Are the people in Middletown, Ohio “killers”?

As their budgets strain, communities have begun questioning how much money and effort they should be spending to deal with overdoses, especially in cases involving people who have taken near-fatal overdoses multiple times. State and local officials say it might be time for “tough love”: pushing soaring medical costs onto drug abusers or even limiting how many times first responders can save an individual’s life.

“It’s not that I don’t want to treat overdose victims, it’s that the city cannot afford to treat overdose victims,” said Middletown Council Member Daniel Picard, noting this industrial town in northern Butler County might have to raise taxes in response to the crisis.

Often, the only thing separating whether an overdose victim goes to the hospital instead of the morgue is a dose of naloxone, also known by the brand name Narcan, a medication that can reverse the effects of opioid overdoses.

Two doses of an injectable form of naloxone, Evzio, cost $4,500, up from $690 in 2014. The price of other forms of the drug, including the nasally administered Narcan, typically range from $70 to $150 per dose, officials say.

…Here in Ohio, first responders say it’s not uncommon for overdose victims to have previously been revived with naloxone at least a half-dozen times.

…Picard, the council member, has proposed a controversial three-strikes policy in which first responders wouldn’t administer Narcan to repeated overdose victims.

Here is the Tim Craig at WaPo story.  I do not know what is the proper response to such opioid cases, or how much money should be spent.  I do know that somewhere, somehow a line has to be drawn.  And if you are reading a discussion of health care policy that does not acknowledge such a line, and set out possible standards for it, beware of sophistry and illusion.


0 strike policy would be much more effective.

Yes, that's exactly the message i tried to pass in the bible! "No mercy for sinners!"

Not entirely obvious that using heroin is a sin!

Cuz everyone overdoses their first time on heroin, there was no way they could've possibly realized they made a mistake without first overdosing. Thus we have to cut road, health and school funding for everyone because each time one of these deadbeats tries to kill themselves it costs the same as half a year of school for a child. I wonder what the bible says about letting anti-social people destroy society.

Oh you're so right, totally the exact same situation. I'm such an idiot. Jesus's heroin was god, they don't call religion the opium of the masses for nothing.

Well, lets be clear - they are all deadbeats, otherwise they would pay for their own roadway, healthcare, and educational use in cash at the time of service.

Probably those of us who are responsible will have to kill everyone who ever willfully used a government service; the ironic thing is the heroin users might fight on our side.

Hi, Jesus. It's me again.

I know You love the bastards that scorn, caricature, and repudiate You; then use Your Holy Name for a political weapon. Me, not so much love. I'm working on that and I need Your help.

Oh! Are people in the UK murderers because they will let Charlie Gard die?

"then use Your Holy Name for a political weapon."
You can only make it if you are Republican and/or makes lots of money out of it.

Charlie Gard can't be cured no matter how much money you spend. An overdose victim can be cured for a few thousand dollars. No comparison between the two.


Especially in the Old Testament, the Father of JC was a tough love disciplinarian.

somehow you all missed the fact that a 0 strike policy is preemptively punishing everyone.

No, it is not.

Original Sin

In the story it mentions that a large majority of overdoses are 1st time overdoses, so the law wouldn't apply to them-so the proposed law isn't going to save them much. Perhaps what they need is the ability to import generic naloxone at a fraction of the cost.

Nice spot. Another solution, without reading the article, is to make attempting to overdose or actually overdosing more than three times a capital offense, with immediate execution. However the US Supreme Court would likely strike such a law down as unconstitutional, and thus society would be forced to warehouse these suicides at a greater cost than the cost of the drug.

TC's trolley philosophy example!

It's accelerating the "running out of other people's money."

America is not "serious" about the burgeoning opioid crisis.

The voters need to decide more whether money spent on canceling losers' Darwin Awards is beneficial to the Commonweal.

Another thought: order police officers to shoot at pushers on sight.

Or, introduce the Ian Fleming "00", license to kill concept to the so-called "war" on drugs.

Never happen. The powers that be are not "serious" about ending this crisis, or any of the others, for that matter. .

Yeah, the Supreme Court tends to look down on capital punishment without trial.


Seems to me scotus is in favor of private executions without trial. What other purpose do unfettered gun ownership have but more bullets to the brain private solutions to all sorts of problems?

US vets have high self execution rates, often with guns, but many with fentanyl hotshot. For many using guns, they relieve society of the burden of their family by killing the family as well.

Logically, bullet to the brain is required by conservatives arguing the young should never pay for the costly old. Only a bullet to the brain prevents the young become old and thus forced to pay the cost of the old. Bullet to the brain at 25 means you remain forever young.

The Republicans have written into law huge penalties on the young for failing to put a bullet in their brain. Insurance premiums of the young increasing 10% a year as punishment for living a year longer, for failing to self execute.

Anyone who ever purchases insurance should kill themselves immediately. I strongly suspect the rest of us will live to 100 with very low medical costs, and about 100 other problems will also fix themselves with the irrational and stupid gone.


Think we found the drug user on the thread.

Administering nalaxone is not that costly; it's drug treatment that's both fantastically expensive and offers only dismal long-term success.

If there's going to be rationing (as there must be, at some point) it would seem to make more sense to try to reserve costly treatment to those likely to benefit from it (probably because they've truly "hit bottom" and are highly motivated) than to ration availability of nalaxone?

Protecting the extraordinary rents of pharma cos over saving lives of ordinary Americans is what makes libertarianism such a popular credo in American politics. +1 for authorising generic naloxone asap.

Ordinary Americans that overdose on heroin multiple times a year...

Exactly, pharma profit is much more important!

Pharma "profit" is not much more important, but ignoring the consequences of making America a less profitable market is dangerous. I don't think we should be subsidizing pharmaceutical innovation for the rest of the world, but the trade off isn't "people die of overdoses and stockholders get a better return" or the inverse.

The drug obviously is generic. Some asshole must own a patent on a delivery device.

Very likely true, but not the only possibility.

For example the combinaton of the treatment + the delivery device might be a package that requires separate regulatory approval, and only one vendors combination has gone through those hoops so far.

Other stories can be imagined.

Tell me again how pharmaceutical companies gaming the regulatory system to extract big extra profits is an indictment of libertarianism....

Why not just read the Middletown announcement as a negotiating ploy aimed at getting a reduced price for the drug? Surely the "line" to be drawn is not number of offenses but dollar cost.

Prison, apparently, is no longer an option. Legalize the drug if you wish, but punish (let's prefer "forcibly restrain") abusive consumption of social services.

Why not just read the Middletown announcement as a negotiating ploy aimed at getting a reduced price for the drug? Surely the "line" to be drawn is not number of offenses but dollar cost.

Prison, apparently, is no longer an option. Legalize the drug if you wish, instead punish (let's prefer "forcibly restrain") abusive consumption of social services.

Curse those dastardly libertarians and their reverence for highly regulated monopoly medical products and services!

+1, a tough love approach would work better.

Contrary to common myth, withdrawal from opioid addiction is not any worse than having the flu. The indulgent attitude has, by promoting continued use, probably killed a lot more people than it has saved.

" withdrawal from opioid addiction is not any worse than having the flu", of course, I wrote that on the genesis, page 717.

Sir, you weren't alive in Genesis. And don't to duck the issue by bringing your dad into this.

Here's the gotcha for stupid hypocrites like this:

The left scorns, caricatures, and repudiates Jesus then uses Him as a political weapon. That being said (trite), the right is equally wrong when it weaponizes Christ.

The Holy Trinity is a mystery beyond my fallen (and dull) human reason. I'm unqualified to comment on it.

I think the Gospel of John's proem intentionally imitates the beginning of Genesis to indicate Jesus (the logos) was there.

Yes, but at that point he hadn't learned carpentry or writing yet.

Ah, another liberal takes a fifteen minute break from denigrating Christianity to try to use it as a political weapon, citing what's supposedly "on the genesis." You can save it, as I'm an atheist. You guys think you hate the religious right? You're going to really hate the secular right.

Trump 2020.

"You guys think you hate the religious right? You’re going to really hate the secular right. Trump 2020."
I thought he was a Christian. He got Dobson's personal Chrisrian stamp of approval. How many Christian can say the same? Obama can't and he actually spent years going to church (but apparently not paying attention to Reverend Wright's sermons). It must be wonderful to be an atheist and share the ship with Dobsons, the Grahams and Falwells of the world. I always pitied people who were economists and had to work with the right (economists in Brazil's Workers' Party for example), but by comparison, it seems they have it easy - leftists at least can agree money exists.

"t must be wonderful to be an atheist and share the ship with Dobsons, the Grahams and Falwells of the world"

And democrats share the ship with the CPUSA. Point?

I am not sure more Democrats have noticed the CPUSA since the 1950s. Do Deleonists and Trotskytes threaten your peace of mind, too?

Originally an evangelical Oxford University academic and priest in the Church of England, Newman then became drawn to the high-church tradition of Anglicanism. He became known as a leader of, and an able polemicist for, the Oxford Movement, an influential and controversial grouping of Anglicans who wished to return to the Church of England many Catholic beliefs and liturgical rituals from before the English Reformation.

Actually, even on its own standalone merit, the idea that the county can save money by letting overdosing addicts die, seems questionable. What costs occur after death? How much will be spent on fostercare as an example?

>---- "I do not know what is the proper response to such opioid cases, or how much money should be spent "

well, this is a governmental/legal question. We already have basic principles with which to analyze this issue. Start with U.S. and state constitutions.

Are American & Ohio citizens born with a legal requirement to provide unlimited health care to all other "needy" persons in the nation/state?
Of course not; such a concept is ridiculous and economically impossible.
There is certainly no constitutional requirement anywhere for any such medical undertakings (but legislators rarely feel constrained by formal constitutions).

Private charity is a totally different issue, obviously left to individuals. But ask yourself ... how big a personal bank check will YOU write (right now!) to help these 'overdose' persons (?)
Would you donate 1% of your personal assets for this (?) -- how about 10% or 50%? That little decision exercise will quickly reveal your true opinion about this alleged opioid crisis and how much money "should" be spent.

No one here will donate a dime to the opioid crisis battle, despite any pretensions of deep support for that cause. ducked the primary issue entirely and launched into a subtle personal attack on me

Pretty sure thats not a county expense, but rather federal

Rent seeking in the USA - JFC

Trade Name Nalox
Manufacturer Samarth Pharma Pvt. Ltd.
Unit 400mcg
Type Injection
Quantity 1ml
Price Rupee 78

"Two doses of an injectable form of naloxone, Evzio, cost $4,500, up from $690 in 2014."

I'm sure that's just coincidence.

I generally prefer Alex to Tyler as the former doesn't inflict his opinions on matters non-economic on us!

Why stop there.

If you have a kitchen fire, and it was your fault, the firemen should not risk their life to save you.

If you drive too fast and fall in a ravine, and are in danger of being swept away and drown in the stream, too bad for you.

If you get drunk and you...well, you would never get drunk, so that example of someone rescuing you or taking you to the hospital in an ambulance isn't relevant.

What if you've already "accidentally" set four kitchen fires this year?

And each time the renovation makes it nicer.

There are four things that limit addictions.

1. societal pressure. Religious, legal, economic.
2. fear. You take this you may die, or you will end up like those lowlifes.
3. High price, unavailability. More available intoxicants become the first choice.
4. Personal choice. I like my brain, and dislike the buzz from intoxicants, even when medically required.

So you take away the first three, and you are left with however many people in your population fit in #4.

In the 90's the reality here was that if you needed medical care you would wait for months. Cancer? Make an appointment with a specialist and you were lucky to see them in two months time. But if you needed a needle to inject an illicit drug into your arm, someone would deliver it to you wherever you were for free.

The result was a decade of Conservative governments.

If as someone says, the choice is between cardiac care and overdose drugs, the people paying for it will choose cardiac care.

What if you got drunk more than once in your lifetime.

By the way, if you keep having kitchen fires, you keep paying to get a new kitchen. I thought I was making a point about social insurance and common usage of reserve resources but I guess some missed the point.

Maybe we should have a court determine, in advance, whether you get to use these resources. You get an attorney, the city gets an attorney, just to assure due process. We'll give you appeal rights before we kick you out of society.

As an attorney, this will be good for business.

"By the way, if you keep having kitchen fires, you keep paying to get a new kitchen"

The insurance company will certainly rebuild your kitchen 4 times a year. Wait, maybe not, which is exactly what we are talking about.

For an attorney you are either significantly more clueless than normal, or the exact right amount of disingenuous.

There would be ironic justice if your house burned down because the fire department didn't come to put out your neighbors kitchen fire

So clueless. I would have bet the other way.

You can be sure you'd be facing a major premium increase or a non renewal.

Republican death panels

For Opiod abuse.

Governments will spend hundreds of millions on an overpass to save a handful of lives. Billions per life fighting terrorism.

Sure there's a line. But that line is normally seven or eight figures, not five.

...Government already spent Trillion$ on its "War on Drugs" -- with no success whatsoever... and hugely destructive effects on American society

do you detect any problem at all with the social mechanism of letting politicians make such big decisions for us ??

"with no success whatsoever"

Really, you think no one was ever deterred from using drugs by the illegality and the cost caused by the illegality?

That's a funny definition of success.

Certainly, some people have been deterred. But others have been encouraged.

By putting the police and law in on drug policy, those who want to rebel end up taking drugs, as that is an easy way to do it. Once they are on the other side of the law, they often end up completely outside the system, where they are a detriment to society.

The war on drugs marginalises people and pushes them into organised crime. It increases the health cost of drugs because they are done in unsanitary conditions, while not effectively reducing usage.

It was a miserable failure on every count.

Though, yes, it did dissuade some people from doing drugs.

"those who want to rebel end up taking drugs, as that is an easy way to do it."


"those who want to rebel end up taking drugs, as that is an easy way to do it"

Would you rather they rebel by committing crimes which have victims?

"It increases the health cost of drugs because they are done in unsanitary conditions, while not effectively reducing usage."

Again, do you really think it didn't reduce usage?

We ideally need better data on the effects of illegality on consumption of narcotics. Both the deterrence effect and the countervailing "glamour" effect would benefit from some estimates of magnitude.

I'd just note that given a significant proportion of the population has done illegal drugs anyway, and a significant minority would probably never do them even if they were legal (in the same way a proportion will never smoke), I suspect that prohibition reduces the user base by a factor of 3 or so relative to the "drugs are legal" alternative. YMMV.

My personal take is that the amount consumed and number of users is only weakly linked to harm, both personal and societal. Prohibition greatly increases the harms of consumption; it funds violent criminal syndicates, fuels theft and violence, imposes deadweight costs, imposes large enforcement costs, criminalises lives which are otherwise productive, prevents effective treatment, reduces product quality and consistently (and hence accidental ODs), increases the spread of disease, and robs the state of potential lucrative tax revenue.

My suggestion for decriminalisation is that we could tolerate more users if the average harm-per-user fell faster.

You are using governments as a generic term. The spending you're describing is mostly federal. The article deals with local governments, with much smaller budgets.

In fact, when the adults are talking about highway safety or building safety or environmental safety, they do tend to use a measure of how much it's worth to save someone's life.

At $70-$150 a dose, the Naxalone has to be, by far, the cheapest part of the emergency response (far cheaper than the personnel costs, in particular). This is not an amount of money that should be leading to a 'When is it OK to just let them die?' conversation.

Note that the high priced patented thing is the auto-injector designed for lay people (the intra-nasal formulation is also pricy iirc). EMS can draw drug out of a vial and administer the correct IM dose. It's nearly the same issue as the epi-pen; drug is inexpensive but low utility bells and whistles in a gadget are patented.

The personnel costs whether they're out on call or sitting around the firehouse washing trucks. If they have to add EMT's to meet the increased demands from overdoses, that's a different story. The article doesn't mention that however.

Well, the fire department might be superfluous anyway. It's come up here on MR a few times.

True, I suspect its just too political to mention the much larger (and what I assume they are really trying to avoid) cost of the expected chances of repeat occurrences multiplied by the emergency response in the first place.

Injectible naxalone is surely no longer under patent. (it was common and had been in use for many years when I worked in a hospital pharmacy 20+ year ago.) it's also not drug without a good market. (Even it's use in hospitals is not trivial.). So, there is no reason for it to be so expensive. Why is the domestic market not working here?

Yeah, this is probably a glitch in the "markets before governments" utopia. Patents are supposed to be a deal for the common good. This is not the common good. So .. let's draw a line for who doesn't get treatment?

That may not be common good either.

I should rephrase that. Obviously patents are not "extreme free market." They are just looped psychologically into the basket of things that Americans consider "free markets" at this point in time. And many supporters of "free markets" will argue the self-injuring principle (not just here!) that they are willing to suffer for corporate profit elsewhere.

When you think about it, that is a form of altruism. A strange altruism in my opinion, but an altruism nonetheless.

(I have never used heroin, but I imagine that by the time you buy it, you are past realistic, or grounded, risk assessment.)

A real cynic would argue that it's corporate profits coming and going. First on opiate over-prescription, then on overdose treatment. Citizen as lab rat.

I am gobsmacked. I am informed below that this IS a generic drug, at $4500 a pop.

check for the patent on the delivery system. The epipen drug is generic, too. They just own the needle.

Few of you are debating the matter at hand, instead preferring straw men. Read Schelling (1968); he was a Democrat by the way. Then get back to me.

Maybe some are strawmen Tyler, but the most charitable reading of your post just comes off as you making an awkward point. It's certainly true that cost vs. benefit is always overlooked in these discussions, with people appealing to emotional principles instead. Okay fair. It's just that in this case, of opioid overdoses, the one drug that instantly reverses it all and turns a sure death into a sure survival is pretty cheap. So it's an interesting point to make, or at least an interesting time to bring it up. If there is anything unequivocally clear in our emergency costs, it's that nalaxone is worth the cost.

A more interesting point might be that nalaxone is often a restricted drug, so addicts cannot administer it to each other, requiring EMT time instead.

"Apart from the fact that an emergency responder shows up, checks a list, then watches someone die in front of them."

That happens all the time:

The argument could be made that, if the individuals continue shooting up, they have effectively signed their own DNR order.

Okay fair. It’s just that in this case, of opioid overdoses, the one drug that instantly reverses it all and turns a sure death into a sure survival is pretty cheap

That is not exactly correct it instantly makes not die then but there is a chance that will die a day, a week, a month later.

In Colorado one can get it from a pharmacists without a doctor's prescription. One lone wolf good samaratin has personally saved more than a hundred lives that way. First responders in Denver save more than 400 lives a year with Narcan.

The Sheriff in Butler County (where I grew up, as did the author of the Hillbilly Elegies) is the only Sheriff in Southwest Ohio not to have his deputies equipped with Narcan and he makes it a point to be clear that his reasons are not economic. He doesn't do it because he feels that drug users are morally weak and therefore deserve to die.

Narcan is not an edge case. Most legitimate cost-benefit studies value human lives in the several millions. Preventing an otherwise almost certain death with Narcan is extremely cheap and brings clear benefits.

tyler is ignoring the fact the the cost to save a life is way less than in almost all other such calculations and the local government is letting people die to be spiteful.

The cool green moderator post is back! Jessica McClure lives! (and has two children).

For those of you too lazy to Google, I offer this:

“There is a distinction between an individual life and a statistical life. Let a 6-year-old girl with brown hair need thousands of dollars for an operation that will prolong her life until Christmas, and the post office will be swamped with nickels and dimes to save her. But let it be reported that without a sales tax the hospital facilities of Massachusetts will deteriorate and cause a barely perceptible increase in preventable deaths—not many will drop a tear or reach for their checkbooks.” (Schelling, 1968) “The death of a single Russian soldier is a tragedy. A million deaths is a statistic.” Joseph Stalin (quoted in Nisbett and Ross, 1980:43)

Oh, now I get it. Tyler is Tyrone is Stalin! Is that it?

ten thousand difficulties do not make one doubt. It is that a less-formed artist burrows, that a greater shovels as the poet Stravinsky once said.

It may be an interesting question in the abstract but Matt above gets it right: Naloxone is yet another generic drug that was patented more than 50 years ago but whose price continues to increase because of the difficulty of introducing cheaper competitors into the market. The government of Alberta in Canada is able to supply take-home Naloxone kits at a cost to itself of only $27:

As we've discovered, it doesn't help if a drug is off-patent if there's only one licensed manufacturer in the U.S. and imports are banned. The ethically challenged single-source manufacturer can calibrate how much public outrage they're willing to brazen out and charge accordingly. No other manufacturer is going to go through the costly process of getting FDA approval to manufacture the drug when, as soon as they do, the existing company will simply drop the price back down and deny the new entrant the profits needed to pay back the cost of setting up production. And since everybody knows this, there won't be any new entrants.

You'd think there would be progressive wonks and progressive billionaires eager to show how the regulatory state can be fixed by setting up an NGO to handle this...force that single factory to lower the price. Can't Soros or Steyer, or Bernie Sanders raise enough money?

Or is the plan to fix the regulatory problem with another layer of regulatory tape to speak?

I do think all sides could agree to something like re-importation and MFN pricing. Maybe just say "for all new drugs going forward."

This is needed whether we go single payer or full-throated free market reforms.

The Progressives don't care at all. Ideologically, they support monopoly producers, which look very much like government production in socialist countries. Note that dishonest Ricardo complains about capitalism when it is his own preference and the preference of tens of millions of socialists like himself that are directly causing this.

Bernie Sanders and Ted Cruz sponsored a bill to allow generic imports from developed countries. Thomas should perhaps spend less time in foam-flecked rants against me and more time calling his local representatives asking why they have failed to address this problem with a solution such as the Sanders-Cruz bill.

The existing company will simply drop the price back down and deny the new entrant the profits needed to pay back the cost of setting up production

Wasn't this one of the purposes of Kickstarter? The community could form a non-profit to hop through the regulatory hurdles and start manufacturing it themselves.

As to Tyler's point, though, if not this instance it is going to come up someplace else: at what point do you cut things off? If the answer is "never" then your civilization goes bankrupt to be replaced by another.

Why would your civilization be replaced if it went bankrupted? Plenty of countries have defaulted, and they still exist

You're right, I shouldn't be so blithe with economic terms on an economics blog.

Defaulting on your debt can be fine. But if you don't know how to say "no" to some particular spending, essential spending in other places will get displaced. Water/sewage systems take a lot of work and money to maintain and are not easily fixed if they go bad. Crime that gets past a tipping point where criminals know they are unlikely to be caught is not easily reset. Public health endeavors and education funding lacks. When you finally get to the point where you can't pay the bill for the thing you couldn't say "no" to, it's too late, you have burnt all your seed corn long ago.

No one cares who was a Democrat. Tyler this post echoes the Bloomberg post from your pal McMegan about the Grenville fire. Handwringing and moralizing about abstract trade offs without looking into whether these specific costs are all that significant. Do any of you libertarians intend to ever have real political influence for your ideas or are you content to write impotent posts online forever? Because your type consistently picks the stupidest grounds on which to fight your battles.

Whatever you think maybe should be done with the drug price, isn't being done. And still the local government must choose, and the point remains that they are over-strained and unable or at least unwilling to meet the obligations you all think they should bear. I ask a question: are they killers? It is a genuine question. Must we always invest more in cardio rescue units, at all margins? It would indeed save some lives. Natasha makes sense, but most of these responses remain weak. It's not about whether some particular political point of view wishes to have impact, it is about figuring out the right answer to dilemmas like this.

Lol, the prior test theory of problem solving: wish the problem didn't exist. I wonder why no one takes progressives seriously.

"It’s not about whether some particular political point of view wishes to have impact, it is about figuring out the right answer to dilemmas like this."


It is most certainly is about "some particular political point of view" and that's exactly how you framed the issue -- you focused on the political entity of Middletown Ohio and the 'state & local officials' who are dealing with this decision. Whatever outcome results, it will most assuredly be a "political" decision.

Government policies and decisions are everywhere & always "political"... based upon who exercises the most power in any specific situation.

The notion that government politicians & bureaucrats objectively 'figure out the right answer to dilemmas like this' is absurd (...that's the Ross Perot view of practical government).

"I ask a question: are they killers? It is a genuine question."

Is it? Like I've said many times before the whole "hey there are costs we need to think about" argument is completely banal. Since municipal governments also don't fund emergency rooms on every corner are they killers? I mean that might save lives. I think they should administer the treatment and maybe send a bill for after the 2nd or so times. I know that in Canada, despite having universal coverage, they still bill nominal amounts for things such as emergency response to reduce abuses. But then again this whole question just boils down to "should a city keep paying for X even though it can't afford to pay for X any more?" Well gee I guess not....but what's so insightful about that question?

The thing is, whatever outrage there is about this decision isn't really about this decision, it's an outrage over the entire crisis - which I know you want to blame on bad morals which have seemingly sprouted out of nowhere. If you are upset that people are not discussing this specific municipal decision ceterus paribus in an academic way...well you're on the internet I don't know what you expect. What this is really about is the ridiculous situation we are now in where we need to accept that huge swaths of the country are simply going to be routinely ODing on opiods and are we either going to ultimately have federal funding to treat these people or we just go through a process where large swaths of the country drop dead. Was this the unwritten chapter in Average is Over?

“should a city keep paying for X even though it can’t afford to pay for X any more?” Well gee I guess not….but what’s so insightful about that question?

Because waiting until you can no longer afford something to stop paying for it is incredibly destruction of institutions.

You scream "banal banal banal" but lots of people are completely unwilling to hear this. If a majority of the people won't admit there is a very serious problem coming, stop attacking the people pointing out the problem as wasting everyone's time by saying obvious truths.

FWIW, I thought the Republicans behaved abominably by accusing Obama of creating death panels (when the entire decision was about voluntary end of life care, not death panels, but they still re-poisoned the well).

It's the trolley car problem politicians hate most - whom shall we not save. And it's about to get much more intractable. For decades the question could be sidestepped in the healthcare context. Disease response to an intervention was analogized to the variable response of barley plants to a fertilizer and all the faces of the sick were blurred into a single, faceless, average patient. For a new treatment to be approved Mr. Average under the new treatment must fare notably better overall (e.g. adverse event rates no worse than usual) than Mr. Average under the old treatment. This arrangement allowed for economies of scale even for rare illnesses since almost everyone with the disease would henceforth be given the new treatment. And that kept drug prices down from being even higher than they are.

But consider the future rapidly approaching in which politicians can no longer pretend that people and their afflictions are like Guiness' barley crops. There are immune therapies coming in which bone marrow is harvested by one group, separated by another, analyzed by a third, a new cell surface marker is proposed by a fourth, the code is engineered by a fifth, attached to the patient's T cells by a sixth and shipped back and infused by the first, who then harvests more marrow after a month and ships it off to the second who ... Even if all the people involved work for minimum wage, and all the expensive gene chips, IHC antigens and ... that are used just once are sold at cost the price will still be very high. And obviously there can never be a generic version.

Now imagine that opioid addiction is a disease and that it too is just a category for what is a constellation of individuals with similar symptoms but unique causal pathways requiring the creation and continued modulation of a patient-specific biologic. At some point even the most hardened progressive politician is going to come to the realization that scarcity will force him to decide whom, specifically, will die. And he'll have to have an argument why. That's when he'll get out of the trolley car game (but he'll take satisfaction from having gotten away with his Kobayashi Maru hack as long as he did).

Cost/Benefit is the most important part of policy making, not your feelings.

Yeah of course no one is denying the importance of cost benefit analysis you Clown but the point is utterly utterly banal.

The point is a direct riposte to the central message of the favorite ideological weapon of leftists like yourself: you always prefer spending, and spending can always save lives, so you can always paint your opponents as killers and you do, because you are a scumbag.

Thomas, honest question: do you believe that your childish, brainless, angry and empty partisan posts have any effect on anyone reading them? Do you think any "leftists" or moderates or whatevers read this stuff and go "hmmm, he's so right, I am changing my priors!".

I mean if you just get your lulz being angry and trying to be witty and signalling to other anonymous pixels that your pixels are super conservative and all, that's your right. But isn't that wasting your time?

I disagree. This pisses off the kind of people who would never vote for any libertarianish candidate: the snowflakes and the SJWs. Would it piss off the proles? Don't think so. They are libertarianism's real problem. It's absolutely correct that libertarians are cursed to "write impotent posts online forever," but for a completely different reason.

The long run problem will be solved from demand, but the short-term problem can be solved by supply.

If they let someone die because of an overdose, they of course are not a killer. They are the subject of an immovable object.

And this looks like a really good resource center for figuring out other alternatives you might have for dealing with the things you're facing: 1-877-8-HOPENY

The real economics here is (1) that horizontal fiscal externalities make it hard for local areas to raise significant funds. The federal government should be riaising the tax revenue for this and then sending it down to the states. The money in the senate bill seems to be a move in that direction. (2) ODing has no external costs--if any maybe positive since you save on future Medicare/acid and SS spending. Emergency revival services should presumably be privately provided and paid for but with Pigouvian tax to correct for fiscal externalities. (3) You would have an obvious potential adverse selection problem when selling OD revival insurance so... that gets you back to mandates or public provision. Ugh.

The federal government should be riaising the tax revenue for this and then sending it down to the states.

No, they shouldn't. The federal government could cut an unrestricted check to state governments (and states an unrestricted check to localities) to allow for the purchase of a miscellany of goods and services by governments in depressed areas absent abnormally high tax rates. Smart deployment of such premia would be for the development of public works and education, not redistribution.

Also a sickening amount of sarcasm in these comments.

Draw the line for opiate overdoses in the same place you draw the line for heart attacks.

Vancouver has safe injection sites and an active harm reduction program for addicts, and is seeing the deaths from overdose increase dramatically.

Is the availability and common use of Naxalone seen a corresponding increase in overdose deaths?

@derek: Cue to the GMU professor who advocated putting a sharp dagger in the center of an automobile steering wheel, to promote safer driving, think about it! And think about it: a one legged stool in a nitroglycerine factory that requires concentration to keep from slipping off; one false move from an inattentive, lazy factory worker and it's all over for everybody in the factory, no dosing off! And think about IT: an information technology specialist with a vial of nitroglycerine wrapped around their neck, along with concomitant hammer attached to vial and chain, and one rude response to a customer could lead to an altercation involving hammer, vial and neck in a most vile manner, talk about losing one's head and blowing one's top!

Bonus trivia: the Kingsman movie ending was really dumb. OMG youth have no taste anymore.

This is what America has become. People's desperation and disillusionment with their leaders is so big, the richest and most powerful government in the world can not deal anymore with the droves of people tryingnto end the pain.

I thought they were just trying to get stoned...

You must search the deaper causes.

My aunt has responsibility for ensuring that nuisance / hoax callers for ambulance services are cut off from service in one (rural) region of England.

It's not so much the 'cost' in pounds, but rather the opportunity cost. There are often more calls than there are ambulances available.

Admittedly they aren't usually in acute danger when they call, but they do lose the ability to make real requests in the future.

"Two doses of an injectable form of naloxone, Evzio, cost $4,500... The price of other forms of the drug, including the nasally administered Narcan, typically range from $70 to $150 per dose, officials say."

So only authorize the use of the nasally administered form. Isn't that the same solution to high health care costs that advocates of single-payer propose...i.e., "death panels"?

This is what should happen. Often in single payer systems, the patients don't even know and are not told that other alternatives exist.

"We've done all we can do" leaving off "within government allotted budgets for your kind."

I view that as sometimes a benefit: the grieving family doesn't need to make the tough call or beat themselves up.

But it also means you don't even know that there's a better drug that would work for you. (Example, in Taiwan doctors would often ask if I planned to return to the US...and then suggest some drugs to look into there that were not available in Taiwan or available at least from national health.)

Sometimes ignorance is bliss.

This is probably my biggest issue with "consumer-driven healthcare" that the Republicans say will help. People want all sorts of crazy crazy stuff because we live in a culture where TV doctors who break all the rules to save someone's life are heroes, pay no attention that the person with the saved life was an active swimmer who now has no control of his bowels. Even if it was free, a lot of it would be of negative value. And of course it's not free. (It's often hard to get out of these scenarios regardless of money: check out )

Being able to go on peacefully is one of the best things for a person and their surviving family.

@ Bill - So is there no personal responsibility line anywhere? I’m not sure if it’s the third irresponsible, same action or the tenth, but without some line it’s simply irresponsible to every other taxpayer. As this country grows more socialist and more govt heavy, there becomes more responsibility on realizing hey tax spending is the collective of all taxpayers, and compromises have to be made in how he govt spends its money. Otherwise, you eventually wind up in a Venezuela like situation, where there’s no more other people’s money to spend.

Just say no seems to be the response for you. How well did that exercise in personal responsibility work.

When it is used consistently on a societal level.

I have kids. What should I say to them? "Just say yes"? Dammit, I'm saying no.

They are sensible little pre teens. They listen when I tell 'em "just say no" to lots of stuff: scary strangers, Trump, Hillary, and especially bringing a Castroite to the house.

I've called 911 several times over the last decade. Typically, 10+ men show up 20 minutes later with 2 fire trucks and an ambulance, regardless of whether those resources are appropriate to the situation. If someone takes a ride in the ambulance (which they push even when not very appropriate), they bill you $500-$2000 to pay for the excesses (frequently not covered by insurance).

I do agree that a line needs to be drawn somewhere, but this sounds especially horrible when emergency services tend to throw away so much money anyway.

To be clear, when I say that "I agree that a line needs to be drawn somewhere" I'm not necessarily agreeing that the line is anywhere near a few thousand dollars of a drug.

Presumably, they send the extra vehicles and manpower because they are available and not needed in more urgent situations. Like the military, it makes sense for first responding agencies to be staffed to deal with catastrophies -- ideally paid for through taxation rather than "billing" people -- which means they will have excess vehicles and people around a lot of the time. Some local fire departments rely on volunteers to get around this problem but you need highly trained people for medical emergencies or worst case scenarios.

This is where the distinction between average cost and marginal cost comes into play. The marginal cost of sending a few extra salaried employees who would otherwise be sitting around reading the newspaper is $0 and the marginal cost of an extra vehicle or two is a few dollars.

Many firehouses are overstaffed and overpaid, and sometimes those calls generate overtime.

Fire trucks show up to all sorts of non-fire events because they need to make themselves useful, since we have so few fires these days (less smoking, better building codes, more fireproof materials). But even if it were free, having two fire trucks show up helps no one. If you need to get rushed to the hospital, two fire trucks blocking up traffic are a strict negatives. It's a gaudy show of force.

My father was a fire chief in Providence RI and he was among a group who decided to start charging for rescue rides because some people were calling the rescue for scheduled surgeries. They just made it a little more expensive than a cab.

‘Two doses of an injectable form of naloxone, Evzio, cost $4,500, up from $690 in 2014.’

Trump will bring drug costs way down.

Yes, they are killers and their murder weapon is complacency and a lack of imagination.

In Western Europe we do not have a system to leads to some local council having to ponder, let alone decide on, such an issue. Yet our health care is better and cheaper and in discussions of our health care policy, the issue of the monetary line hardly comes up. When it does come up and some number is mentioned, most people are fine with it, acknowledging it just makes sense and the number of reports of people that feel they were unjustly cut off of medical care are so low that we are probably erring on the 'spend a bit more' side of caution.

You are being distracted with these ethical conondrums. The fact that this conundrum comes up at all is the problem.

Isn't the goal of the Senate healthcare bill to push even more of these decisions down to a lower level, for "cost savings?"

I'm a single payer supporter but I dispute this notion that "the issue of the monetary line hardly comes up." Of course it does, it has to. Is the government, or the private hospital paid by the government, going to pay for this expensive new machine? It may save lives. If a new medication is developed, does the ambulance stock it? These questions have to come up.

It *hardly* comes up, in the sense that it's not a big important thing that comes back in every discussion on healthcare, as if its the most important thing stopping us from having better health care, like it does in US media, politics and discussions. Of course it does come up and is discussed explicitly when necessary. But it's miles from what happens in the US, where e.g. Tyler Cowen will draw attention to it every time the subject comes up. That's just not necessary in a healthier (!) system. It distracts from more important issues preventing better health care. Money is not the issue.

They've decided ahead of time instead of having the patient decide. That's probably a better way to go, but they are still definitely making those calls, just like that town in Ohio who is trying to decide ahead of time "this is when we won't send ambulances any more."

like it does in US media, politics and discussion

Basing something's importance on how often you see it in the media is silly.

Every time there is a health care bill, accusing the other side of killing people is a cheap way to score easy political points. And since we are debating a health care bill now, this is going to come up. Because the media hates the people proposing the current bill, they are going to make extra super sure that this is discussed wall-to-wall.

I agree that discussing these things out of sight often gives better results. But I'm also very aware that as soon as I say "it's often better to discuss things out of public sight" people -- sometimes the same people who want the same results -- will flip their collective lids. Because "you're discussing this behind closed doors!!!" is, again, a cheap way to score easy political points.

Western Europe also rarely creates the drugs needed in this situation

@Meets WRONG!

They are being funded by the US market. Firms in Europe make more money selling overseas than to their neighbors.

What Western Europe is this, where the money is unlimited? I know Scandinavia and there there's a constant political debate about how to fund welfare ... which is extremely costly and which has been reduced from its former high levels.

The point is that the debate does not revolve about how much may be spent on an individual life or about how much some individuals cost. Of course there is debate about costs and spending, but it mostly comes down to: if we pour a bit less money into the system, how does the system adjust? We don't focus on "which expensive drug do we scrap, so 5 'unlucky' people will die earlier", even though those choices are absolutely being made.

In the UK, the cost of treatment is not so much in open political debate. It's mostly handled by in a 3-way fight between health care trusts, agencies (NICE), and doctors.

On the other hand, there is a constant public debate about "more money for the NHS" in terms of salaries. The public are quite aware of resource restrictions.

The big bills are for the patented delivery mechanisms. The patents on the drug itself ran out long ago. The generics run about $5.00 per dose.

I wish the Republicans would start mentioning "rationing" in the AHCA debate. "Death panel" has a nice ring, too.

I see an estimate of $450 per QALY from Narcan. The point at which a US drug is considered cost effective is $500,000 per QALY. So this is not even a close decision and perhaps you should consider why you think it is.

One can disagree about where the finding for the narcan should come from but not whether or not it is worthwhile to provide.

You might also have some fruitful discussion with a colleague about the issue.

What is the life expectancy of someone who has already OD 3 times?

No, it just means the standard for QALY is off by at least a thousand.

Treating something basic and super dangerous like appendicitis costs more than $500 per QALY. Generic statins are more than $500 per QALY. This is a relatively cheap intervention.

Obviously, if someone is drowning, there is no obligation to jump into the water yourself especially if you are not a well trained strong swimmer. However, if saving a life requires a minor and low risk undertaking, then I do think it should be done. We actually do often use well trained strong swimmers as life guards in a variety of venues. Shouldn't society place a high value on human life even on the lives of people who are distasteful such as opiate users? The alternative would be to have some rating on individuals that would specify how much we are willing to spend on their safety. If the alternative is the preferred option, I would place a low value on people who talk on their phones in the checkout line at the supermarket.

I would place a lower value on people who walk in front of my moving car while on their phones, having no idea that they are in a street.

Yeah but just try and hit one, and see who gets the blame. And I mean hit as in a gentle educational "nudge".

I thought the trade-off for drug legalization was that you don't get to socialize your expensive, destructive habit on the rest of us.

Which of the drugs mentioned as causing overdoses is legal? Or was this a hypothetical question not germane to the post?

"Two doses of an injectable form of naloxone, Evzio, cost $4,500, up from $690 in 2014. The price of other forms of the drug, including the nasally administered Narcan, typically range from $70 to $150 per dose, officials say."

It's important to note these prices are what *AMERICANS* pay for the drug. Every other country pays fractions of a percent of that amount (India, for example, pays ~$1.50).

It's indicative of Professor Cowen's morality, or lack thereof, that line he proposes drawing is one of human lives, rather than pharma profits, as the most obvious solution would be "allow the purchase of imported drugs." The idea that a drug costs X in country A, and costs .0001x in Country B, reeks of market inefficiency.

1. Allow importation
2. Emulate Portugal
3. Focus more on allowing people with real pain to get the treatment that actually helps them

"reeks of market inefficiency"

It reeks of price discrimination. Try to read a thread or two in which Alex criticizes the effect of the FDA on drug availability and cost in the US and you'll see that the same people here complaining about the price of drugs are the most vocal proponents on limiting the supply of drugs.

"It’s indicative of Professor Cowen’s morality, or lack thereof, that line he proposes drawing is one of human lives, rather than pharma profits, as the most obvious solution would be “allow the purchase of imported drugs.”


Cowen is a corporate whore.

It's very rare in a rich country like the U.S. to find any individual thing we absolutely can't afford. So saying "a line must be drawn" implies a hard constraint that doesn't actually exist. We can afford naloxone. The question is whether we chose to buy naloxone instead of using that money for other priorities.

Saying "we don't chose to pay for life saving overdoe medication so we can have lower taxes, or higher education spending" is a more appropriate framing of the tradeoffs that must be made. Saying "we can't afford it" is a cop-out that avoids the appearance of any such tradeoffs being made.

Who is we, kemosabe?

There's a local government, a state government, and the federal government.

Only one has its own currency.

This is the beauty of federalism, it is supposed to force trade offs down to the lowest level of government, and let people decide. Those people, of course, are the ones who face the costs of the trade off decision. If they decide to raise taxes to 99% to pay for All the things!!!! then they can do that. If they decide to cut funding for opiate degenerates they can do that and focus on education. The idea here is that actual stakeholders make the decisions.

Of course there is nothing stopping the bleeding hearts here from starting/donating to a non profit to provide aid to local governments that have high opiod crisis costs. where your mouth is. You can spend as much as your money as you want on the problem. Or not.

Of course the lowest level decision making can be forced down is to the individual. Maybe the county should have a registry where you can purchase naloxone ems coverage....or not as you choose.

Let the stakeholders with most skin in the game pony up for an overdose drug, which they must carry around with them. Make this mandatory at the point of (drug) purchase.

It would probably be easier and cheaper to set up communities in rural areas where diamorphine is administered by medical professionals. People would be able to check-in at will but not check-out until they are clean. It would be a mix of a minimum security prison and a dope house but with clean drugs and (minimal) medical care. I'm sure that this would be way cheaper and would offer more dignity than the current drug enforcement framework.

This would have a lot of secondary and tertiary effects on property crime rates, property values, cost of border enforcement, etc. Not exactly a total decriminalization.

BTW I live an hour northeast of Middletown, OH and lots of people agree with Daniel Picard. I feel like lots of the commentators who are throwing consternation at Tyler don't really understand the cartoonish level of the epidemic and how fed up normal citizens are. Picard's proposal is definitely extremely controversial in Ohio though.

Wouldn't "tough love" also apply to locking them up in a mental/rehab institution? The stated costs of "Half a dozen overdoses" are around 27.000$ - which would perfectly cover a couple of months in such a facility.

Yes, I know.. liberty, laws, destroying yourself isn't illegal, human rights yada yada. Look, morally the burden is on us to get out that comfort zone where we keep telling ourselves that overdosing to death is a decision of free will. How much free will is there left in a junkie? And how much of his mental illness has been around _before_ his addiction (and thus being the reason for it)?

I guess the point I'm willing to make is, that it is better ethics to take liberty (e.g. medication by force) away from insane people as long as your goal is to enable them to have it back later.

It's funny how cost/benefit analysis never considers the benefits of rehabilitation as an alternative, and how the benefits of rehabilitation extend over a lifetime.

Last evening we had a couple over at our house who had studied the Norwegian rehabilitation and incarceration system, where, if you are incarcerated you get trained for a job. Recidivism rates are low.

So, in the cost benefit analysis, consider the costs and benefits over a lifetime, and don't assume the job ends with a can of Narcan. Maybe it tells you something if you ignore the problem, and treat only the incident, that the costs relative to the benefits of alternative programs will be lower than if you address the problem and work on rehab. Of course, it could come out that the can of Narcan is cheaper, and maybe is, than other solutions that address the problems, which is why they probably only offer Narcan.

Re-hab only works like 10% of the time.

Also, stop imagining you can recreate Norway.

You are wrong. Rate for US per government is about 40 percent. Abroad higher


In my experience many psychotic people will eventually never get off medication and even with meds in their system could hardly work. But the amount of psychotic people < junkies?

Even as an libertarian one must admit that the top-tier Darwin Award talent is less blamable for their own demise than purported and that our chicken-out by blaming it on them and their "free will" is immoral, stone-cold bullshit.

Tough laziness. The ball is in our court, not in the addict's one.

"Re-hab only works like 10% of the time."

Rehabilitation could only work 0% of the time and Bill wouldn't care. Rehab = government paid jobs for leftists and compassion for the downtrodden; it doesn't matter if it effective, Bill still gets that same high.

Ask Bill if he knows any drug addicts. Ask him if he has ever fought addiction himself. Ask him if he's ever found himself in a rehab clinic. I have personal experience in this realm, having grown up in a not-hip-cool-trendy-city where all your friends have master's degrees. You have to want to get off drugs. Rehab isn't magic, despite Bill's monumental ignorance and superiority complex.

"I have personal experience in this realm, having grown up in a not-hip-cool-trendy-city where all your friends have master’s degrees. "

Given this background I'm surprised you even know how to type and construct sentences quite frankly. You're a regular Eliza Doolittle.


I guess you'll have to ask Rush Limbaugh how his recovery is coming along.

Thomas, in my youth I knew drug addicts who received help and recovered. Today, I know themthrough a son in law doctor who tells me many are veterans. Why don't you propose that the VA deny treatment to veterans with your three strikes program. Dare you.

@thomas: I argue, Bill's suggestion doesn't add any new government job - it just says what type of government job is added.
Addiction untreated and drug related crimes will at some point be dealt with by government workers anyways - the police and justice system.

The addiction does the adding. We're just debating the smarter type of job to add.

Narcan has a notable Cost Disease Problem. But it's several orders of magnitude LESS than hyper regulated, liability laden, SJW-converged horror of Big Drug Rehab.

Even a Libertarian Dream of hyper efficient rehab would mean locking up a certain % of failures for YEARS - and that's repulsive to influential snowflakes, cat ladies, etc.

I wonder how Singapore handles multiple overdose patients? And execution of pushers isn't the answer.

Exactly. Locking them up "for YEARS" for their own good is what I propose here.

It doesnt have to be turkish-jail-style though, norwegian-correction-center fits better to my magination. And what Im imagining is taking away liberties but again Not because they're criminals but because, Liberty kills them.

Also once we Start with that, rehab should become a Bit more successfull because of forced injection of ataractics.

For those who chose not to operate in a faceless environment, here is a report on Drug use and rehabilitation in Norway.

factless not not faceless.

Here's an idea: use of heroin or unprescribed use of prescription opioids is a crime, so give them the drugs and then punish them for the crime. Give them two weeks in jail, just enough time for the (not worse than the flu) withdrawal symptoms to work their magic.

But, I sense that, because "muh mass incarceration," that is unthinkable, for both the libertarianish like Cowen and the snowflakes. That spending two weeks in prison would be preferable to possible death does not much matter to them.

With other drug problems has this been approach been successful at reducing usage?

To imagine that the type of people who celebrate the rising rates of white suicide (which is parallel to opioid use), the destruction of the family and the church (which provide meaning in life), and the annihilation of the rust belt (which used to provide economic opportunity) care at all about opioid overdoses is laughable. JAMRC spends 90% of his time on MR expressing disgust at not-elite strivers, or anyone not elite but with some motivation. His and the Democrat party's condescension is a symptom of the same trend that is driving drug addiction.

"anyone not elite but with some motivation"

Buddy that's an oxymoron.

This is my favorite part. The irony.

Years of blaming minorities for their dysfunctional communities. Now it's your communities. And the gospel of responsibility fades away, like a shitty 80s movie ending.

Democrats didn't cause this fiasco. Rich white kids sipping lattes in Williamsburg have never set foot in these communities. Their dysfunction is their own. Just like republicans are not responsible for the crime rate in east Baltimore.

Every unhappy family is unhappy in its own way. And they all point fingers outwards.

Just lower the damn tax rate and let it sort itself out.

I do believe though that while rich white kids in Williamsburg didn't cause these problems - the blame does lay substantially at the doorstep of American economics department and the technocratic class.

Years of blaming minorities for their dysfunctional communities. Now it’s your communities.

People who behave badly are responsible for what they do. The question is what the larger society is to do about it, since such behavior has an impact on various 3d parties.

Tangential to Cowen's point, but one wonders how many of those overdoses are due to the inconsistency of the drugs used? If I'm accustomed to injecting white powder that's 3% active ingredient and the rest milk sugar and floor sweepings, then I'll plan my dose accordingly; and that means that when I happen to get a batch from an honest supplier, I'll unwittingly take far too much.

This is a point in favor of legalization. When I buy a bottle of booze, I know just what I'm getting; I can trust the greedy corporation that manufactures the stuff to sell a consistent product, so that I know just how much EtOH I'm getting in a glass. Similarly, if I were buying my opiates and opioids from Altria or Brown-Forman, I'd know how much active ingredient I was getting, and could confidently adjust my dose to get the effect I wanted without risk of OD'ing.

Not how it works. At least not with heroin. Every time you must inject a fraction more to get your high, because you build up immunity.

(Also you want a special, splendid high ... not just an ordinary one, so you add juuuust a touch more each time.)

Thus OD-ing often occurs right after jail/court/rehab etc release, when the addict has been clean for a short while and it is easy to miscalculate the dose. This would be tricky even if it were a scientist doing the self administering, not an addict who has probably also consumed some booze, a joint, etc.

Like opiates and -oids, nicotine produces tolerance. Yet we don't see nicotine junkies super-puffing cigars or injecting e-cigarette liquid to get a "special, splendid high"—they do enough to keep the withdrawal symptoms away, and stop there. I suspect that the majority of opioid addicts would conduct themselves similarly, if they could obtain their fix legally, conveniently, and inexpensively.

As with the devil quoting scripture for his own purpose, one can also cite Schelling for another purpose as well.

Take the phrase "Opiod Epidemic". Now, consider the words "tipping point" and epidemic and you'll understand what I mean. Opiod users might be the persons that "infect" or persuade others to use the same release mechanism. This expansion of use causes new recruits to recruit others, leading to the epidemic. A tipping point.

If you've read Schelling, you know the word phrase "tipping point", and if you know cost/benefit analysis you also know that you don't just look at one interdiction (and its costs) while ignoring the failure to interdict and correct without considering the costs of others of adopting the same conduct from their interaction with the infected individual.

I am sure that the costs of interdicting one ebola victim is quite high. We spend money to correct, detect, and prevent...not because of one individual, but because of the effect on many others was well.

By the way, re Tyler's comment on emotions, just remember: humans evolved with emotions and they serve a purpose to protect the species. Curiously, we did not evolve into an emotionless Dr. Spock.

The reference to Schelling is in response to Tyler's comment in case the context is necessary to understand the comment.

Mr. Spock. Dr. Spock was a pediatrician who wrote books on child care.

Ha ha. The Spock I was referring to was Spock of Star Trek, adding the Dr. to his name to put him in an emotionless medical scenario. My apologies for the confusion, but I wonder if the creators of Star Trek deliberately chose the name to create the anti-person of Dr. Spock the pediatrician.

But, good point.

Better solution: spike all drugs in the cities, towns and rural areas with fentanyl, and just kill them all off

It's annoying Tyler's habbit of deleting prior's comments and deleting all the legitimate replies, then welcoming him back later. Tyler should permanently ban him and leave his comments up so that everyone can see why.

Tyler's edits sometimes seem weird, but perhaps there is some hidden pattern, reducing overall complacency.

From the article, Middletown OH has responded to about 600 OD calls for 2017 so far. So let's call it 1,200 per year.

Wikipedia says there's about 49K people in Middletown. Let's say on average you need two doses to revive someone. Injectable that's $9K but the cheaper nose version that would only be $140. So for the year that cost is maybe $168,000 to $10,800,000. From it appears the city budget is around $125M per year.

Few factors though:

1. You can bill people for medication used on an emergency call. More opioid abusers than you'd think have insurance.
2. Medicaid/care patients means that some of this cost is tapped to state and federal budgets.
3. You can place a psych hold on someone if he appears to be a danger to himself or others....overdose would qualify.

3. a. Results based health care compensation. Pay for rehab of those revived. Compensation like this: $1000 base. If patient does not need another OD treatment for the next 12 months, $9000 more. If patient gets a job and holds it for 6 months after treatment, an additional $2500 to rehab place and $2500 to patient.

"Here is the Tim Craig at WaPo story. I do not know what is the proper response to such opioid cases, or how much money should be spent. I do know that somewhere, somehow a line has to be drawn"

Well not really. We could afford, if we had too, a person who insisted on overdosing every other day. Is it optimal? No of course not but the idea that we cannot afford $70 per dose OD drugs is absurd. I guarantee the drugs kept for heart attack and stroke victims that enter the ER don't even begin at $70 per dose.

Rehab is far more expensive than you imagine, and it only works 10% of less of the time.

If there was an actual cure for addiction we'd not have many addicts.

Your other ideas are probably already being done. Medical facilities are very smart at trying to bill others.

Rehab providers almost always charge on a 'per service' rather than 'per result basis'. If part of their pay was based on outcome you would have a radically different incentive structure.

Also why is rehab so expensive? It mostly consists of a few beds, people sleeping for a good portion of the time, a doctor and a nurse or two on staff. Medications used are minimal and do not require advanced equipment or diagnostic tests. There's no intellectual property involved either so you're not dealing with patents or other factors that might make costs higher

It's not inherently expensive which implies to me you could get a lot of it for relatively decent money. More importantly in the big picture it pays for itself. Most addicts will hit a low point and then recover over the long run. If you shortened that period and saved a few OD episodes or got a person back into normal society by rewarding holding a job for a few months you'd greatly increase our society's capacity for production.

I agree it could be cheaper or have better incentives but housing troubled people is inherently not that cheap.

Still, if you can make those changes and control costs I'll put you in charge in a heartbeat.

P. S do you have any evidence that most addicts recover on their own in time?

I'd like some good news.

No data but personal experience. I've known people who were stone cold addicts but at some point 'aged out' of it. I've also known others who were essentially functional addicts, holding down jobs, paying rent but still messing with stuff. Sometimes it kills them, sometimes they just stop, other times it's just a part of their whole life.

Housing troubled people is not cheap but it's also not that expensive. Don't you think you could find a place for $1200 a month? Add in food....$1500 a month... Why exactly should 30 day rehab cost tens of thousands of dollars then? Yes you need staff and medical experts but again no one says you need 30 days full supervision. I could imagine a rehab that was paid on a long term incentive system would be less about housing people 24-7 for 30,60 or 90 days and instead be about intensive outreach after they return from an initial detox.

The cost of housing recovering addicts isn't mostly the rent or food; it's labor costs. Nurses, several categories of nurse assistants, shared access to a doctor, therapists, orderlies, security guards, administrative staff, and so on, all subject to political and union requirements and pressures, including the widely-discussed problem with pensions.

Most rehab places are private outfits and un-unionized. Yes medical staff is a cost but they are spread out among multiple patients and unlike those checked into a hospital they don't require a lot of medical intervention. Detoxing can be done at a mental hospital by putting people on a 72 hour psych hold after an OD. A longer term rehab need not be a jail with lots of guards.

Liability. Good luck facing down one of the greatest lobby arms of the Democrats: class action litigation firms.

Let me know once you guys square that circle. Then we'll talk paying for rehab.

Read up on when addicts / users typically OD. It's often after a period of rehab. (Or jail.)

Shits hard to dose right. Like dialling in the tamp, grind, water etc of for a new espresso machine.

Also addicts need a huge amount of attention during rehab. It's not like having a room full of schoolmarms who are capable of self discipline. These are often restless agitated men.

May rehab compensation partially dependent upon whether the user has any arrests or OD's 6 months after treatment.

When mothers should be allowed to kill babies at government expense, but an addict attempting to kill himself everyday should be forcibly revived at government expense, the only commonality is the preference for government expense.

>>3. You can place a psych hold on someone if he appears to be a danger to himself or others….overdose would qualify.<<

In many states, these holds are a joke for treating chronic addicts. A cynic may say they're designed to ensure the average rehab 'customer' returns multiple times.

Don't like spending $4500 for the OD drug? Make the 'hold' less of a joke.

You are only an "overdose victim" if someone administered the dose against your will and/or without your knowledge. If you did it to yourself, you're nobody's "victim" but your own. Why should I pay for your repeated stupidity?

You won't get cucked again?

That's my favourite WHO song - We Won't Get Cucked Again! One day it will be a reality.

New Hampshire has the second-highest rate of drug overdoses in the country. Eric Adams in Laconia (population 16,000) has been assigned one task: to stop them.

People, listen up: this thread has morphed from cost-benefit of overdose drugs (of which apparently some are off-patent) to an implicit thread about preventing suicides. Go here: and click on the map, then the red dots, then the case study associated with each read dot, and notice that the vast majority of the deaths of foreigners in Thailand, which this website tracks, are suicide. It's so routine. Like that death park in Japan in one of Ian Fleming's James Bond novels. Happens all the time, over 40k times a year just in the USA.

Bonus trivia: I suspect, but can't prove, that Roger John Hussey ( fell to his death from the parasail when the operator, as a joke, unhitched his safety harness. I had the same thing happen to me in Phuket but I was holding onto the straps for dear life. But I heard the boy unhitch the metal fastener for one of the safety harness releases. I think it's a running joke among the parasailing crew there, I'm pretty sure they do it as a dare between themselves. Well, either that or Mr. Hussey committed suicide and made it look like an accident, but you notice in the report the parasail operators say it was an accident, which itself is suspicious, i.e., how would they know?

Just because I suffer from Acalculia, as well as art deco, does not mean I don't understand that roseate gypsum hedge ledgers were not invented by the Egyptians. Conquered by Alexander, his general Ptolemy, then the Romans. But they kept kohl around their eyes to block out the sun. Sonograms were not frequent then, they knew nothing of paint or pigment, called it mud. Cuneiform Calculi formed in 3200 BC and Cleopatra.

Another undeserving "fill-in-the-blank". I would point you to a piece by David French, "We Are All Murders Now."

"Who killed Bob? Let’s first ask this: Whom do you want to blame? Whom do you need to blame? Because we can make almost any allegation work. But there is one thing that we cannot, must not, do. Our politics matter more than his choices. We cannot blame Bob."

By all means please continue to rail against choice whether an addict, a woman, or Bob. My question would be where is the God, the family values, and the introspection? If it was your parent, sibling, spouse or child could you be so callous? So many have lost their way spiritually.

The cost/benefit is pretty clear. If anything, we should be subsidizing heroin and fentanyl and shipping it into the cities, the suburbs and rural communities to aid in the extermination of the human cockroach infestations that have been allowed to fester there for decades and decades.

In case no one has said it yet: In some places, people who take voluntarily risks (like mountain climbing) are charged the costs of rescuing them. Post the prices of the OD reversal drugs in the "recovery houses". Obviously collecting the money wouldn't be require these recovery houses to have a license/with deposit to cover such expenses. They could then charge the recovering dopers (I guess the taxpayers would end up paying though, but at least it wouldn't be the local folks, thus forcing a wider consideration of what to do).
Indeed, it's a problem. Can't stop people from killing themselves if they want to (even if they might not want to under very different conditions). Speaking from personal experience.
Free drug centers: Give people all the free drugs they want as long as they use them on-site, with superfluous warning that "you have a high risk of ODing, and possibly dying, if not administered a recovery drug. Would you like to purchase some?" But then they'd probably think, naw, ain't gonna happen to me. Ain't gonna OD. If I do, I' won't die. Some will save me. They have to, it's their job. Anyway, what's so great about being alive if you can't get high. You have to go sometime. Live fast, die young, and leave a good looking corpse".
But then you have to pay to dispose of corpses. In the end, it really is a matter of how much it costs to keep people alive who don't care (or care less about staying alive than getting high).
BTW there are economic solutions, as long as the number of corpses in reasonable. They are pretty horrible, but people managed to live with them before. We may have to get used to them again in the future.

The single most important line from the article:

"Two doses of an injectable form of naloxone, Evzio, cost $4,500, up from $690 in 2014"

From a manufacturing perspective, there is no reason for a drug to ever go up in price.

Right you are, and some say upstream of this post that the drug is off-patent, making the increase even more enigmatic.

I doubt this is busting Middletown's budget. (I also doubt that municipal governments are the optimal locus for straightforward welfare expenditures).

When will the patent be up on Narcan (is it up already)?

I see my question answered above. I agree with Tyler that at some level of expense you have to let someone kill themselves. (BTW you can save lives in Africa for few hundred dollars.) The town is not a killer and by extension neither are the Republican congress and Trumpty Dumpty are not killers if they dump the PPACA.

Next idea: if all drugs were legal and accessible without a prescription would some company be able to create a substitute that is very difficult to OD on.

Regulation and health: The case of mandatory prescriptions and an extension

The effect of requiring consumers to obtain prescriptions for pharmaceuticals on mortality is examined for a sample of middle-income countries. In countries enforcing the requirement, infectious disease mortality is no lower and poisoning mortality is higher than in those not enforcing the requirement. A broader measure of government intervention—public expenditures on health relative to GDP—is shown to have moderately adverse effects on overall life expectancy.


I'm not a doctor or EMT but I think there's no way to know for sure if someone is dying from an OD. Even autopsies point to the most probable cause of death.

Is there something that looks like an overdose but it's not? What if the overdose is the combination of heroin and a prescribed drug? The proposal relies on information that is not available to make a good choice.

Sheesh, at 4500 bucks we're talking about pennies here compared to some of the other medical costs that some uninsured people rack up on a recurrent basis. There is one woman who comes to the hospital consistently because she keeps swallowing things. The last time I saw her she had swallowed a couple of razor blades; the time before that it was a pen that lodged in her duodenum. Most of the time we get away with pulling the objects out with endoscopy, but she has had multiple surgeries as well. These treatments cost the taxpayers tens of thousands of dollars per episode. This has happened dozens of times.

Or what about motorcyclists who don't wear helmets and get in a wreck after drinking + marijuana + cocaine? Their de-compressive craniectomy + ICU stay + treatment for additional injuries + long term hospitalization, rehabilitation, etc will cost the state hundreds of thousands, possibly millions of dollars.

What about diabetics who don't exercise, smoke, over-eat, don't control their sugar, and then get chronic wounds and ulcers on their feet? Dozens of debridements by podiatrists, vascular interventions by surgeons, treatment by wound care specialists, hospitalizations for infections, which usually culminate in an amputation. Sometimes, this same population gets renal failure; then we do dialysis (at the cost of ~100 thousand of dollars per year) or maybe do a kidney transplant eventually, with all of the long term follow up, treatment for complications or infections, etc which that entails.

I mean to talk about whether we should give narcan to someone with a drug overdose. Talk about rearranging the deck chairs on the Titanic! Those costs are a pittance and are hardly even worth debating when compared to the rest of the American medico-legal industrial complex, which sometimes strikes me as a giant, blood filled leech sucking away at the jugular vein of the US Economy.

Ironic metaphor (leech) considering what used to be considered "medicine" centuries ago. But also telling...medical care costs a lot partly because it's so advanced now, and so essential. Medical care didn't cost much in the old days because there wasn't that much to be done. It's not nefarious, it's the essence of the thing itself.

Also, that blood sucking is how many very good paying jobs get funded in the US. People forget every dollar saved in medical costs is another dollar not earned by someone.

Re: I do know that somewhere, somehow a line has to be drawn.

There's a valid debate to be had about which expensive but uncertain treatments should be paid for in terminal cases. But outside of an acute emergency situation requiring a triage approach (scarce resources sent to where they will do the most good) has any place ever drawn a line on sending EMTs to potentially life threatening emergencies? The day we start doing that (again, excluding major disasters where triage must be applied) is the day we forfeit any claim to civilization-- and will merit whatever judgment God, karma or nature want to mete out.

Then came Peter to him, and said, Lord, how oft shall my brother sin against me, and I forgive him? till seven times? Jesus saith unto him, I say not unto thee, Until seven times: but, Until seventy times seven.

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