similar results, and I don't think that's a coincidence. The "swing" states also happen to be "median" states. States that are at extremes in various ways tend to be highly partisan already. WV and Connecticut and California and Mass and NY and Maryland and ND and SD are would go last under either of our systems.

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So Hawaii gets to go to the back of the line because they have too many Asians and Pacific Islanders?

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Oddly drawn states being lands of contrast is something I know well, as I could go on regarding how Idaho might as well be three different states.

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Hey. It’s hard to find your reply on My phone. Let me know if u want to get coffee sometime and BS. I should be in town a few days.

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Sure, let me think of a good way to connect--or do you have a method of contact where I could reach out to you?

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It isn't possible to redraw state lines, as I know you know, but it would be possible without a new Constitution to organize the federal government into regional federal administrative districts, headed by federal governors confirmed by Congress and responsible for federal administration in the district. The Cabinet could basically be a council of federal governors.

And to tie this into today's topic, FDA recently proposed regulations that would preempt licensure laws for drug wholesalers and 3PLs, as directed by the Drug Supply Chain Security Act and replace them with a federal licensing system -- which just goes to show how much of what State govts do is subject to federal preemption under the Commerce Clause.

Btw, Congress should broadly preempt state licensure laws, especially in healthcare, not just in the drug supply chain.

https://www.fda.gov/about-fda/economic-impact-analyses-fda-regulations/national-standards-licensure-wholesale-drug-distributors-and-third-party-logistics-providers

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I am not aware of a legal prohibition preventing two or more states to renegotiate their borders. I always thought they were free to do so, should they want to.

I once drew up a plan for Nevada and California to swap Clark County for a handful of eastern California counties that would leave both states with roughly the same population as before and therefore the same Congressional representation. I didn't know there was a statutory impediment.

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The Oregon Territory should never have been split up, it baffles me as to why it wasn't admitted as a free state in its entirety the same time California was as part of the Compromise of 1850 in order to fully shut off slavery from spreading to the Pacific. If that had happened, you'd have a state with 20 electoral votes that would still go 11.7 votes for Biden in 2020:

https://kevinhayeswilson.com/redraw/?share=67ab15c75d58e64f8g3hi67j159k4l44L102n92o99p105q120r64s16t24u14v83w87x82y115z11AL2AL4AL3AL2AL3A2L6ALAL3ALAL9A93B17C10D21E33F62G100H53I88J77K36L67M5N46O66P95Q14Rm27RV2Rm10RV3RV43Rm114RV6Rm18Rm8R29S14T133U14LV12LV11L55W72X11YL5YLYL3Y

However, if you're going to split up the Oregon Territory, the next link below is the way that it should have been done. Two states west of the Cascades divided by the Columbia River, a third state consisting of southwestern Idaho and eastern Oregon (the latter agitating to become a part of "Greater Idaho") with the Snake and Columbia Rivers as its northern border, a fourth state consisting of eastern Washington, northern Idaho, and Montana west of the Continental Divide (this has been called the state of Lincoln in several proposals), while Eastern Idaho gets merged into Utah, given it too was heavily settled by Mormon pioneers to an extent that the rest of the state was not.

https://kevinhayeswilson.com/redraw/?share=67ab15c75d58e64f8g3ui67j159k4l2m2ShS2mhSh3m3Sh2m2S2mhSm2hmhmSmhS2mShS3m102n92o99p105q120r64s16t24u14v83w87x82y115z11Ah2Ah4Ah3Ah2Ah3A2h6AhAh3AhAh9A93B17C10D21E33F62G100H53I88J77Km5LmLmL3m2LmL2m3LmLm2LmL4mLmL67M5N46O66P95Q254R29S14Tu61Uu70Uhm2h2VmV3hmh5V2hVhVhVh5V2h2VmV2h55W72X23Y

Yes, the states east of the Cascades are still awfully small, to say nothing about the lowly populated rump of Eastern Montana that's left, but that's what would make the most sense culturally in the Northwest.

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"Everything west of Hagerstown (or arguably Frederick) is Appalachia, too."

The more I think about this, the more I think it's unfair to Portland and Seattle.

Chicago and LA, I'll concede.

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Ha, right. The bounds of this comment end where the land starts getting flat again.

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County level data might not help much. The biggest counties (eg Maricopa, Los Angeles, Kings) also have extremes of wealth and poverty. You’d need to get data by census tract for it to tease out wealth effects.

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"County level data might not help much."

Oh, it would be a big improvement over state-level.

"The biggest counties ... also have extremes of wealth and poverty."

Fair point, but there aren't that many of them.

"You’d need to get data by census tract for it to tease out wealth effects."

Yup. About time for Milan to hire an intern.

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Slowboring could use an aspiring data journalist like me or 1,000 smart, young people. I would like to see Matt’s analysis laid on top of more serious numbers

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"Slowboring could use an aspiring data journalist like me or 1,000 smart, young people."

You really think it would take 1,000 smart young people to do as much data journalism as you can? I would like to see your analysis of that claim.

I'm so old that one smart young person could do as much as 1,000 of me.

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I was curious and looked. The counties in and around baltimore/DC are by far the worst. Western Maryland has a small increase but not awful. There's some thought that the existing trafficking infrastructure in baltimore/DC/New England is why things got worse there than you'd expect.

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i knew you’d say that

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It was an easy prediction to make, for a top-notch data journalist like you.

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I had something of the same thought which led me to wonder what the national map would look like shaded according to the legend. I’ll bet that purple over W. Virginia would bleed across the borders into its neighbors significantly.

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While those states certainly do have poor areas, they are still much wealthier than other states by nearly every metric. They have a much higher median wealth than other states and their poverty rates are much much lower.

There is still suffering in those states, but objectively they are wealthier.

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deletedFeb 16, 2022·edited Feb 16, 2022
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I agree but we have to be careful with how we use the words "rich", "poor" and "affluent" because people who are somewhat poor in the US are actually affluent by the standards of the poorest countries.

Drug overdoses do seem concentrated in globally affluent communities. But within the USA, they are a bit more concentrated towards the lower end of the SES ladder.

It's also easy to confuse cause and effect. A lot of the people I went to high school with were on track to be fairly middle class but addiction dragged them down and they ended up living in very low income neighborhoods. So they'd be marked as "low income" when they died or die, but they had been more middle income 10 years earlier.

The same happened to the people who lived in my current house, which is in a higher income - around 2005 they sold the house for a bargain price to a house-flipper because of financial problems triggered by their addiction.

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i think the country point is key. And more to the point before you say the issue is the direction of the economy, Portugal's GDP is below 2009 levels. From 2008-2015 their economy experienced a prolonged contraction of over 20%, and yet no real public health crisis to speak of. Life expectancy actually grew faster during that contraction than during the modest recovery since.

Some years ago on the Weeds the crew talked about a study that indicated in a developed economy people die more in expansions than recessions because basically people drive more, smoke more cigarettes, and do more drugs. Unfortunately this doesn't suggest a very clear policy solution.

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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.

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"My little brother died 2 weeks ago of a heroine overdose."

Holy crap. I am so sorry to hear about your loss.

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Really do appreciate it

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I’m so sorry

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Appreciate it, Milan

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Thank you for sharing this, my heart goes out to you and your family. I am lucky to have an extremely non-addictive brain/personality, and stories like this make it easier to understand the struggle that so many people experience.

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I am so sorry for your loss. Reading your comment thread about using drugs to dull the pain of life reminds me of what my recovering addict mom taught me growing up: “we have to learn to deal with life on its own terms.” And she would continue by saying she didn’t do it to feel high or drunk, but just to feel normal and okay. Words of hard fought wisdom I’ve tried to incorporate and pass on to my teens.

Ahhh, it’s so hard. Again, so sorry for what you and your family are going through.

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Thank you and thank you for sharing that wisdom. That really is it.

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I’m so sorry for your loss. As a parent I really appreciate you sharing this. What would you recommend parents look out for or be careful about when it comes to keeping their kids away from drugs, or dealing with suspected drug use?

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My quick response and will think more:

It is a really important and tough question, for which I do not have a real answer to. We have two boys (6 & 10). L (6 year old) was just diagnosed with ASD as well, whereas J (10 yr old) has ADHD and definitely anxiety, possibly some aspects of depression. I share bc all of these led to me and my brother searching for something outside of ourselves that will make "it all go away" or make the differences between us and others less evident (to ourselves and others). We share your same concern.

I can state, pretty confidently, that there is nothing my parents could have done to keep me and my brother from getting a hold of and trying drugs. Any kind of drug. That was the case 20 years ago when I was in Highschool and I bet it has only gotten easier. There is no making sure they only associate with the “right kind of person”, school, neighborhood, or anything I can think of that could have stopped us from being exposed and using if we wanted to. Additionally, and this is conjecture, it at least feels like the desire to do so was a bit already baked into our chemistry.

So what do we do? Well were still figuring it out. I know one of my problems growing up was that I did not know myself. I did not know my limits, but beyond that I didn’t know what my state of happiness was, or contentment or satisfaction or just enough. And always sought those things outside of myself. I think my brother had it even harder and knew himself even less. So we are trying to create the space where our kids can really understand themselves and their own needs. I was lucky that I was into philosophy and psychology at a young age and could find a lot of support in books, which helped me then turn around and reflect on myself. I was very lucky I had that and eventually the love of the family I now have. Not sure if it will help, but we want to equip our kids with tools to have that level of reflections and the love and support available when it isn’t enough.

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So sorry about your brother. Wanted to echo this parenting advice as someone whose only family has dealt with a lot of addiction and work with a lot of addicts. I think that the deaths of despair model misses that despair isn't just about the hardships life throws at you but also how you understand and deal with those.

The things that I have tried to be very about with my daughter are: Life is often connected, wonderful, and joyful but that it can also be incredibly painful and unfair. Every human experiences pain (physical and emotional); envy, lonliness, shame, anger, and sadness at levels that feel beyond our ability to handle at some point in our lives. Some people more because of circumstances or because their brain chemistry makes these emotion feel stronger. People eventually use drugs because they are addicted and not using them is in itself painful. But people start abusing drugs because they offer a brief escape from feeling this feelings or artificially create good emotions for a short period that the person feels that they need. But they do so by hijacking your brain chemicals making them less able to naturally feel those good emotions and more impacted by the negative ones. They also distract you from addressing the causes of your negative feelings by either changing your circumstances or your understanding them. So you need to learn how to experience and dwell in those feelings and not run away from them.

When she was little we experimented with things like somatic practices, mindfulness, and meditation techniques as well as some cognitive behavior therapy lite. Now that she is a teen we are having to reintroduce those and deal with it more deeply. Its been a good reminder that you never grow out of needing to learn those lessons more fully.

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RemovedFeb 16, 2022·edited Feb 16, 2022
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Thanks for sharing. That quote has definitely been in my head the past few days as I drive the kids to school

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I'm very sorry to hear of your troubles.

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I am so sorry for your loss.

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Thank you

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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.

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This was what I learned in policy school. RAND had done a huge study and found that each time you put someone in rehab you get them to stop using for that period, and likely for some amount of time after they get out and even if they relapse, you are reducing their overall consumption and thereby lowering the harm that they cause to themselves and the community. And that there is no difference in the likelihood of rehab succeeding connected to it being voluntary or involuntary. People who go to rehab to avoid incarceration have as much remission as those who check themselves in.

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This is the best thing I've read on the subject all day.

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I’ve been thinking lately that maybe the solution is drug jails. Segregate users from gen pop, make it very akin to a rehab facility with comfortable accommodations, but make it mandatory and enforce participation in treatment. People will say it is draconian, but you are completely right that physical separation and time are the two ways people quit.

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Ya, agree. Something like this is necessary if we actually want to solve the problem.

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Disagree. I don't think it's any of governments business what I put in my body

And people have to want to get clean.

I did everything under the sun. I even did 10 months in jail.

I stopped partying as I grew up got married etc

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Feb 18, 2022·edited Feb 18, 2022

I tried to stay away from "should" statements. Whether or not the government *should* do this is a moral and ethical question. However, I think it's undeniable that it is the only way to address the problem that's likely to have success.

Whether or not that means we *should* do it is still an open question.

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Feb 16, 2022·edited Feb 16, 2022

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

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Feb 16, 2022·edited Feb 16, 2022

“ 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. ”

How do you figure that they are able to make a valid choice?

For example, some people have their first drink (or several) and say this is awful - and they rarely if ever drink again. Some people (the majority) have a few drinks, enjoy it and drink reasonably for the rest of their lives. And then you have the small percentage of people who have their first drink and every neuron in their brain blazes in unison MORE!!!

That’s true for all drugs.

Do you think they are making a rational decision given their intense susceptibility to whatever drug they are addicted to?

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Let's throw a discussion of free will out the window and just focus on practical implementation. How do you propose to make addicts stop using drugs? I'm saying that a judge-ordered, mandatory rehab doesn't do anything. What are the methods you plan to use, that have not been effective in any country to date, that you've come up with?

It's an unsolvable problem. There's nothing state or federal governments can do for people who voluntarily choose to abuse hard drugs

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No offense but you are giving up ridiculously, laughably easy. There's plenty of countries around the world with far lower usage of illegal drugs. Even among western countries, Portugal's approach seems far better and worth looking into.

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My mom was a recovering addict with 26 years sobriety and said addicts have to hit rock bottom to find the motivation to change. Places like SF make it harder to hit rock bottom with the open markets and law enforcement that tolerates it. The addiction just gets more profound and ingrained—addicts are surrounded by other homeless addicts using in broad daylight and the hopeless lifestyle is reinforced because it’s tolerated. It’s incredibly cruel. As the previous commenter posted, there needs to be a choice between forced rehab or jail. You can’t force people to recover, but at least they have a chance (it took my mom 8 stints and she came out the other side to live a very fulfilling, beautiful, sober life surrounded by people who adored and admired her.)

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Except that judge ordered mandatory rehab does work some of the time, permanently. Far more often it works temporarily. Additionally, in many cases it makes the individual aware of resources which they may utilize later in life as their problems become more incapacitating(which is often the case).

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Feb 16, 2022·edited Feb 16, 2022

I think you should be able to do as much drugs as you want. The second you become a public burden/nuisance you get sent to a secure facility.

The alternative to a secure facility would be (in the case of narcotics) implantable buprenorphine.

https://archives.drugabuse.gov/news-events/news-releases/2016/05/fda-approves-six-month-implant-treatment-opioid-dependence

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How are you defining public burden?

One place I think it's unclear is parenting. If you have a kid should you be "allowed" to shoot up heroin?

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Apply the same standards as you do to the wine mom who is passed out in her own vomit ever day when the kids get home.

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Maybe. I don't know, it's not so simple to me because even though the theory is the same there are some massive qualitative differences. Probably 200-250 million americans have tried alcohol but only 3-5 million (kind of a wild guess, admittedly) americans have tried heroin over the last 10 year and maybe 10% (again a guess, but somewhere in the ballpark) of them are dead.

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" The second you become a public burden/nuisance you get sent to a secure facility."

This idea makes me very nervous - because who decides when someone is a public nuisance and for how long they should be put away.

The US already has a prison population of over 2 million. Are we looking to add a couple more million for being a public nuisance with drugs?

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Feb 16, 2022·edited Feb 16, 2022

I’d say vagrancy and a lack of gainful employment would be a good start.

If you want to get drunk in your own home, great. If you end up in a pool of your own feces in someone’s doorway because you don’t have a place to live - off you go.

And, now that you mention our prison population, a lot of those folks would have been in a state hospital 70 years ago. I’m not sure our prison population would increase. I would also add that these folks wouldn’t be convicted of a crime*. If they could get clean no felony conviction.

* of course due process would apply.

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Completely agree with this. There are a lot of challenges for patients in getting access to buprenorphine - docs are still limited in the number of patients they can treat at once, and have to take on extra training (a requirement that doesn't apply to docs dispensing pain meds) - https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner. There are also long-acting injectable medications to treat OUD, but they're limited-distribution specialty drugs that are really expensive, so it continues to be challenging for patients to access them. Consequently a lot of OUD patients are receiving abstinence-based treatment that's been shown to have a much lower efficacy rate than medication assisted treatment (https://pubmed.ncbi.nlm.nih.gov/32280122/)

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Agreed. My understanding is that different drugs have very different addiction patterns.

From my understanding, marijuana is not that addictive, cocaine is not necessarily that addictive, but heroin famously is EXTREMELY addictive.

That doesn't necessarily mean we need the full War on Drugs on it, but as much as I'm pro-legalization for some drugs I'm much less sure about my stance for heroin/fentanyl etc.

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Even if you legalize the drug, you still need to regulate it in such a way that many usages will be criminal.

Let's say we legalize tomorrow...can my kid's daycare teacher give their class fentanyl to calm them down? Can I open a heroin pub across the street from an elementary school? Is it OK if the police and firemen and ambulance drivers relax after work with a spoon and a needle? Is it OK if my neighbors with 3 kids start spending more and more of their time and money on heroin and less on raising their children? Is it OK if your kids 3rd grade teacher disappears one day because. they fatally overdosed?

Probably none of those things are OK, which means simple legalization doesn't even solve half the most serious problems.

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Everything you mentioned applies to alcohol. Alcohol is a super dangerous and powerful drug.

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Not everything, but a lot of it does.

My point is "legal" still means regulated, ie, many usages are actually criminal. It's not legal to drink and then drive, for example, and I can be fired for showing up drunk.

But it's oversimplified to say it's the same thing. Alcohol is not as addictive as heroin, and does not have the same potential to kill suddenly (as opposed to after years of chronic use). Something like just under 1% of Americans use heroin and it's killing something like 3-5% (my best guess) of those users a year.

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Feb 16, 2022·edited Feb 16, 2022

I’m curious about that. I had a colonoscopy recently and one of the things given as part of conscious sedation was fentanyl. All I can say is, meh.

I mean you’re probably right. I’m just curious how those things are ranked.

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What prevents all those folks from getting sh*tfaced drunk in those situations? A combination of reasonable regulation and the fact that not everyone is constantly looking for a way to get high covers most of it. If it was legal, would you do it? I wouldn’t.

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It depends an awful lot on what we mean by legal. Is it sold in specific state-owned shops? Or is it supplied in the same way, but police just look the other way?

There's still other differenced between opioids and alcohol that need to be considered. One is the addictive force is quite a lot higher. The other is that acute danger is probably also much higher.

I wouldn't go out and try an opioid tomorrow if it was legal, but I would be concerned that my teenage relatives might try it out if they were even more readily available. I was prescribed Vicodin once myself and I probably would have kept using it for as long as a doctor prescribed, I certainly kept using it past the point of pain in my gums (wisdom teeth pulled)

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Feb 16, 2022·edited Feb 16, 2022

"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."

I'm not sure that it's 50%, but I do think that many advocates for progressive social policies fail to grasp what I think of as the "Acceptable Levels of Survival" problem. (From the Architect's monologue in "The Matrix: Reloaded": "There are levels of survival we are prepared to accept.") I.e., there is a non-trivial part of the population that is willing to accept an extremely low level of "survival" if it means they don't actually have to work or can work intermittently/very little. Which, from a libertarian perspective is fine in isolation (or at least presents a private problem for family and friends), but becomes a societal problem as soon as you develop broad social programs, public services, etc. that don't recognize this reality.

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Why not do something more like Portugal where drug use isn't treated very much like a criminal matter, but they do require the addicts to attempt to fix themselves if they wish to fully participate in society?

If you're going to shoot up heroin, I guess that's your right. But I don't think society owes you a job in that case.

It's worth mentioning that a lot of drug addicts have children. How is letting people shoot up heroin fair to their kids?

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do you want anyone with their kids while going through withdrawal? really?

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If fentanyl is driving the presence of the visibly homeless in major cities, giving up means accepting a massive shift to the right in city politics generally.

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I don't think it is though. Fentanyl is no worse financially than heroin or meth. It just kills faster. My understanding is fentanyl didn't even really arrive substantially on the west coast until fairly recently, like 2019-2020.

But I agree Left failures on homelessness and especially the visible homeless will eventually shift portions of the urban voters to the right.

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How would you say that arresting people for simple possession addresses that issue? I mean, seeing as arresting people for possession is what's the norm now- how would you say that's working out? Remember, they just get released from jail with a court date 1-2 days later, as even America doesn't have enough jail capacity for every addict found with a bag of crack or fentanyl.

Remember, you can still arrest people for *other crimes that they commit*- just not possession

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Anything less than full legalization means we still get all the violence and OD deaths from prohbition

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Interesting, do you know whether any other place somewhere else in the world has taken that approach?

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I would be curious to read more on how the police in Portugal actually investigate and prosecute drug dealers without having the ability to force users to help them in exchange for having charges reduced or dropped. There's a lot of undiscussed differences in European law that usually lets their police do a lot more stopping/detaining/searching without cause compared to the US (see the debate over pretext stops here vs most European countries just having a law that says cops can stop any car without a reason).

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I think I’d be on board with a program if “do to thyself as thou wilt” coupled with “the second it impacts others you spend long periods of time in jail away from your precious drugs”.

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1) Have you read, like, anything that Popehat has written about the prison system?

2) Define, legally "impacts others"

3) Makes assumption that users are making clear, rational decisions.

#3, source - friend was in horrific car accident that, honestly, it would have been a kindness if he hadn't survived. Is now absolutely lit to the gills on opiod pain medication that have been legally given to him. His decision making due to this is muddled at best. And the totality of his situation is one where a box truck t-boned him into a jersey barrier, and then had modern medicine do the only thing they can do. But if he slips once, fuck 'em, he goes to prison? Nah.

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“Slips once”

I thought, in context, that I was clear enough in meaning “robs someone for drug money” or “drives under the influence”, not “uses drugs”.

There are basically four possible policy approaches to this problem:

1. Zero tolerance, i.e. East Asia. I am philosophically most aligned with this, to be frank, but getting there from where we are today would require *punitive* levels of incarceration for simple drug use until it filters into the wider culture that you *will* end up in prison for it. We’re talking a prison population of tens of millions of people for decades until drug use tapers off to near-nothing like in Singapore or Japan. Obviously unacceptable, harms are far greater than benefits.

2. Public health/public order maintenance, i.e. Portugal or perhaps the Netherlands. This is my preferred outcome, in which we focus efforts on removing as many people from the pool of users as possible while also effectively punishing those who will not or cannot give up the habit when they harm others. But I’m not confident we can do it.

3. Status quo, i.e. US. In which we have all the “benefits” of a war on producers and suppliers but are quite lax to users even when they inflict harms on others, mostly because our police lack the bandwidth to deal with the latter after pursuing the former.

4. Liberalization and public order. This is what I outlined above, in which people are permitted to harm *themselves* all they like but get quashed quite brutally if they harm others at all. Not my preference but I think it’s the only thing we can realistically *do*.

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I like #2 also, and I wish more people would seriously engage with it instead of saying some version of "there's nothing that can be done"

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We should try, no doubt. Worst that happens is we end up with something like #4.

But it does require a coherent effort to enforce public order too. This stupid lefty strain of “chaos=liberty” needs to be shot and buried once and for all. It’s done nothing but harm the vulnerable among us since the hippy movement concocted it in the 60’s.

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If slip means "uses drugs again" that indeed sounds very harsh and counterproductive. But if slip means "gets doped up and drives erratically" then it's not so clear, as he may cause another crash. That's the way I interpreted Dave R

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The latter.

Let’s be precise: “Slips once” sounds terribly sympathetic, but in reality is a euphemism for “robs a convenience store to get drug money” or “runs down a child driving high”.

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“runs down a child driving high”.

I reserve my right to run down any child who is driving high.

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Man, it is very easy to get drugs in prison. Nothing to do on the inside but get strong and get high.

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I’ve had the same thought for a bit now. Also as it would potentially help with the drug trade/border issues.

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Ah, no doubt. When do you forecast we'll win the War On Drugs then, General? It's only been going on for (checks notes) a century now. We'll just round up all the addicts, make them go to Drug Court, and then the war will be over?

A quick look at that meta-study leaves me desiring a whole lot more info. For one thing its cost-benefit ratio is based 'criminal justice system costs', which is given one line and not explained further. Would any of these costs include.... locking up folks for possession? Couldn't we uh just eliminate that cost by choosing not to do so?

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"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).

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"exacerbates it, concentrates it, & on the margins makes it easier to remain an addict"

Yeah that's the key part that Matt seems to strawman a lot.

If someone was saying drugs are the primary driver of homelessness I would also disagree with that. And I would agree with Matt that housing is the primary driver.

But drug addiction and mental illness can still magnify the problem quite bit.

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This was the paragraph that jumped out at me, too. I'll just add that most things aren't monocausal. Drug addiction causes people to make bad choices that result in loss of employment and isolation from more stable friends and family. If that happens to you in a place where you and all your addict buddies can pile into a trailer on a plot of land nobody cares about, then you won't be homeless. If it happens to you in the middle of a high-COL city like San Francisco, then you might find yourself on the street.

Does that mean "high housing prices" put you on the street or was it the result of your addiction?

Surely it's both, in some sense.

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Thank you, I was hoping someone would push back against that (inaccurate) reduction of Shellenberger's arguments.

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Just listened to a Shellenberger podcast. I wouldn't say he claimed progressive policy caused drug addiction, but he very clearly articulates that addiction is singularly responsible for the homelessness problem. However, when he talks about homelessness he is really only talking about chronic, unsheltered homeless populations on the streets or "open drug dens".

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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.

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Per that link, it would require a separate vaccine for each opiate ( oxy, hydro, heroin, fentanyl, etc.) That seems like an obstacle. With methadone, a problem is that the treatment eases withdrawal but doesn't get the user (very) high. Some people then use huge amounts of methadone and overdose easily, because it causes the same respiratory effects as opiates. If the vaccines don't block those respiratory effects, then it wouldn't prevent overdoses.

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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

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Agree. The shelter I volunteer for has a subx clinic with drop in and it is very popular and heavily used but we have only so much capacity and it can be hard to find.

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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.

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I don't know. I work in a public defenders office, and I've seen plenty of married addicts. Some married before they had a habit, some after. Work does seem to make a difference, though, particularly if it's work they can take pride in.

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There are a lot of married people. But what’s the ratio of married to unmarried and who are the worst and how does it compare to the population as a whole.

My Brother in Law was a prosecutor. He recently went into family law. But we had interesting conversations. He was an odd mix of liberalism and conservatism.

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Feb 16, 2022·edited Feb 16, 2022

Some kind of community stake. The liberal in me knows the 50’s aren’t coming back, the conservative in me says “we damn well need to find *something* then!”

EDIT: and that leads us to extremely angry arguments about mandatory universal service… :p

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The conservative in me knows what it would take. But the realist in me knows that anything short of a massive cultural change is not gonna happen. It’s not just that we need work, it’s people need work with meaning. Between automation and outsourcing, combined with the easy lure of drugs, video games, and porn we are in for a rough few decades.

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I don’t think “work with meaning” is it, because it’s very hard to argue that work had much “meaning” in anything but an imagined past.

Work is a paycheck for the vast majority of people; if they’re lucky they do not hate what they do to earn those checks. That was very nearly as true in 1890 as it was in 1960 as it is today.

If “meaningful work” is the source of social stability, we’re screwed and always have been.

No, I think “a stake in a community wider than just your immediate family” is the right answer.

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We could have a long argument about this. How meaning is derived from multiple sources. What you do is just one aspect. But also why you do it. It’s an or proposition. Someone who is a cashier at a strip club might not have a job that is meaningful, but if they are doing it to support their wife and kids then it does have meaning.

I won’t disagree with the last sentence. I think we are trying to say the same thing.

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I think that, if you define "work" expansively, then these two concepts could be related.

Similarly, if you define "meaning" expansively, then the toil of yore could be construed as meaningful if you're providing for your family, helping your kids do better, and so on.

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Lol. You said the same thing that I did.

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Having just had a nice fun discussion that reminds me how utterly batshit the reactionaries are, I'm going to take a hard, hard pass.

Religion and traditional values (whatever the fuck *those* are) are not the answer here.

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Feb 16, 2022·edited Feb 16, 2022

"Oh yeah, we added women to the workforce rather abruptly - did it work the way we hoped it might?"

If you ask this in mixed company you deserve whatever harm comes your way.

Yes, rapidly doubling the size of the labor force assuredly impacted wages and wage growth by increasing employer bargaining power.

But only a profound misogynist could possibly believe there was any alternative.

That “addition to the labor force” was made up of tens of millions of individual people who should always have had rights *and* societal norms that would support their freedom to join or not join any profession they choose.

Wage effects be damned, no one should be willing to grind them in the gears of “societal stability.”

You can ask that question if and only if you support forcing *men* whose wives have careers back into the home to support them to maintain worker bargaining power. Otherwise, shush.

Women are not responsible for a bunch of men deciding to wreck themselves because women gained the freedom to tell them to get fucked and turned out to be better at their jobs.

EDIT: this is the single most woke thing I think I’ve ever said.

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"But it can be said, Larry Summers says, "maybe girls process math differently than boys" and gets fired. Meanwhile, the whole industry basically changes its behavior to recognize the potential of this. And, like I said, a decade earlier this was totally not controversial."

I have been working my way towards a general principle in this sort of context.

If you say something that is not bigoted, but which bigots might agree with, then it is your responsibility to phrase it very carefully to make it clear that you are not making the bigoted version of the point.

Like "The Israeli government and military treat Palestinian people unjustly under the occupation" is a reasonable point. But there are lots of ways of making it that antisemitic people will capitalise on. For instance "Israel is killing children", which would be routine anti-war rhetoric about other countries, ties into the Blood Libel when used about Israel, so you have to make the point in other ways.

So, if you're going to say "maybe girls process math differently than boys", then you need to say "not worse, not better, just different; and by not worse, I mean 'equally effectively'".

Also, Summers didn't just say something that can be easily reduced to "maybe girls process math differently than boys". His third point could, very generously, be reduced to that, though "maybe girls aren't as interested in math as boys" is, at least, equally fair. The second could be reduced to "maybe the best girls just aren't as good at math as the best boys" (it was an argument about standard deviation rather than about means, which is why I reduced it to "the best" rather than "girls aren't as good as boys"), and the first was "fewer women want highly-demanding jobs than men".

I can absolutely see that someone who was very conscious of the issue that you raise (as you clearly are from your background) would hear or hear about the Summers speech and conclude that this was the important part of it and that people objecting to the speech had to be objecting to that part, because that was the important part.

But that's, well, not what he said. This is (quoting from the speech), his own summary of his point.

"So my best guess, to provoke you, of what's behind all of this is that the largest phenomenon, by far, is the general clash between people's legitimate family desires and employers' current desire for high power and high intensity, that in the special case of science and engineering, there are issues of intrinsic aptitude, and particularly of the variability of aptitude, and that those considerations are reinforced by what are in fact lesser factors involving socialization and continuing discrimination."

So, no, I don't think Summers was fired for saying "maybe girls process math differently than boys", because he didn't say that, he said something very different and something far more objectionable.

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Know your audience.

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How about this (super vague idea incoming):

At some point it becomes obvious that overdoses are a bigger health problem than covid was (I posed numbers elsewhere in these comments). And that's just the health aspect. Add in the societal damage and it's not even close.

When that's widely acknowledged, then maybe NYTs-liberal America starts getting full-on judgy-puritanical shaming attitude to hit the problem from the left (oh, you had a little coke? are you literally trying to kill people in Mexico?)

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Replying to wrong comment?

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deletedFeb 16, 2022·edited Feb 16, 2022
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Sometimes you just have to assume good faith. I don’t think it’s ridiculous to assume that people are talking about good marriages.

And yes. Polygamy is bad. On an individual level it’s not. People loving people is good. But something that is individually good can be bad as a whole. It’s like Asimovs three laws of Robotics. Eventually there had to be a 0th law putting humanity as a whole above the individual.

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Polygamy works out fine at the societal level if there are as many women with multiple male partners as there are men with multiple female partners.

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Communism works if people prioritize the greater good more than personal gain.

It’s hard to fight thousands of years of evolution and culture.

The problem with the multiple male partners is the bottleneck of reproduction.

Only one dude is going to be the father of any baby.

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I think you seem to be assuming that this is theoretical.

Go ask modern polyamory communities and they will very strongly respond that there are not big differentials in the sexes - they might tell you that the stereotype is that there are more women with multiple men than the reverse, though when statistical evidence is collected it tends to be closer to 50:50 than people in the communities think.

And, uh, if evolution and culture were so strong, then there wouldn't be nearly as many gay people as there are.

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It’s one reason why I like this comment section. A wide variety of interesting views that tend to address the issues instead of getting caught up in straw man arguments or taking things out of context.

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This dovetails really nicely with yesterday's article. Yes, social media has created different challenges that we'll have to discover how to properly handle, but I too am optimistic we'll get there, even if it's a long and tricky path to get to.

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I am optimistic as well. But there are always people who will suffer in any society. We need to be empathetic and attempt to mitigate their issues.

I’m on my way back to Boise today. Finally!

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Excellent! We're getting a dusting of snow this morning, but this weekend is looking, by February standards, like a beautiful one to take advantage of some outdoor activity.

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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.

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I can actually provide some context here as an anesthesiologist (not pain management boarded but we get continued education from our department's pain management division). There are only so many receptor types that can provide analgesia and many of them hit the same addiction neutral networks. The new innovations in pain management are actually mechanical (well-placed spinal cord and peripheral nerve simulators and such). No opiates, just electricity. For acute pain management (like surgery), regional anesthesia has exploded in popularity with the improvement of ultrasound imaging and is used in conjunction with multimodal analgesia (acetaminophen, NSAIDS, ketamine, alpha-2, neurontin). Unfortunately, opioid-free surgery is still very difficult to accomplish in most cases despite our best efforts (in fact is probably counterproductive with current tech). We have a lot of helper meds but opioids are still our best pharmacologic weapon by a wide margin.

Cannabis has been studied for pain but the results have been underwhelming. Probably works for some people but not to the degree that optimistic proponents expect. Caffeine may also have some positive effects (it's long been present in Excedrin and Fioricet, for example) but still just a "helper." Kratom is interesting because it hits a lot of receptor types at once so it's a natural multimodal analgesic but, to my knowledge, isn't hitting anything unique.

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My understanding is that what makes Kratom unique is not what it hits but what it doesn't hit. It is able to act on opiate receptors without causing a significant risk of respiratory depression, even at relatively high doses:

https://www.sciencedirect.com/science/article/abs/pii/S0028390817303933?via%3Dihub

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I thought caffeine’s effect in painkillers was to dilate capillaries to improve blood flow and medication delivery? Incorrect?

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It's an adenosine antagonist. Here's a pretty accessible review. Its vasoactive effects seem to specifically help migraine, though.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5018099/

Interestingly, we use epinephrine with local anesthetics (like lidocaine) using the same principle you describe, but in reverse. Epinephrine constricts vessels that would otherwise take the anesthetic away from the nerve. Keeping the local anesthetic hanging around prolongs the numbing effect. The mouth is highly-vascular which is why dentists use epinephrine in the mix (also can reduce bleeding as well).

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If you read Dreamlands, you’d know the US has tried and it’s hard. The addiction seems to be inherently linked to the pain relief.

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Isn't the addiction and pleasure enough? Why does there have to be a problem that needs fixed?

My one experience with an opioid was vicodin, which I was prescribed after my wisdom teeth were taken out. I remember it as one of the most incredible feelings of my life, and I was happy that that the prescription was for only 2 weeks because if it had been prescribed for a full year I might have kept taking it.

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That's so interesting. I have also had pain meds a couple of time for procedures/injuries of a similar magnitude, and I didn't have this reaction AT ALL. I have never finished a prescription for pain meds, even though I am a baby about pain. I really, really dislike the feeling of being "out of it"/not in control so I drink very little and have little interest in drugs (other than the occasional microdose of edible cannabis to help me sleep).

I can understand the need to control pain - as an aside, we had a terrible time getting refills of my mother's pain meds when she was dying of lung cancer when the opiod crisis was beginning to come into view - but the addiction/pleasure part I can only imagine, and it's hard to do because my brain doesn't work that way.

So I'm finding this comment thread especially interesting (fortunately, it's a slow day at work).

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Feb 16, 2022·edited Feb 16, 2022

I actually find your comment interesting for the same reason. I guess I've heard somewhat similar things from other people but you spelled it out really clearly. It almost didn't occur to me that it wouldn't work on others the way it worked on me. It's kind of scary to me being a parent that whatever part of my brain that loved Vicodin is probably being passed to my kids.

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I think you never know. My Irish grandfather was an alcoholic who embodied every aspect of the cliche. My mother, the youngest of five, was frequently tasked with picking up the pieces, but he did things like jump out of a moving car when it was passing his favorite bar and drive through a fenced backyard to evade the blockade set up in the driveway to keep him at home.

My aunts and uncles, all of whom grew up in this household, vary considerably in their approaches to booze. My mom didn't drink a lot; an aunt loves her wine but doesn't have a problem with it (doesn't drink and drive, isn't a sloppy drunk, she is a social-working nun); another uncle and his kids drink a ton - they show up to a morning event in tracksuits with a cooler full of beer - but they have remained nominally functional and he has somehow outlived my mom, who quit smoking decades before she got sick, by a long shot. Nobody is or was like my grandfather.

My sister is similar to me, despite our genetic heritage (our father drank a fair amount, but not sure how much was owing to the "Mad Men" era), and few if any of my many, many cousins seem to have any substance issues. I grew up making my dad martinis (plural!) when he got home from work. When I was in high school, my parents were the most permissive vis-a-vis booze - I tried various kinds of wine as well as those martinis, and didn't like any of it - but I got into the least amount of trouble.

So you might not have much need to worry, especially since you're modeling a good example for them.

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I think all drugs can appeal to some folks more than others. I also do not like opioids. The spaced out feeling just feels vulnerable not fun. My husband is the same way but when he had to take them for a long period after two shoulder replacements and then stopped he went through some pretty painful withdrawal symptoms. But I have definitely enjoyed the ampted feeling of a Claritin D just a little too much which is why I opted for Welbutrin instead of aderall for my ADHD. I think I could be a speed addict way more easily than an opioid addict.

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I *hated* Vicodin. It made me feel like I was comatose even though I was conscious and moving, talking, etc.

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I mean, Kratom's already widely available in many gas stations and every dodgy 'smoke shop' in America, not to mention online. If people want to use it, it's already out there for them

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founding

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.

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My understanding is COVID made just about every form of social ill worse. I link below to a UK report within weeks of lockdowns being imposed citing a global increase in domestic abuse. That doesn't mean the interventions were a mistake. However, efforts to account for those costs should have been made when making cost-benefit decisions and if they weren't, that is a mistake. Certainly at this point it would be disappointing if they are not.

https://publications.parliament.uk/pa/cm5801/cmselect/cmhaff/321/321.pdf

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Had there been no government interventions, plenty of people would _still_ have decided to stay in and avoid contact with others.

Others would have died and their families would have grieved.

The mandated NPIs probably increased some/many forms of social ills over no-NPIs+Covid, but some of it was also just the virus killing/scaring people.

I agree with Binya that I don't think the social ills were considered enough in the cost/benefit analysis of mandates, but NOT all the cost came from the mandates.

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founding

I agree with you that people's behavior was not only (or even primarily?) driven by government interventions, except for kids in school. However, I would argue that news reporting which minimized or obscured the vast differences in age-related lethality drove fear in a way that was disproportionate to actual risk profiles.

The result (in my view, subject to change based on data), is that the COVID response will needlessly impose a long-lasting negative response on younger people.

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Link? I believe it, but the research would be nice.

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Two points in the paper I think are important

- They count total deaths, so the "flatten the curve" model where you slow the spread and keep ICUs running but the same number of people get infected eventually is not counted as a success.

- As a previous commenter pointed out, people take voluntary isolation measures anyway, so the control group of "no lockdown" is still not business as usual. I think it just says that the government declaring which businesses were essential was ineffective on top of what people were already doing to reduce their risk.

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This is a bizarre take. "Experts" don't make policy; that is what politicians do. I don't know any "expert" who liked the Trump administration's initial response to Covid, and even the clown show that was CDC guidance on masking was downstream of what the political appointee surgeon general in that administration wanted. Ditto for Iraq; President Bush and his team were extremely clear about their desire to do regime change in Iraq long before any "expert" consensus on the subject.

I say this with a tremendous amount of humility, because I am in some sense a public health "expert" (although I teach, rather than do policy): experts are downstream of the decision-making as often as they are driving it, and on the biggest questions, they are much more likely to be on the receiving end than on the policy-making end. They may offer suggestions, but implementation is a predictable game of telephone with the results you would expect. That's just life in a rough-and-tumble democracy.

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Feb 16, 2022·edited Feb 16, 2022

I think you have to understand that the worst crime in the eyes of some Slow Boring subscribers is making an upper middle class person think about the consequences on others of their actions or god forbid do something that they don't want to, and anyone associated with that even tangentially is regarded as beneath contempt.

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Actually, the worst crime on Slow Boring is asking "can we eat outside today? It's so nice!"

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Boy, the pandemic utterly ruined the hottest of Matt's hot takes.

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Feb 16, 2022·edited Feb 16, 2022

I’ve no interest in repeating the same argument endlessly. I think the repeated attacks on the public health community are contemptuous and I’m expressing that view.

Personally I’m very grateful for the various experts who produced vaccines in record time and organised their administration to hundreds of millions of people

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This is true on Iraq. Most of the dreaded natsec blob was pretty ambivalent about the war. The CIA's initial assessment doubted that Saddam had a real nuclear weapons program. The war was fundamentally a political project, led by ideological political appointees who exerted a lot of pressure on the bureaucracy and the establishment to go along with them. Brent Scowcroft, whose picture could have been in the dictionary next to "establishment," was famously declared persona non grata in the administration for pushing back.

In the end, the establishment obviously didn't push back hard enough. They didn't think it would be the disaster it turned out to be, and they were deferential to the politicals. But the idea that the establishment actively *wanted* to invade and *led* us into Iraq is rewriting history, and unfortunately I've been seeing it from commentators all over the political spectrum lately.

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Iraq is a great example of what I'm talking about. If you look at the actual play of events, very, very often you will notice that "expert" consensus tends to coalesce around some version of what policymakers decide. Half of your "experts" will advise doing something two notches to one side of the policy ("it goest too far!"), and the other half will land two notches to the other side ("this isn't going far enough!").

Bush, Cheney, et al. did not get excited about regime change because they were reading Foreign Affairs. And a million hot takes in WaPo, the NYT, and CNN did not flower until after the Bush administration telegraphed its interest. I assume you are too young to remember the debate and events around it, but I can assure you, as someone who lived through it, that Republicans had been kicking around the need to "do something" about Saddam basically ever since Gulf War 1, in part because we (yes, I voted for W the first time, back when I was a die-hard Republican/conservative/evangelical) remembered so fondly Operation Desert Storm, from the good ol' days, back when men were men, before Bush 1 gave in to the cowards and stopped at the border of Iraq, and...I digress.

And so it goes. Go back and look at the mask debate--really, really look at it. The dirty secret of "experts" is that it is a far less meaningful category than people assume, for all kinds of interesting sociological and political reasons. The fact that you were forced in the end to say, "See! Some folks in San Francisco and Ontario did stuff!" is the whole ballgame. What you did not say was, "People at the highest levels of government, where it was possible to make a serious dent in the pandemic, were driven exclusively or even just primarily by carefully considered expert opinion garnered by consensus from the top people in the airborne infectious disease and pandemic response domains." And you didn't say that because it is not true, anywhere.

What you're left with is some folks at the local level WHO PROBABLY SPECIALIZE IN HEPATITIS OR DRUG POLICY (because you may remember that little opioid epidemic that we were worried about...) making Covid policy and a bunch of people whose "expertise" is speaking on TV or writing newspaper columns who knew what to do in Iraq after Bush made the policy. And that's where the expert argument goes to die. And this is bad! I don't like this state of affairs!

But it is what it is. The world is complicated.

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founding

Isn’t San Francisco one of the places that has gotten through the pandemic with both the least medical problems caused by infections and the least socioeconomic problems caused by the interventions? Seems like they’ve actually done it right when they gave public health authorities the power rather than mayors and governors.

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Well, they kept schools closed for 15 months, with unknown effect as of now, but likely not good ones.

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Feb 16, 2022·edited Feb 16, 2022

I've re-read this and I honestly find it curious how anyone could come to this view. I don't know the details of US public health. I've seen Fauci speak plenty though. The idea he is part of a tyrannical elite that's intimidated all dissent, and which actually itself needs silencing, I really have no idea how one comes to that view. He seems to be doing a normally competent job (i.e. including plenty of mistakes), while having his family's life threatened by anti-vaxxers.

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I think some parts of this are spot on but some parts may be way off.

One stat I keep coming back to is suicides. Suicides actually went down just a little bit during the pandemic. If the underlying driver was pain and mental stress then we would expect suicides to go up, right? Another one that I don't cite as much (because I don't have the stats at hand) is consumer debt stress, which I understand went way down as people at the low end of the SES scale had more money during the pandemic than before.

My strong belief is overdoses spiked because of 2 other pandemic related changes: #1 prisoner releases and #2 all the extra covid relief and unemployment money. #1 is a well-known overdose trigger as people get out of prison some of them will hit drugs really hard. #2 made it possible for addicts to buy a bit more drugs than they did pre-pandemic.

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We (commenters, collectively) have had this argument before, and I've made this point before: covid restrictions kept people out of in patient drug/mental health treatment, reduced prison/jail populations, and cut back on in-person drug testing through probation and the like. I think that, more than any general increase in stress, despair, or ennui, led to increased overdoses and associated problems.

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founding

When I look at those charts, what I see is a temporary slowdown for everyone in 2018-19, that is overlaid on another trend where all non-white groups had been accelerating their growth faster since 2016 or so. 2020 was just a return to the trends of 2017, with all groups at a higher level.

It would be interesting to see someone try to actually make the case that some of this can be attributed either to the virus or to the mitigation efforts, but I haven’t seen anyone make a good-faith attempt to try to separate these effects. And in this case, since the growth rate for everyone is basically the same as it was just a couple years earlier, it’s implausible to suggest that very much of it is due to the pandemic (unless we can explain the slowdown in 2018-19 and show why the pandemic and/or response to it stopped that slowdown).

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A lot of times differing ethnic rates are actually caused by regional patters. If something is hitting the SW hard, it's easily confused with something impacting Latinos nationally. Ditto with the SouthEast and Black people, or the upper midwest and Appalachia and white people.

I think that's some of what happened here, because the big increases of the past 3-5 years have been in the west and south. This page has a map with the last 1 year increase:

https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

My understanding is this happened because dealers have begun more and more to sell white powder heroin East of the Mississippi, whereas previously it was mostly just sold in the North East. White Powder can be cut with Fentanyl whereas the black tar form of heroin can't. Black heroin has been the majority of heroin on the west coast.

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founding

That makes a lot of sense. It would be interesting to have these regional, or state-level, or county-level numbers for the past several years, to see if it sheds any light on why the growth rate decreased so much in 2018-19 (and even went negative for some groups) before returning to trajectory in 2020.

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The CDC Wonder Underlying Cause of Death Database has that all available and one could check all the regional / ethnic patterns for clues. Maybe I'll get around to it

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Feb 16, 2022·edited Feb 16, 2022

> 2020 was just a return to the trends of 2017, with all groups at a higher level.

You're correct there was an upward trend prior to covid, and it is important to recognize that sans Covid overdoses would still be at a higher rate than they were in 2019.

But you're taking argument this way too far. It's clear from inspection that the slope in the 19-20 interval is significantly steeper than any prior interval - for every single group! The article Matt took the visualization from states outright: "While overdose deaths in the U.S. were on the rise long before the outbreak of COVID-19 in March 2020, such fatalities have accelerated during the pandemic, the CDC has noted."

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founding

The graphs all look pretty exponential, apart from the pause in 2018-19. I would want to see this on a logarithmic chart to know whether the greater steepness is just exponential growth with the same base picking up again starting from a higher absolute rate, or whether there was actually a change in the base of the exponent.

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From 2019 to 2020, the number increased from 70630 to 91799, a 30% year-over-year increase. This is the largest year-over-year percentage increase in the dataset. For reference, the second largest was from 52404 to 63632 in 2016, a growth of 21.4%, and third largest was 21.2% in 2001.

https://nida.nih.gov/drug-topics/trends-statistics/overdose-death-rates

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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

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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.

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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.

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This aligns with one of Shellenberger's ideas (and what Darawk gets at below) which is to send addicts to a treatment center far removed from the streets where they can spend time receiving wrap-around services to (hopefully) be able to re-enter society. But that would require cities to recognize and treat them as addicts, not victims of abstract, structural economic forces.

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If you happen to check out the Lancet /Stanford commission study that Matt cites it seems to have this problem. Reading it I get the impression that addiction strikes people randomly like cancer or strokes. It's all about how doctors need to treat addiction as a disease, which is fine as far as it goes. But it's not the sole way society needs to look at the issue.

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I have spent many mornings volunteering at my local shelter calling every impatient detox place in King County to see if they have an open bed so that I can try to get maybe three of the two dozen folks who show up in the morning wanting to get into detox. The rest have to wait and try the next day when many don't show up because their window of having hope or recognizing their worth has closed. Our drop in clinic for medically assisted addiction treatment is open four days a week and we have never had an unclaimed appointment. I have had folks on the street, often freshly freaked out by a recent near OD ask me to help them find any kind of bridge to treatment. There are lots folks out there who don't want to get clean, think that they are unable to get clean, or don't think they are worth the effort. But there are also a lot of folks who desperately want to get clean and don't have sufficient access to treatment when they are ready for it. Even those who do almost never get a gold standard of care with sufficient impatient supports. It can feel perverse to chase folks to threaten them with jail when they aren't looking to get clean while we aren't offering services to those who want them.

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This squares completely with darawk's point below (or above, whichever way it appears to you)

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“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/

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Ah, now I'm sure it's Chesa Boudin's* fault!

*First held elected office in January 2020. The guy works fast!

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I didn’t take that to be a literal accusation. But it’s certainly true that he hasn’t done his job.

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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.

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"No, it isn’t kale, it has side effects and you might get lung cancer if you smoke it long enough..."

You talk as though kale doesn't have side effects. Or cause lung cancer if you smoke it long enough.

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I’m for legal weed but is there any evidence that people are substituting it for opioids?

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I am against legal weed. It’s long term negative effects are underestimated. But the genie has been let out of the bottle.

Sure weed should be legal. But individually I view weed smoking on anything other than an occasional basis as a personality flaw.

Yes. I know that makes me a curmudgeon.

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Yeah I definitely don’t think smoking every day is good for you but it’s perfectly legal to drink every day and that seems to be worse so if we’re allowing that we should legalize weed too. Some people are going to abuse it but it’s not like there weren’t stoners before legalization and if on the margin some people switch from alcohol to weed that’s probably better for public health (e.g. people start fights when they’re drunk but they order pizza when they’re high). Everything in moderation.

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I’ve seen data supporting this in the past, which is the biggest reason I support marijuana legalization despite the downsides of doing so. The data suggested not that pot is a substitute pain reliever, but more that some people are just going to use drugs and having more relative supply of less harmful drugs leads to some people not escalating to opiates. I’m sure that it’s not 100%—some people start in canniboids and then escalate to opiates —but the net impact is positive.

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My issue with weed is that the negative effects are more insidious. Being drunk is visibly and immediately bad. At least done to extremes. Whereas weed is dangerous in a way that the people who are suffering from it’s deleterious effects (lack of motivation being key) are unaware.

Reading between the lines. You smoke week occasionally (just nod) but you are also an outlier. A highly successful and smart dude who works out and is probably pretty socially skilled.

It good to s back to a point I made earlier where something can be good (or not bad) on an individual level but still be bad on a societal level. My example was polygamy. It’s good for people to love each other. But polygamous cultures have big issues.

And I hope u are trying to get Matt to talk about his gym routine!

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I agree that having a weed problem is less noticeable/more socially acceptable than having a drinking problem, at least in my circles. But I think you're underrating how many heavy smokers are aware that they have problems. It's like cigarettes — plenty of people will say "I should really stop smoking" but then just have a hard time quitting/reducing their usage. But they're very much aware that their usage is negatively impacting their lives!

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"I am against legal weed....Sure weed should be legal."

So, I assume you mean something like, "I am against anyone's using weed, but I am in favor of weed's being legal"?

'Cause usually when people say, "I'm against legal weed," they mean, "I think weed should not be legal." If you meant that, it would sound incompatible with "Sure, weed should be legal."

But if "against legal weed" simply means, "no one should use it, despite its being legal," then that's a position I can understand. Heck, it's how I feel about lots of things -- weed, SNL reruns, leisure suits, you name it. They should be safe, legal, and *rare*.

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You have me. My weak comeback would be. If I was against weed being legal… I would say I am against weed being legal. For instance. I believe that people should have the right to say stupid things. But I against people saying stupid things.

But honestly. Good point.

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No, no -- I was not trying to play "gotcha".

I was trying to get you *out* of a contradiction, not convict you of one.

But now that you've had a chance to reflect -- do you come down more on the side of thinking that weed should be legal, or thinking it should not be legal?

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I am mostly agnostic on the issue. If you had to press me… I think the negatives of illegality probably slightly outweigh the negatives of legality. But could easily change my mind with data.

I have many loved ones who smoke week. I don’t want them to go to jail though.

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I havent run a regression, but the map you compiled from the CDC data seems to make my point. The western states have more dispensaries and much smaller increases in opiate deaths.

I’m not sure the causation would be people giving up opiates and lighting up. It might be that people don’t get hooked on opiates in the first place because they have pot to manage long term pain.

If you forward me the CDC data and I can get it into a spreadsheet, I’d love to toy with it once my jury comes back.

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The reason the Western states have lower OD rates is related to the heroin supply. In the NE heroin is in a white powdered form that is easily cut with fentanyl. On the left coast they use black gum / tar heroin that can't be mixed with fentanyl. In 2020-2022 that's slowly changing and west coast OD rates are catching up

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On the west coast fent deaths are usually from folks using fake pills that have fent pressed into a carrier medium rather than actually being cut with heroin. That is resulting is a lot of deaths from younger earlier users actually who are more likely to view a vicodin they are given at a party as safer than shooting up when that may not be the case any more.

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Massachusetts has legal weed, and it has certainly had no effect on heroin use. Nebraska does not and has the lowest rate in the country.

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This is an intriguing hypothesis; it passes the initial smell/BS test. I would love to see what you come up with.

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Cannabis isn't nearly as effective as opiates at reducing pain. Might have an adjunct role that could reduce opioid requirement but is not remotely effective as a substitute.

Interestingly, my patients who turn to street drugs for acute pain often take meth. Don't know how effective it is or if it's just what was available, but it's enough to see a pattern.

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For folks living with chronic homelessness meth can seem like a good short term plan. It costs like $5. It makes it so you don't feel cold and don't need to sleep. You are not hungry and are sufficiently disassociated from your body to feel less pain and discomfort. It is also about the worst drug you could possible take in terms of long term impacts and incurable addiction. But the appeal is pretty understandable.

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