On fentanyl, from the comments

I always find it helpful to recall that the US was the not the first country to be hit by fentanyl. Estonia, for instance, had a massive wave of fentanyl deaths that started before the US, without all the US prescription opioid consumption, and peaked sooner. Currently, their opioid supply has moved beyond fentanyl to derivatives that are even less safe.

It seems to me that the problem was not overprescription per se. Rather, as in Estonia, there seems to be spiral where opioids are seen as acceptable drugs of abuse (entering into the space of marijuana, alcohol, tobacco, and ecstasy), illicit suppliers elect to increase the addictiveness and potency of their drugs, and we end up with much more deadly drugs.

The biggest problem US docs created was removing the social stigma against opioid use and abuse. We created a perception that being addicted to opioids was no big deal, mostly safe, and something that people could do without losing all their social standing.

Does decriminalization work? Nowhere near as well as cultural barriers. Portugal, for instance, has safe injection and all the rest, yet it is experiencing a new wave of heroin use as old addicts return to heroin thanks a weakened economy. And lest we forget the difference in price for legitimate opioids and heroin/fentanyl is not all that high. Legitimate heroin supplies are going to cost at least as much as black market opioids so I suspect we will still have a lot of users who end up on fentanyl derivatives (for which there are no safe prescribing guidelines, nor even data for simple things like LD-50).

As with most major problems, the cause and solution are likely to be social. Historically, these sorts of epidemics die down as people die and the younger users decide to not try the things that killed all their older peers. Quite possibly all our “harm reduction” strategies and treatments will delay this process and leave more people dead; a first pass analysis of mass naloxone treatment suggested that it was associated with difference in difference increase in the opioid death rate due to increased use.

Unfortunately, I see no way out of the current situation that does not risk leaving many, possibly more than current rates, people dying.

That is from a commentator named Sure.

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"The biggest problem US docs created was removing the social stigma against opioid use and abuse."

The social stigma was weak and ineffective to begin with since it wasn't hard to hide usage. The real problem was treating it as the cure for all of life's problems instead of medicine with a specific purpose. Dealing with a divorce, job loss, or any usual problem in life? Take a pill.

"And lest we forget the difference in price for legitimate opioids and heroin/fentanyl is not all that high." Seems like the fact that this is false is the biggest problem. Fentanyl and heroin deaths started rising when the price of those drugs relative to opioids dropped.

Harold G, I'm afraid I don't see much of a difference between a decline in social stigma and the process you describe, which is also a shift from social stigma to social encouragement to take opioids. People internalize the rules of society, so social stigma and guilt operate even when people are capable of hiding usage from others.

There are few "innocent" deaths from drugs. Most who die are a drag on our society and a waste of skin.

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If you price by morphine equivalent, street retail price is not that different.

Regardless, legitimate fentanyl is going to have to pay for GMP, certification, taxation, and a bunch of expensive quality control. Street fentanyl (or eventually, derivatives) is going to always be cheaper.

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Part of the quoted comment is nonsense. The social stigma against addiction did not weaken: we still regard addicts balefully.
What happened is that drugs like Vicodin and above all oxycontin were marketed as having a very low potential for addiction. That was false, but it allowed the use of these drugs to snowball because people thought they were safe. And since people addicted to legit Rx meds were not living in the streets and making trouble for the rest of us, it took a long time for the risk to penetrate public consciousness. Moreover many of us have had a script for these meds for some very limited purpose and did not become hooked on them.

I can only speak from my experience, but within medicine we certainly changed these perceptions. Addiction went from being a moral failing (roughly the 80s and earlier approach) to being merely a "dependence" of biological origin. "Pain is the fifth vital sign" was official dogma and openly accepted dependence/addiction.

As with most medical policy, the relevant group is not the average member of the population, it is the marginal one. For a lot of my patients they started on opioids after being introduced by friends and family. Frankly, their stories are not all that different from my patients who have alcohol or marijuana troubles. They took a drug because they had some stressor, social circumstances presented the drug, and it worked for a while.

As far as getting addicted, that depends entirely on how you count addiction. Is it merely having an unpleasant disturbance in homeostasis (e.g. changes in bowel motility)? Then addiction rates are high. Is it developing substance use disorder? Then addiction rates are low.

Are prescription opioids dangerous? Some. But then so is most of the stuff I prescribe. What is really dangerous setting up social networks that facilitate drug taking and reinforce abuse norms. After all, I have seen the same phenomena come through with gambling. Sports brackets and other gambling activities are almost always harmless; yet as gambling becomes more normative we start seeing increased rates of DSM defined gambling disorder. Somehow opening casinos is correlated with more gambling disorder. Somehow having friends and family who gamble is correlated with more gambling disorder.

And again we can use difference in difference to that opening a new casino nearby changes something. Which is especially odd given that online bookies have been operating for decades now. Somehow what your friends and family do matters.

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There is a lot sense in that comment, but I think the real reason is that no had any idea how easy fentanyl and its even more potent derivatives are to synthesize. I didn't even know the structure of fentanyl until I looked it up Wikipedia a couple of years ago, but as an organic chemist with a PhD, I could make a kilo of the stuff in less than a week using multiple routes. Even putting strict controls on access to key advanced intermediates wouldn't slow me much more than an additional week since the key advanced intermediates are also easily made on large scale using even more basic and harder to control materials.

In short, I blame Wikipedia.

The Estonian below pretty much blames the Russians, but then, who doesn't?

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Given fentanyl's very low weight LD-50, and your admission that you could easily make a Kg, you are hereby declared a WMD.

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"Historically, these sorts of epidemics die down as people die and the younger users decide to not try the things that killed all their older peers."

Citation, or is this just ugly wishful thinking? Alcoholics have been killing themselves off for centuries without this "epidemic" pattern, and as I understand it alcohol is more toxic than traditional opiates.

There are certainly papers that demonstrate how cultural effects and stigma against alcohol were more effective in reducing alcohol deaths than Prohibition itself (though some of that stigma was a legacy of Prohibition with causality in both directions, so it's complicated.)

I'm biased on this question simply because I have anecdotal evidence; my grandparents, even when in the worst pain, absolutely refused to get opioids for any reason. The claim that the social stigma against opioids has been lessened rings true to me.

As I noted above drugs like Vicodin were marketed as safe. Even the term "opiOID" suggests they were something different from the bad old narcotic opiATE drugs. And of course most people can take these drugs on a very limited time basis for some acute issue and will not become addicted to them.

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I could not find a copy I could easily access, but I believe it may have been Morgan's Drugs in America: A Social History, 1800-1980.

In any event, morphine was widely used in the Civil War and became all the rage for addiction and abuse. People saw the trouble it caused and then began, in the main, swapping to cocaine. Did individual drug user swap over to something new? Not a whole lot. More often they died, often before their non-using peers, and new habits emerged.

As far as alcohol, first high proof alcohol is relatively recent. Cheap high proof alcohol is certainly only a couple of centuries old. The ability of the masses to drink themselves to death quickly is pretty novel. Within alcohol, we saw repeated fads for hard drinking, which, in an era before molecular biology functioned on a lot of similar mechanisms. Gin is bad, let's try bourbon.

Maybe there is just a baseline number of users out there who will glom onto whatever are the popular drugs of the day ... but the fentanyls are vastly more toxic than what has come before. The death rate currently handily exceeds that of the AIDS epidemic.

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Nothing to worry about. Nature has a way of dealing with those who abuse drugs. The species will be stronger for it.

I worry the problem isn't sorting itself fast enough. We should subsidise fentanyl. Think of the long term savings for tax payers!

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I think of this like soda and Doritos. We evolved to resist certain threats, but synthetic drugs and big gulp sodas are not threats that culled our ancestors.

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So basically, the solution is to create a new form of social stigma around those drugs. How? By showing graphic content to teenagers?

Say mean things to people taking opioids and then cancel them. It works on social media.

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"Unfortunately, I see no way out of the current situation that does not risk leaving many, possibly more than current rates, people dying."

'Sure', ironically, sounds very unsure.

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LD-50 ? This guy is talking about LD-50?? Sad. I stopped reading at that point since I doubt that anyone who believes LD-50 data would be useful for fentanyl-similars /fentanyl analogs (not "derivatives" for crying out loud!) has a clue - about anything.

otoh
ld50 is an objective & very useful (not sad) metric for toxicity!

Though not for illegal street drugs.

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If you want to legalize something, you are going to need to run through some process to make it safe. Getting the LD-50 is a first step, not a last, for being able to prescribe it safely.

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I wonder what tribe the Sacklers belong to

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I got really strung out on Fentanyl long before it was cool - in the late 1990s. I had a job working in a hospital, around narcotics, and, well, with a little work it wasn't hard to have access to a lot of it. Security was amazingly lax. I actually greatly preferred morphine or even demoral (but not hydrocodone/Oxy - that stuff was too wimpy.) They were much "smoother" than fentanyl - with fentanyl you go up fast, but it doesn't last long and you come down hard. At my peak, I was fixing up every couple of hours, at least, including waking up in the night for it. It does a number on you - it's hard to hide (much more so than morphine.) I lost probably 40lb in 6 months, from a modestly low weight before. I looked like shit and felt bad when I wasn't done up. The derivative things - sufenta and alphenta - are even worse - really awful - very high peak, super crash that leaves you feeling sick, puking, shaking, etc. Sufenta is so strong that it's easy to get too much. Alphenta is weaker, but the peak and crash is super fast. I always knew how much to take w/ fentanyl or morphine or whatever, but with those things, it's easy to go wrong. (For people w/o medical grade supplies, it's easy to go wrong in any case.) Thankfully for me, I left the job, and walked away from it to never go back, more than 20 years ago. None of my friends did it, so changing my life wasn't that hard. (My friends who knew all thought it was crazy and awful. They were right, mostly.) It's the changing one's life that is hard in relation to quitting. Anyone who has done this stuff had dealt with the physical withdrawal more than a few times in any case.

I've heard that crack has a quick-up-quick-down profile that is similar to the derivatives you describe. Any thoughts about why crack hasn't made a comeback? (Or maybe it has, and I just haven't heard about it?)

As Frank Zappa remarked way back in the 80s, drugs go on and off the "charts." When I was growing up, I couldn't hardly imagine that anyone would be stupid enough to use cocaine. Then I hit my 20s and pretty much everyone was doing it. Not me, though. I've always been a square.

I noted heroin's comeback way back in 2012. It's had a good run. Eyeballing the Google Trends "charts" just now, it looks like meth might be making a comeback.

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Crack is quite common here in Baltimore. It's just not the "drug du jour," that the media raves about. That was meth for a good long time in the 00s, but then the opioid epidemic epidemic hit the headlines in the Great Recession and the meth epidemic languishes forgotten too.

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There is an army of ineffective government paid drug counselors in California. combine them with the Mexican cartels pushing open borders via soft money. Combine that with the current Mexican president. Combine that with California failed state culture spreading east. Combine that with corrupt national politicians who cater to the mob. Combine that with state actors in foreign lands smuggling precursor to Mexico.

I dunno, meth and fentanyl seem to be military grade stuff.

I am a retired small landlord in Fresno. What I see is heatrtbreaking, most ly parents going through the discovery process that one of their kids got hooked on meth. Seeing them discover they have a severe ten year disability problem. They begin discovery and learn their whole family life now revolves around a sibling with brain damage.

There are national political implications, for example, national voters will no elect a California for quite some time as they hear daily reports of meth coming from California and poising their children. People everywhere swapping stories about how some family they know got a kid caught and the drugs delivered to their neighborhood from California based cartel. Not so smooth for national unity.

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Meth, typically smoked, has been the drug of choice for denizens "experiencing homelessness" in Sta Monica and Venice in recent years. Every time (okay, every once in a while when) cops decide to stop somebody suspicious, that person, typically male, seems to have a crack pipe and a bunch of fuel for it on his person. You pass people toking up on commercial sidewalks in the early afternoon.

The tweakers spend the nights strolling the streets, high and dangerous, and line up around six a.m. outside the local St. Vincent's "services" center for breakfast and showers.

Last year, heroin/fentanyl crept into the mix. Park workers started finding syringes near abandoned encampments.

Through it all, no bicycle or stroller or wheelchair has been spared; all are stolen for parts or to haul belongings or as panhandling props.

Meanwhile, the local shelter has empty beds because it requires sobriety.

LA's proposed solution: Building affordable-to-free apartments on public (free) land close to the beach in Venice at a cost of $400,000 to $450,00 per unit.

Nightmare. I have dealt with the same, pure nightmare.

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What are we solving for? I don't disagree with interview with Ben, nor do I have heartburn with Sure. It seems we often disagree with the solution we're working towards: minimize deaths from substances (focus on alcohol and tobacco), highlight problems with China and Mexico (fentanyl a good place to start), minimize costs to health care system (possibly legalize, increase treatment of addiction), etc. I realize we're not trying to solve climate change or nuclear war threat, that said, it's still valuable to heed the lessons of Little Boy Blue.

By treatment, do you mean rehab? And is Orange County with its 1,117 rehab centers the model the whole country should adopt? Or is this like universal pre-K: when we scale up, it's on the assumption that we will replicate the outlier, whatever is the best program that ever existed?

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I am from Estonia and have covered the fentanyl crisis over the years a bit.
Indeed, fentanyl entered the Estonian market around 2002-2003 and very quickly pushed heroin out. Prescription drugs, marijuana, ecstasy, alcohol had no part in this story. From heroin to fentanyl. This was the story.
To clarify a few points:
- At first, fentanyl came from Russia. Later local production was added to the picture. As far as I understand, fentanyl is not very hard to produce.
- In Estonia, it hit Russian speaking less educated younger male population.
- Fentanyl has stayed very much in this demographic group.
- For the younger Estonian speaking population, marijuana and extasy are a way to go drugs. Fentanyl has not penetrated this demographic group much.
- For middle-aged and older, both Estonian speaking and Russian speaking groups, alcohol is no 1. Fentanyl has not penetrated these groups either.
- Estonia does not have ghettos in any meaningful sense.
- Like in all "Vodka belt" countries alcohol consumption is indeed relatively high, but OECD statistics are misleading. Estonia has low excise taxes and we have large cross border alcohol trade from Finland and also from Sweden. Foreign "Vodka tourists" will inflate OECD numbers.
- There have been lot of discussions why fentanyl, what has been so popular and deadly in Estonia, have not penetrated very much neighbouring countries /Finland, Latvia, Sweden).

Just to clarify. When I say inhabits the same space, I do not mean that these drugs are causally related. I just mean there is a mental space for drugs that are mostly "safe" and for those that are not. In reality it is a continuum, but the perceived distance between a "safe" drug, like caffeine or alcohol, and "dangerous one" can change. From what I have read, Estonia had an alienated set of Russophones where the perception of heroin grew less socially prohibited for a new generation, this led to increased use and fentanyl became a way for the dealers to score a buck.

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Also, I am skeptical that state intervention has helped in the case of Estonia. There have been some improvements in numbers, but this can be just a statistical artifact. There was a collapse in fertility at the beginning of1990- s. As a result, the demographic group where fentanyl is dominating (young Russian speaking male) is just shrinking. Less potential consumers means less actual consumers means less overdose deaths.

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On a related note, I found a particularly strong link between income levels and prescription opioid supply per capita (implied income elasticity north of 3 in OECD cross-section), and somewhat similar results for many illicit drugs, and overdose deaths.

https://randomcriticalanalysis.com/2019/11/07/a-tale-of-two-covariates-why-owid-and-company-are-wrong-about-us-healthcare/#rcatoc-obesity-isnt-the-only-disease-of-affluence

Which undoubtedly explains why West Virginia has the highest death rate - by far - in the U.S.

It's perfectly possible for idiosyncratic factors to play a non-trivial role and for systematic factors like income levels an even larger one, especially when the idiosyncratic element is sub-national and the systematic component is national. Moreover, though WV may be poor by US standards, they still have higher real disposable incomes per capita than the great majority of other OECD countries.

But what stands out is that West Virginia, one of the poorest states, still has, by far, the highest mortality rate from opiates.

And as noted by the Estonia, there is not really an explanation for why Estonia has such a problem, and other similar countries don't.

I'm *not* arguing income explains *everything*, just that it's an important predictor. Poorer and less educated regions within countries do tend to significantly perform worse in a variety of mortality and morbidity metrics even while richer countries increasing face relatively more problems relating to behavioral/lifestyle factors. From my perspective, it's hardly surprising one of the poorest parts of the richest countries in the world would struggle more than most with opioids and a variety of other issues (e.g., obesity). WV, in particular, has faced a number of challenges even prior to the opioid epidemic.

FWIW, I think this is why the graphs on your page are so powerful. They show both the trends and the outliers.

Thanks. I appreciate it!

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To be somewhat more specific, I believe there are other important determinants of opioid abuse. Human capital, social capital, and *relative* status probably are important (job market, marriageability, etc) . Though these issues may not loom particularly large when comparing high-income OECD countries at the *national* level, they are likely to be much more significant when disaggregated *regionally* or even at the *individual* level.

I believe income *mostly* operates as a proxy *within* high-income countries. Relatively poorer regions and individuals are also, statistically speaking, less educated, less intelligent, less likely to be married, employed, and so on and so forth within most high-income countries. Such factors likely predict opioid abuse quite independent of regional or national income levels. National income levels probably also predict for reasons not entirely linked to individual income levels (the average income of your country predicts behaviors, choices, amenities, etc quite independent of your own income).

If I were to try to predict this on a regionally disaggregated basis, I'd look at both national income levels and regional indicators of this sort (employment, marriage, etc). However, we don't even have regional opioid overdose rates readily available and this is rather beside the point I'm making vis-a-vis national income levels. Though you may not be entirely persuaded, my arguments here are internally consistent and WV hardly a surprise (at least not directionally speaking).

'However, we don't even have regional opioid overdose rates readily available'

Depends on what you mean by regional - the US government provides information per state. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state

What is interesting is you will see a fairly clear regional pattern involving parts of the U.S. With Utah an interesting outlier (in the bad sense) and Virginia (in the good sense).

Yes, I've before performed multiple analyses with state and regional data in the US of this sort. It's getting comparable data on *specific* causes of death at a regional level internationally that's more of an issue (IHME provides regional estimates for a handful of countries). The broader regional pattern you're probably looking at is consistent with a lot of other issues (lower midwest, appalachia, and parts of the deep south).... Utah generally isn't part of it.

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New Hampshire seems to be number 2
WV has some selection effects as more with good self control have left the state. Ethnic group could also be a factor.

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It would be interesting to plot drug deaths against the time since alcohol brewing began in the country.

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No mention of fentanyl as a higher-potency substitute for heroin that increases payoffs for smugglers? I don’t see why legal heroin would cost at least the same as black market heroin. And do users really want to do fentanyl or is it finding their way into their purchases without their knowledge?

Legal heroin already exists in some jurisdictions. It is called diamorphine and its cost per dose is massively more than the prices of street heroin.

Why?

Because manufacturers do not like killing a percentage of their customers. Diamorphine requires that production facilities meet GMP standards and preferably in a manner that minimizes contamination with allergens. Then there is the whole regulatory angle where not just the drug, but the mode of delivery, the fillers, etc. must also be studied and approved.

Then we get to potency. Fentanyl is about 100x more potent than morphine when you look at morphine equivalents. Carfentanyl is 10,000x more potent. And that is not the end of potent binding to the mu opioid receptor. 4"carboethoxy omefentanyl is estimated to be 30,000x more potent. Using these higher potency options legally would mean expensive testing to nail for morphine equivalencies, precision dosing, and all manner of expensive paperwork, after all the drugmaker is on the hook for a multi-billion dollar class action lawsuit if they screw it up. Using street derivatives is cheap, people die but nobody can sue an illegal dealer for using dangerous, untested, and bad quality control.

I mean seriously, who is going pay for human testing for these derivatives to figure what the safe dosing actually is? This is not THC where acute overdosing takes effort, this is something that readily stops users from breathing.

Safe is expensive. If you are willing to go cheap and inject heroin, with raging Hep C epidemics, rather than pay more for black market pills, I just don't see people being willing to pay large premiums for safe diamorphine instead of cheap fentanyl derivatives.

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And Xi Jinping smiled.

Drug abuse rates are increasing in China too.

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"Legitimate heroin supplies are going to cost at least as much as black market opioids so I suspect we will still have a lot of users who end up on fentanyl derivatives"

So the brutal world-wide anti-drug policy doesn't even make it more expensive? I'm genuinly surprised.

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Social stigma doesn't much play in when it comes to fentanyl, because most people who use it don't even know they are taking it, since fentanyl is mostly cut into drugs including heroin, meth, cocaine, and pills.

Accepting all this is true, we might be better off legalizing heroin and letting Walgreens manufacture it.

+1 Although on 60 minutes a few weeks back they claimed one seller was advertising the there fentanyl was so good the x people had died using it.
Nevertheless I would legalize it all and hope that some company develops a substitute that satisfies the users but is difficult to OD on.

OTOH, the threat of OD might be keeping people away from it, before they're getting hooked. Legalization might turn into a whole lot of zombies walking around.

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The stigma is not so much as against a specific drug, it is against a certain way of being high.

People who use molly are often highly stigmatizing of people who do heroin. Both may think themselves better than going on a PCP bender. Opioids were once a freaky out there thing that only the most crazy drug users even tried. Now they are viewed, at least by the patients I get to see when a bad batch comes to town, as just another choice on the menu.

Which is why I fault docs for overprescribing Oxy; not because Oxy is terribly dangerous (though it is, in spite of the marketing) nor that many patients died from it (though mostly via diversion) ... but because it helped make a certain, highly dangerous, way of being high more socially acceptable.

Fentanyl and derivatives are indeed about drug deaers maximizing profit ... but the willingness of people with ages old problems actively desiring an opioid high is pretty new in the West.

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A girlfriend of mine had cataract surgery in the morning. I was surprised she called me that afternoon. "I'm high on fentanyl," she said. I asked her how that was going. Not earth-shattering yet, she said. Okay. Why are you telling me this?

She just wanted me to know, in case it was the beginning of a valiant fight against addiction. She was getting her support system in place.

Silliness notwithstanding, my friends uniformly seem to fear becoming addicted to pain medication. I suspect their kids are the same.

Sure is right. What a mockery of the current dismay over stratification and "inequality" this reckless abandonment of the social stigma surrounding drug use, whether it proceeds as far as legalization or not, will cause.

Thats crazy. You don't need anything for cataract surgery. Well, a small shot in the eye...

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It's crazy to me that we still talk about the difficulties in stopping drug abuse, or any crime, when there is a country that has literally already solved these problems.

We could end drug abuse by next year if we adopted Singapore's policies identically. Blanket the country's cities in cameras and quickly execute anyone caught with over a small amount of any illicit hard drug. Sure there may be some false positives, and that's a shame, but the resulting fall in drug abuse and crime rates would make up for it by a mile.

Thanks, one of the questions that occurred to me was whether there were any examples of countries that had successful anti-drug policies. It seems there are.

There was a comment up thread about the “brutal anti-drug policy”. US policy at least seems accommodative, rather than brutal.

We spend tens of millions on needle exchanges, treat the nth trip to rehab as a press event for celebrities, politicians advocate for normalizing marijuana use and limiting pre-employment drug screening. Drugs are routinely sold on street corners, we don’t even seriously inconvenience sale.

This is not only not brutal, it’s not even serious.

Marijuana was probably misclassified in the beginning. It looks like it's worse than beer or wine, less bad than whiskey. Certainly a whiskey habit will kill you sooner.

For the rest? I'd go for a semi-libertarian solution. Make them all fine with doctor's prescription, under or supervision. That would allow the doctors and patients who want to tinker with psychedelics to do it without bothering the rest of us. It would allow free research in all.

Buying or selling without a prescription should be a crime, but whether a violation redirects you to health services or criminal investigation should probably be a matter of scale.

Call me a softy, but I think someone with a gram of cocaine should be offered counseling, rather than prison. A kilo, maybe the other way around.

I think you hit all the right spots there. I used to think pot was less harmful than beer, even though I'm a beer drinker. But now I'd say you're right.

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BTW, speaking of economics and public policy, I think legalizing pot for tax and profit was a mistake. It's a weed. It should have been legalized for home cultivation and *not* for sale. This would have prevented all sorts of weird incentives.

Also should have been regulated as per THC content; it's not your dad's pot anymore.

The problem is, regulatory regimes don't work so well after two or three generations have come of age ignoring the law. Legal grow states (CA, OR, etc.) now have tons more marijuana than anybody wants and export to states that haven't legalized. In addition, non-taxed marijuana is much cheaper and buyers aren't inclined to start being persnickety about buying state-approved, more expensive stuff now.

Frankly, in this day and age, all drug laws should be looking at doses of active compound(s) for regulation.

I am known for not liking legalization, but if we were thinking through ways to end THC prohibition, it would have been far better to decriminalize growing/consumption and not creating a new industry, like gambling or alcohol, where corporations stand to profit from offloading huge amounts of negative externalities on those of us who do not use.

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Most people don't get as aroused as you by the idea of the state killing social outsiders, so it is not a goer, except in the world's smiliest dictatorship, where what the best people love to do most is to flee.

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Politics is the art of the possible and people would not tolerate that in the US.

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Seems way too much stigmatizing of all drug use, too little realization that various drugs are substitutes for each other, and no recognition that drugs can be fun!

Too little recognition that most drug "treatment" programs are both costly and ineffective. And nowhere more so than when coerced and subsidized.

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there are 7.5 billion people in this world...in the overall scheme of things does it matter if several million of them become addicted to opiates and die early as a result?...this is a tragedy for some individuals and family members who may care...otherwise world keeps turning round life goes on...

Nonsense. The suffering of my fellow countrymen is more important to me than the suffering of a million people some place else. The opioid crisis hits close to home by being home. The simple fact that this blog post is discussing it reflects the importance of a drug usage problem in the US as opposed to a drug usage problem some place else.

Your attitude in which people are fungible and are equally deserving of our care, alarm and empathy (or undeserving, whenever people make "the world is full of people" arguments) is the outlier here.

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surfie, that's pure nihilism. You can pretty much send this sentence with anything: "....in the overall scheme of things does it matter if ____________"

After all we're all dead soon anyway, and eventually the Sun will devour the Earth. So let's not fix anything.

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I think Sure should get the Commentator of the Year award here; he's consistently had deep, technically informed posts on medical matters.

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