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wespiser_2018

Good write up. The US is really grappling with diseases of despair, and heroin/fentanyl addition is on of the biggest ones impacting the wellbeing of our society. A massive slice of talent and raw human resource is just dying every year, but the solutions that have worked in other countries are just impossible to implement here due because the the methods that are known to work are politically dead on arrival.

I'm a strong proponent of the US taking the approach the Swiss took to combat their opiate epidemic in the late 80s and early 90s. Anyone that is addicted to drugs can get the drugs they want, they just have to already be addicted first, and accept the drugs in a safe environment. It would be extraordinarily expensive, but cases like Jacks are already costing us much more than just giving him drugs, keeping him alive, then having healthcare professionals be there at exactly the moment he decides he's had enough. The effect on new users would be profound as well: as all the current users naturally age out of wanting to use hard drugs, the majority of drug dealers (other users themselves), won't have the capability to introduce new people to hard drugs.

However, we seem to have this huge moral hang up in the US about giving addicts drugs, even though we know that will save lives and money by reducing crime and lowering overall healthcare costs. For all the money Jack's parents spent on rehab, and hours spent watching him, none of it could prevent them burying their son the day he got a bad bag of heroin. For a case like Jacks, only safe drugs and injection sites would keep him and the millions of people stable before they are ready to move on.

The US is just not prepared to do what it takes to solve the opiate epidemic, and it's so frustrating to what tens of thousands of people die while we aren't anywhere near getting our act together. It's a Vietnam war in OD deaths, every year, and the Sacklers just walked with no criminal liability. Unless we do something drastic to reach these people, the opiate crisis is never going to go away.

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As a Swiss person who spent a few years in the 90s going to primary school on Langstrasse, watching junkies shoot up, and having to be careful in city parks to not step on the mountains of used needles… that is about the WORST idea I have ever heard.

The Swiss experiment in the 80s and 90s was a complete disaster, and it wasn't until the 2010s that that part of Zurich was finally cleaned up. It attracted the worst junkies from all around Europe, it created a crime wave in a country that was crime-free. It didn't work, either, it just led to more addiction, death, and despair.

FWIW, used needles were a common sight in my childhood and youth in the '80s/'90s in Italy too, and we didn't have such policy.

I've literally not seen a used needle in at least a decade, but again, I'm not sure it's because of policy, it seems more likely that people have just, for the most cases, switched to different drugs.

Same in the UK, from Brighton and there has been heroine here on and off, certainly a used to see needles in the 80s.

Used needles are still a common sight in Melbourne.

I grew up in a rural town in NSW and we kids had hardly ever heard of hard drugs let alone ever having been offered any. At best, all we knew of them was that it was an overseas problem and that there were strange opium dens up in Asia somewhere.

We were never warned about drugs in primary and secondary school as there weren't any - with the exception of cigarettes, which some kids tried down behind the school toilet block but that was more a defiance of authority than a real problem. Drugs were never the topic of conversation amongst us at school.

The first time I came across discarded needles and syringes was quite some years later when I was walking around the Colosseum in Rome. It was a bit of a shock to see them in such a renowned place.

I am forever grateful that we kids grew up in such innocence of drugs (that wasn't true of other dangers however).

The sad thing is that that’s probably no longer the case, it sounds like ice/meth is a big problem in rural Australia.

Tragically, that's ever so true, rural country towns both in the US and Australia are now in the vanguard of the drug epidemic. It's not only ice/meth but also opioids thanks in part to the Sacklers.

Fortunately, my family seems to have escaped the illicit drug problem and I no longer live in a rural area, nevertheless sometimes I wish I had Dr Who's tardis to escape back to a much simpler time - at least for a short respite anyway. :-)

In Toronto you're 10 meters from a needle at all times! (Fake number, but they're everywhere)

I grew up near the heroin junkie city of The Netherlands (Heerlen) which also attracted a lot of junkies from the Aachen area. I got a fear of needles likely influenced by the needles on the streets. Thanks also to everyone mentioning which cities contain needles on the ground, I forgot about it being a possible thing (I would not visit such a city, and I live/work near Amsterdam, go figure). Getting my COVID-19 shots was a serious hurdle because of my fear of needles. It also likely influenced my disgust of prostitution (a lot of the female heroin junkies turned to prostitution). Most of these people were homeless, too.

They (local gov) tried a lot of things to fix the problem. Play classical music at the gathering area (the train/bus station). Free methadone. Free needles. Free heroin I don't believe was tried. Give the homeless a task like selling a newspaper called 'street journal', watching everyone pass by looking down on the seller. Cynical me would say these people passed away. I met one of them at a work reintegration company, and I recognized him right away. He had HIV. Though this was in ~2006. I let him listen to one of my favourite music at that time, and I remember he enjoyed it.

I learned of the popular drugs in first of high school (age 12), as part of education (alcohol, cannabis, XTC, heroin/cocaine). In my late young adulthood I ended up trying quite some drugs. Mostly psychedelics, never heroin (or cocaine), and amphetamine only once (from which I know how it feels to be an asshole). They are far too addicting, and destroy lives. I've been addicted to nicotine/cigarettes though, but so has 25+% (?) of society. It was tough getting rid of that habit (I am probably still 'addicted to it' just not practicing).

Lots of good movies (and books) were made about heroin addiction. Wir Kinder Von Bahnhof Zoo. Requiem For A Dream. Trainspotting. Just to name a few. The social setting a (young) person is in is going to have a huge influence. Sure, its also a matter of morals and values and parenthood, but how can I affect which friends my children are going to have in school?

When faced with the prospect of losing a child to heroin based on his friend crowd, you can take action. My family moved to a different states to do a friend-group reset for one of my uncles. Kids are worth fighting for. Do whatever you have to.

Ditto in Spain.

Is it better now? Were there over initiatives that played a role?

Yes, they shut it down in 1992, but it took another 15 years or so to fully clean up the mess it created.

This puzzles me. The Medication Assisted Treatment (metadone and buprenorphine) started in 1991. The Heroin Assisted Treatment (HAT) started in 1994. People that failed the MAT were enroled into the HAT.

Limited first HAT experiments were found sucessful, and thus expanded in 1999. In 2008 both approaches entered the law.

All data from here: https://doi.org/10.1186/s12954-020-00412-0 , but you can found it in a lot of papers.

The opioid/heroin epidemic that hit the whole Europe, took place in the 80's, with AIDS making it worse at later 80's and early 90's, causing all countries in Europe to tackle the problem hard starting in the early 90's. Yet you claim that HAT not only was shutdown in early 90's but that it was the thing that created the mess.

Dates don't add up, sorry. Maybe you are talking about a different swiss experiment, and not the internationally famous HAT.

The first phase of the experiment was to have a free zone in the Platzspitz park, with a needle exchanges, and no interference to drug sales and use. The park became known as "needle park."

https://en.wikipedia.org/wiki/Platzspitz_park

They shut it down in '92, which led to junkies spreading throughout the city, particularly on and around Langstrasse.

It wasn't until a real crackdown that things got better. They tried a few approaches like the treatments you mentioned, but that's very different than the laissez-faire decriminalization experiment that blew up in everyone's face.

There's a good documentary or article about the whole thing I meant to recommend but I can't find it at the moment.

When a non-Swiss person talks about "the Swiss heroing/drug experiment", they are referring specifically to the HAT program, and not to a free-for-drug park.

It's obvious that if you put all the junkies of a county in a single park, without even the minimal hygienic measures, you create a mess. That's not laissez-faire, that's a mess, but to their credit at least they tried something different than the cycle "heroin user -> scum to jail or to cemetery". It would happen with anything imaginable: "now all homeless are allowed in the Platzspitz Park and nowhere else", a month later the park is covered with homeless trash to nobody's surprise.

The HAT is a step further (not backward) in decriminalization: you are hooked to heroin, metadone doesn't work. But you are not a criminal, and thus we will take a medical approach.

"But you are not a criminal, and thus we will take a medical approach."

Absolutely, it's harm minimization for both the addict and for the rest of society.

Yes, I was a bit surprised someone thought I was thinking of a free-for-all drug park. Have they not seen The Wire?

Yes, the Platzspitz/Letten scenes were awful, but these are not what the post that you were initially were responding to was describing.

> It wasn’t until a real crackdown that things got better.

Yes, there was a crackdown, but it’s not like this hadn’t been done numerous times before, both in Switzerland and in other countries, so this hardly could have been the major cause of the permanent improvement (which I think we both agree did indeed occur around that time).

> They tried […] the treatments you mentioned

And THOSE were the new factor, and THAT is what made the difference. The Heroin assisted treatment is still in force (an article a few years ago mentioned that about 1400 addicts in Switzerland are in the program).

> It attracted the worst junkies from all around Europe, it created a crime wave in a country that was crime-free.

Well, that's the issue. No one area within a zone of free travel can exclusively do this. That is, if Ohio did it, druggies throughout the US would go there.

But, as I understood the idea, the free drugs were required to be consumed on premises under the watch of a professional. So why would any drugs even leave the facility.

> ...why would any drugs even leave the facility.

They wouldn't need to. Supply follows demand. When you get enough users in one spot, you'll find dealers. I'm strongly anti-prohibition and I think safe supply and safe injection sites are crucial, but there's no silver bullet. Every simple solution will cause knock-on problems.

Why would addicts pay dealers when they could get it for free? Genuine question.

Typically quantity is limited at safe sites. You can use, but you don't get to blow a whole 8 ball in one go.

That's the theory and it's been shown to work to some extent. The trouble is the drug problem is very complex and essentially intractable.

The best we can do is to aim for harm minimization whilst understanding that the minimum will never be a deep notch but will always be shallow.

I've paid more money to drink alcohol in a location I prefer countless times, so I'm sure some paid for the privilege of doing their drugs somewhere more interesting than the clinic.

Same reason you'd go to a bar to have a few drinks rather than pick up a six pack on the way home. There's more to these things than the substances themselves, something silver bullet salesman often forget to point out.

AFAIK, Switzerland wasn't all that free travel until the Schengen agreement.

But yeah, implicit in these free drugs proposals is a good deal of concentration: bring in the addicts from all over the place, and make them take their drugs in this place here. It brings it's own can of worms. Which I guess is why many methadone programs come with no requirement of supervised use. Sure, they ask for too much (given tolerance, there's little way to know how much they need except skiing), and sell the surplus on the illegal market to users who aren't able or willing to join the methadone program... leading to more deaths from methadon overdoses than heroin in many years. But it's not clear the alternatives are any better.

That's fair: I've been to Zurich in 2019 a few times, and I was amazed by how clean it was. Remarkable. Even compared to a US, east coast city, it was much more cleaner than anything I've seen. However that doesn't mean the problems don't exist.

I do think I got the dates wrong. What I'd like the US to do is adopt a similar liberal approach to prescribing medication assisted therapy, and go as far as we need to go in finding the medication that work for people, like is done today in CH. I don't think the "free firezone" approach is a good idea (akin to "hampsterdam" in The Wire), but getting addicts healthcare and a medically supervised substitute is what I meant. The big part of that in the US, IMO, is fighting the social stigma around adopting science based approaches large scale addiction management, and right now the only acceptable solution is to get people off drugs, then have them OD when they get back on. There is a better way!

It's a really complicated problem but one thing that just stands out to me is the role the doctors play: It's not normal to send people home with these massive prescriptions for opiates.

Here in Europe doctors are very, very conservative with that stuff (and meds in general) while it seems to me that in the US if your "medical experience" even entails the slightest bit of discomfort people get all up in arms over it. Doctors are highly educated people who can no longer play the "I didn't know it was addictive" card.

I have a friend in the US who told me they have an app on their phone where they can just tap a button and the next day they can refill their benzo prescription, and it's been like that for years without having seen a doctor again. That's just criminal behavior from the part of the medical establishment.

I don't think it's a really complicated problem, other countries have tried different things that have worked.

It's complicated for some people to admit the 'war on drugs' has failed maybe, but that's a different issues all together.

What's complicated is that it's not really the drugs, it's the fact that people experience their lives in such a miserable way that oblivion through opiates is a better option.

IMHO this is because of alienation, a loss of community, strong personal bonds, lack of goals.

There's a famous experiment that sums it all up perfectly - the one where animals were given an unlimited supply of cocaine and they took it until they basically starved themselves to death. But when they put the animals in a nice stimulating environment with toys and friends to play with they basically ignored the drug supply.

So yes, providing govt run shooting galleries will stop people from dying and you'll make them slightly less miserable but those people will still live lives that you wouldn't want for your children. They have an illness that needs to be cured.

There's a famous experiment that sums it all up perfectly

I think you're referring to the Rat Park experiment (https://en.wikipedia.org/wiki/Rat_Park), and (as always) its conclusions are not as solid as the myth implies. That's not to say its results have been disproven, but they haven't been confirmed with other studies either.

Still relevant though because if you have a medical problem (addiction) and rather than be provided with care you’re treated like a criminal, you’d feel even more isolated and less part of something good.

The amount of pain meds my wife came home with after her c-section was like 100x what she ever used. I’m sure there are some folks who need that much but I doubt it’s the median.

My recent experience in the U.S. has been that, at least at major hospitals, it's flipped to the opposite extreme, and doctors are so worried about the backlash, that they will leave patients in pain and fail to prescribe analgesics sufficient for post-surgical pain control, if they don't have non-opioid options.

My partner had a post-cancer DIEP flap reconstruction last month at a top cancer center in NYC, and due to the nature of the surgery, couldn't take NSAIDs, which are typically most effective for her (they have blood thinning side effects and were banned for 2 weeks post-surgery to avoid risk of hematomas). So she was left with taking over the counter Tylenol plus prescription opioids. They prescribed opioids 2 days of pills at a time, which required me to constantly drive to pick up new prescriptions (since obviously she couldn't drive), and it felt like some kind of interrogation each time she'd call up and report her current pain levels. As if they assumed by default she was lying or was a drug addict or something, versus someone recovering from major surgery that doesn't heal in 2 days, and furthermore is not allowed to take anything else that's effective (NSAIDs). Hours spent writhing in pain trying to get some pills prescribed and picked up. It only got resolved once the two-week NSAID ban was up. Then she stopped calling about the opioid-based analgesic and just started taking large ibuprofen doses instead. Problem solved, since you can buy as much ibuprofen as you want. But a pretty shit two weeks up until that point.

As a result, I strongly dislike a number of aspects of the anti-opioid backlash. It made our lives worse and caused us more suffering.

I had open heart surgery in the US and the doctors refused to give me opiates to take home in the few days after. They gave me opiates while I was in the hospital, quite generously, which was for four or five days, but they would not let me take any home. I even asked for just five pills in case the pain was unbearable (they literally had just broke my ribs and sternum and sawed my chest open).

I don’t respond much to opiates anyways, but I still find it completely ridiculous.

What you experienced is obviously the pendulum swinging too far (in the right direction). Then again, it should just be accepted that major surgery will always involve some discomfort.

There's a big distance between "5 days worth of low dose Tramadol" (+ max dose of Paracetamol) and "2 months worth of Oxycodone". It's really not a hard problem to solve for the medical establishment.

Yup, there are a lot of people with chronic pain, and the only things that reliably treat pain without being really bad for your system are opiates and weed. Paracetemol (and to a lesser degree ibuprofen) are so bad for you they mix it into opiates so that if you take enough to get high the paracetemol sends you to hospital, and weed is stigmatised at best, and still illegal in most of the world. Ketamine in useful doses has too strong side effects, cocaine-derivatives are only really good locally, and also not great for your system. And that's about all we've got.

As a kid I had migraines, and quickly developed an immunity to the pain-relieving aspect of paracetemol, they were basically candy by the time I was a teenager. Luckily they disappeared in my late teens, but now I'm in my 40s and I get weird pains they call "cluster headaches" in my face. I did some tests, got an MRI, and they didn't turn up anything, which is pretty much the end of medicine, pain management is all there is for me. In Australia we need a prescription for any opiates, so I have to be treated like a drug addict to get painkillers the rest of the world can buy over the counter, it's a disgrace.

> I get weird pains they call "cluster headaches" in my face

if you have not already done this, you could consult an "migraine center". There is no cure but there are some effective (for some people at least) options for treating cluster headaches, like triptans and lifestyle changes (regularity in sleep patterns, etc.)

They're very different from migraines (which I had as a kid), in that there's no visual effects or nausea, and seem to be more localised and less "systemic". I'm always trying to work on my sleep, with very little success overall. I've never tried any of the serious sleeping pills, they seem too risky; but a combination of restavit (an antihystamine) and melatonin can get me to sleep pretty reliably, the problem becomes that it sometimes leaves me a bit too slow and stupid in the mornings.

That is very different to when I was at BIDMC for my plastic surgery rotation as a medical student - I was shocked at the quantity of opiates people were going home with for simple things, let along DIEPs. I gave a talk to my team when I left on differences and focused on opiate prescribing (this was in 2013)

Are the only options doctors can prescribe NSAIDs vs opioids? There is nothing else in between?

As far as I know, there surprisingly aren't other options. I also assumed they would have something else up their sleeve that was stronger than OTC ibuprofen but weaker than a morphine analogue. But, the three classes of analgesics really seem to be Tylenol, NSAIDs, and opioids. A few other things are usable for anesthesia but not something you can prescribe as a pill for at-home pain control. There is also some evidence for cannabinoids, but they're stuck in legal limbo. The other thing that comes to mind is that benzodiazepines can also help in some patients. They don't have a direct analgesic effect, but can help people relax or sleep so as to ignore pain (they can also be habit-forming, but probably not to the same extent as opioids).

There are other painkillers coming and going. In my country, the middle ground was, for years, metamizole. This drug is currently baned in some countries (e.g. USA) for its side effects, while is sold nearly OTC in others (e.g. Mexico). Other drugs like flupirtine or nefopam are about the same: middle ground painkillers, but too bad side effects.

The good thing about opioids is that you can dosage them precisely, and that you have plenty of opiates in a ladder of potency. Tramadol (sold as Ultram in the US) is a middle-ground painkiller despite being an opiate. Same as codeine. Slightly above is tapentadol. Curious thing is despite tapentadol has not been found addictive (at least as addictive as other opiates), it's still an opiate, and so the FDA put it in the same bucket as fentanyl and morphine.

Another analgesic is cannabis. Sadly, it has the same problem as opiates: it was deemed too fun or too good, it seems we must endure pain to make the regulators happy. It turns out people hate pain, so they end up taking fentanyl and heroing under a bridge.

The sad thing about all this is that the regulators decided pain is not a bad thing, so you must endure it. But they decided anxiety is a terrible thing, so you can get as much bromazepam as you need. Even when bromazepan and other benzodiazepines create dependence and tolerance (and the withdrawal is terrible), I'm sure you now at least a dozen people taking it cronically (I do). They are as hooked to that thing as it was heroin but, hey, it's legally prescribed, so no problem here: one pill for breakfast, one before bed, and they are 24/7 high while nobody bats an eye.

You can give Codeine or Tramadol, which are opiates that produce no "high" when taken in standard therapeutic doses. People do abuse them by taking a whole box at once, but you won't end up in a scenario like in OP's story where someone discovers it "solves all their problems" after receiving them for moderate pain from a routine medical procedure, and has them shooting heroin 6 months later.

Pregabalin/Lyrica, I think. It's a seizure medication but as it was explained to me it increases the amount of signal your nerves can take, or it slows the signal, and that reduces pain. It helped me in the past but it makes you tired.

Once, about 10 years ago, I had some mild pain in my shoulder after skiing. It was hardly debilitating, just annoying. I went to the doctor, and within about 15 minutes I walked out with a prescription for 60 Vicodin. I don’t know if things have changed in the states much in that time, as I haven’t had a need to find out. But it still strikes me as odd that they would give me that kind of a pain killer so easily.

I can tell from experience that having to go to doctor, then wait there then having to go to pharmacy then wait there, all in pain massively massively sux.

Having to do it on the regular would be just cruel.

(To start: Just to clarify there's a significant difference between benzodiazepines and opiates.)

> I have a friend in the US who told me they have an app on their phone where they can just tap a button and the next day they can refill their benzo prescription, and it's been like that for years without having seen a doctor again.

Is this the "request a refill" feature that every US pharmacy offers? Granted, benzodiazepines are less restricted than stimulant drugs¹, but a doctor in the US need to at least review a prescription twice a year.

Chronic (daily) of benzodiazepines is bad, and doctors will not² start new patients on this.

There's still a lot of legacy patients who are on chronic benzodiazepine treatments -- doctors should work with them to wean them off, but it's very challenging and disruptive.

Requiring a patient receiving a benzodiazepine at a non-daily level (e.g. for seizures, anxiety, occasional insomnia) to go back to see their doctor when nothing's changed several times a year is just pushing medical costs (money/time) on the disabled.

¹: e.g. Adderall, which can't be refilled

²: Providers are trained not to these days, at least

What's so fascinating to me, is that the current opiate epidemic is largely centered in the US, as we bear the majority of the deaths. That attitude of Drs. over-prescribing, it definitely happened in the US, to various degrees in different places, and not that long ago.

Docs in the US tend to think they are above being marketed to, but Purdue Pharma knew better, and they paid their drugs reps a ton to go out to "everytown US" and convince doctors that they had made a non-addicting opiate. Enough docs bought it, and here we are.

How did they do? Well, 20 years ago drug reps used to be able to take doctors on trips: to sports games, to see the dog races, to museum trips, the price of a day trip with you and one or two loved ones was to sit through an hour (or two) lecture by a rep that convinced you to to prescribe a drug. Not a bad deal!

There were complex reasons why the opiate crisis started, but the environment was ripe for an upstart company like Purdue to come in, reformulate an old opiate, pretend the addiction problem isn't there, then sell a miracle drug because opiates are extremely effective short term analgesics. Long term, we're still paying for it!

I've looked a lot into the opiate crisis, and it's a pretty bad stain on the US medical institution, particularly our medical science. We fucked up.

>A massive slice of talent and raw human resource is just dying every year, but the solutions that have worked in other countries are just impossible to implement here due because the the methods that are known to work are politically dead on arrival.

From the essay, it sounds like Jack was not possessed of any great "talent", or of any particular value as a "raw human resource". He was just a dude, probably easily replaceable from a HR perspective, and these are the sorts who, historically, we are willing to sacrifice in order to honorably lose a war on drugs. (If you want to know what kinds of sacrifices are required to win a war on opiates, Mao is the "best" recent example.)

We live in a cruel economy, where the "losers" are left to find solace in electronic toys and mystery fentanyls sold as heroin. Mostly, the losers are determined ahead of time, and their numbers grow as the middle class shrinks. It's an inhumane system with inhumane outcomes built in.

*I know I'm reading too much into your word choice, it's not meant as a personal attack, it's just useful as a jumping-off point for this post. If I were a better writer I would have figured out how to avoid this impression, but I'm not, so please take my word for it. I think you are basically right about the humane way to handle this.

> From the essay, it sounds like Jack was not possessed of any great "talent", or of any particular value as a "raw human resource". He was just a dude, probably easily replaceable from a HR perspective,

I've seen a lot of smart people fall to drugs. Sure, if they get in too deep too early, they won't have a degree when they die, but they could have had one.

And yes, as an HR person in a comparatively small company, this person is easily replaceable. On a country scale, however, you can't simply replace him - you need the numbers of highly educated smart people and you can't simply "hire" them back from another country. Look at the stereotype of the asian genius - disregarding the other factors, China simply has 3-5 times [0] the population, so they will statistically have 5 times the geniuses to start with. You can't compete when your best bets have a 5% chance to whither away due to drugs.

> If you want to know what kinds of sacrifices are required to win a war on opiates, Mao is the "best" recent example.

How so? I don't know what specifically you're pointing to, but given that other countries handle the situation better with less "sacrifices", I don't think they're necessary.

[0] Depending on US or EU perspective.

>How so?

He waged war like a war. I don't personally recommend waging wars on chemical compounds or the desperate predestined "losers" of the economy, but there's something to be said for winning a war with cruelty vs losing the war with half the cruelty.

"It was the communist revolution that erased opium from mainland China. Mao Zedong , with his political apparatus that reached into every hamlet and home, was able to lay the beast low. He used a mixture of carrot and stick. Addicts were not condemned, but offered medical help and rehabilitation. But those who were unco-operative were sent to labour camps or imprisoned. Dealers were summarily executed, often without trial." [0]

"Smart" people getting hooked on drugs is exactly as tragic as "losers" like Jack, any competition which ignores this is one we should be enormously proud to lose.

[0] https://www.scmp.com/article/547678/maos-drug-lesson-world

Do you have any good sources for info about Mao's approach? Very interested to learn more about this. The wikipedia article seems to corroborate what you have said but provides no sources either :(

Mao's government compelled addicts into rehab and summarily executed drug dealers [0][1]. Drug trafficking is still a capital crime in the PRC. In 2017, 13 traffickers were sentenced to death at a public trial in front of 10,000 spectators [2].

[0] https://www.scmp.com/article/547678/maos-drug-lesson-world

[1] https://en.wikipedia.org/wiki/History_of_opium_in_China#Unde...

[2] https://www.thesun.co.uk/news/3906319/china-drug-dealer-mass...

>From the essay, it sounds like Jack was not possessed of any great "talent" ... probably easily replaceable from a HR perspective

I think part of our problem is we put first value on people by their economic output. We need to realize there's more to being a person other than how much money you can make some rich dude.

I am "not a genius, but not dumb either" much like Jack. But for one reason or the other I seem to have an aptitude for this whole programming thing, and technical stuff in general. Is that "talent"? I guess it's not "talent" in the wunderkind sort-of way, but it is "talent" in the sense of "a decent aptitude allowing me to perform better at these kind of tasks than average in the general population".

I was never addicted to drugs, but for the first ~25 years I struggled in life in much the same way. No education, no real job, no real direction, future, or perspective, no real friends, no girlfriend, what's the point? I suppose my situation wasn't quite as hopeless, or maybe I'm just a different person, and it probably also helps that drugs usually just make me feel weird in a bad way and never enjoyed it much.

Plus, I never stopped programming, or lost my interest in it. It just took a long time to scrape together the confidence to actually apply for jobs. For a time I was either jobless and programming stuff at home, or working minimal wage jobs and programming after work. At one place I managed to "hack" the computer used to scan barcodes and during night-shifts (with often hours of nothing to do) I would write some toy programs to pass the time (more fun than smoking weed outside like some of the other people were doing). I sometimes wonder what would have become of me if I hadn't learned programming as a young teenager, or had lost interest somewhere along the way.

Either way, we'll likely never know what "talent" Jack did or did not posses as he never really seems to have developed any due to a combination of his personality, environment, and just "bad luck". Even the most talented and gifted programmers I know don't "just" do it automatically; they still need to apply themselves and develop their talent. For all you know you might have it in you to be a word-class guitar player, actor, soccer star, or some such. But if you've never played guitar, acted, played football, etc. and developed this talent then you'll never know.

Sure, maybe one Jack isn't a big deal, but what about 1000 Jacks? How much economic output would 58,000 thousand early deaths be in a year where we have a labour shortage and a supply chain crisis on our hands?

Jack might not be the best example of "raw human talent", but people like him contribute to the economy that are hard to measure, and of equal worth to anyone else.

I'm of the opinion that we shouldn't compare lives, but I guess we could compare economic value, and for the thousands in lost lives, even working the most menial jobs, that's still tremendous worth in a country where our birth rate is shrinking faster than ever.

“ The effect on new users would be profound as well: as all the current users naturally age out of wanting to use hard drugs, the majority of drug dealers (other users themselves), won't have the capability to introduce new people to hard drugs”

Why do you believe this to be true?

Giving free, safe drugs will depress demand for illegal drugs: most dealers are users, and are pushed to a high risk criminal activity - drug dealing - in order to finance their expensive habit. They take extraordinary risk for this, including actively seeking out new clients.

If you give out free product, you not only kill the primary demand, but most dealers themselves don't have a reason to continue taking risks - because they can benefit from the free product too.

Purely profit oriented dealers will remain in the market, which is now much smaller and even riskier, since they can only sell to recreational users.

> most dealers are users, and are pushed to a high risk criminal activity - drug dealing - in order to finance their expensive habit

Source?

The smaller the transaction amount, the larger chance that the dealer is going to have an addiction of their own. It’s easier for one wholesaler to sell to an addict (or several) that distributes small amounts to a bunch of other addicts, vs taking on all the volume yourself. Addicts usually know other addicts and have a strong incentive to sell, they need cash every single day.

I doubt you’ll find a source, but the number of users distributing small amounts is probably larger than the amount of people pushing weight (who usually don’t use)

This is based of my experience buying heroin in a mid-sized US metro area, fortunately far in my past. One without an open-air drug market, so deals were done in cars or alleys.

I also have a hypothesis that if it's freely available and boring then more people are likely to quit. The focus required to get it I think is part of what keeps people addicted - the reward is uncertain.

If addicts can go to a boring clinic and get it daily for free maybe they'll at some point look up and wonder why they're doing what they're doing.

Especially if the clinic has easily available assistance and things that can help people quit.

Even in the worst case where they remain addicts, at least they won't OD and they're not funding organized crime.

Probably not as easy with meth though - it's one thing to be addicted and still responsive to incentives, psychosis is a harder problem to handle.

I'm not sure that market is so much smaller. The "recreational" market includes anyone who couldn't afford to publicly admit their use, including for instance single parents who use amphetamines to try to have energy to do necessary things after a full day's work at the meatpacking plant.

It's just how it works. There are diminishing returns to the common drugs of abuse. If given access to high quality drugs of abuse without negative economic and social consequences the body will adapt, use will plateau, and for the majority eventually phase out. A minority will choice to maintain. There are negative health consequences to long term maintenance but it's not like the reality of obtaining poor quaility street drugs in dangerous situtations. It's data driven and based on medical theory so it's not much of a belief. See Swiss and UK medical heroin programs for evidence.

Introducing friction to your ability to satiate your vice is the first step in battling addiction.

That doesn't agree with anything I've learned about battling addiction. Do you have any research or studies that support that? Or other programs with a good track record?

Because, unless you are using the term "friction" to be so all-encompassing as to be meaningless, this sounds like a recipe for a lot of failed attempts to fight addiction.

Every addiction treatment effort is to introduce friction, like dumping out your booze in your home into the toilet, getting a new job that doesn't tolerate smoke breaks, or finding new friends that aren't going to peer pressure you into using. If the vice is easy to act upon, you will continue to act upon it indefinitely.

Actually variability of reward is part of what makes dealing with addiction to street drugs more challenging.

Pareto law effects on the consumption of drugs, and network effects that result from the fact that the majority of street level dealers are doing it for the sole purpose of supporting their habit? No life ruining class A felony is worth the money you get selling drugs, but people do it it all the time because they are sick with a disease and feel they must.

New people will still be introduced to drugs, but there are definitely network effects in opiate addiction that can be mitigated when supply is transferred from an illegal source that requires people to organize and recruit new users with cash, to one that is organized and paid for by the government.

It's not perfect, but even decriminalization has had a pretty remarkable effect on Portugal, at least that's what the latest studies are saying.

The invisible elephant in the US opioid policy discussion is the lacuna between the policy and its implementation.

You have to find a human being to perform the work of enforcing the drug laws. The US has had drug addicts for a hundred years, and the attitude towards opioids hasn't changed very much, but the usage levels go up and down. There's a back-and-forth between "rehabilitation" and " incentivizing" that correlates poorly with the outcome.

What correlates better with opioid use? Recently, the epidemic clearly started with overprescription and then exploded with fentanyl:

https://www.cdc.gov/opioids/basics/epidemic.html

It's important to notice that prescription opioid overdoses don't go down until 2017. This problem started with prescriptions and it won't end until the problem is fixed. Pills should be replaced with patches wherever possible.

The other glaring issue is that the meteoric rise of fentanyl was not noticed until it got out of hand. This is a societal problem: drug messageboard users knew about the fentanyl crisis years before the regulators took any action.

The regulatory system, viz. the DEA, has been starved for talent for decades because nobody wants to work for them. The enforcement-for-profit model of the civil asset forfeiture era of policing has driven talented and motivated people away from law enforcement careers. The people who are left are not qualified or motivated for the task at hand. Enforcement should be more proactive than it was. It should focus on real dangers, not culture wars. Opioids and dopaminergic stimulants are the drugs of self-destruction; everything else is a distraction.

The most ironic thing to hear people chanting in an epidemic of poisonings brought on by illegally and irresponsibly manufactured high-potency addictive drugs is "abolish the police!". These people need the police. But nobody trusts the police.

One quote we were all forced to memorize in school was: "A house divided against itself cannot stand."

I don't disagree with your most of your assessment, except that I do think we should abolish the the DEA. The war on drugs has been going on for 50 years. At some point, we have to admit that drugs won, and address the crisis in the most effective way based on the best, most recent information available to us, which is that addiction is a disease and one that can be effectively managed.

20 years ago, sure, who cares about the DEA, they put dope and guns on the table and largely stayed out of peoples way. Now, we have around 60k thousand deaths per year from the opiate crisis that reaches almost everyone in America. Law Enforcement has no solution, just carry around Narcan while drugs come in through every major port and postal facility in the country.

Let the cops do what they are good at: reduce violence, enforce property rights and keep communities safe, but stay out of healthcare. Give the DEA the best grads, and that won't change the fact that they are working in a system where they simply don't have the power to stop two consenting individuals engage in a prohibited behavior.

>It would be extraordinarily expensive

I mean we spent $300 million a day for 20 years on Afghanistan, it can't be that expensive.

>the Sacklers just walked with no criminal liability

In fact, the media firestorm and the political response made heroin overdoses much worse because they "clamped down" on pills that at least had a dosage on it. Addicts then turned to heroin, which now has fentanyl in it.

Still many more annual overdoses of prescription pills than illegal drugs.

>Still many more annual overdoses of prescription pills than illegal drugs.

Not since around 2016, which is around when the panic with pills started and we started cracking down. It did put a small dent in pills but fentanyl is off the charts. We probably would have been better off, at least in terms of deaths, if we had just ignored the "opioid epidemic."

https://www.drugabuse.gov/drug-topics/trends-statistics/over...

Thanks for the correction.

That's right! in 2011 they switched the formulation of OxyContin. The opiate crisis didn't start then, but it got a whole lot worse!

The Sackler decision had a pretty big effect on me. It's hard not to grow up when I did, lose people you know to the opiate crisis, and not feel a deep sense of unfairness and wrong when the people responsible for so much suffering stay out of jail with a million dollars.

As much as you can blame them for that one act, it's the iron law of drug prohibition at play: Meth becomes Crystal, and opiates become more concentrated. Easier to smuggle, better profit margins, it really only goes one direction: the drugs get more potent every year prohibition is in effect.

> we seem to have this huge moral hang up in the US about giving addicts drugs

For many people, what you're describing all comes down to the law of love. It is not loving to give a person more of the thing that is destroying them.

Perhaps free methadone would be a better option?

EDIT: care to comment? I'd like to know why people disagree.

More often than not, lives are in greater threat of being "destroyed" by the consequences of drug prohibition than the drugs themselves. Addiction is a serious health problem, but impure drugs that lead to overdose deaths, spreading disease through needle use, avoiding medical care for fear of legal consequences, going to jail and having a criminal record, and becoming involved in black market violence are all vastly more common threats to drug users than any drug.

I'm inclined to agree; substance prohibition in any form (except perhaps for nuclear fuel and the like) has a long history of causing an incredibly wide range of societal problems.

But removing prohibition is a far cry from providing free heroin to addicts... I understand the argument about removing the black market, but after seeing San Francisco in person it's hard to agree that free drugs and paraphernalia makes things better overall.

If my friend became a heroin addict, out of care for him or her I would not provide them with heroin even if I could afford it. Why should I treat other fellow humans worse?

Why is it different when we're speaking at a societal level? Love for neighbors should increase, not invert, when the number of individuals concerned increases.

They don't give out free heroin in SF. There are needle exchange programs, and a small number of safe usage sites. Also, you're assuming most of the addicts are heroin addicts. Quite a few of them are meth addicts, who are harder to reach, partially because the type of meth they're getting causes severe psychosis.

Giving meth addicts forms of meth that are produced more cleanly would reduce the level of psychosis and would further reduce the price of meth to a point where it may not be profitable to produce (it's already cheap to the point where it's nearly unprofitable - it requires massive volume).

Giving addicts access to clean drugs provides you an opportunity to help them, a place to keep them away from others while they're using, a way to ensure they don't die while using, reduces funding to organized crime, and removes their need to commit crimes to fund their habits.

You may see it as treating them poorly, but ultimately, you're doing them and the rest of society a benefit.

Is it impurities in meth that give you psychosis? I was of the impression that often it was due to sleep deprivation due to being on meth and not sleeping for days.

All forms of meth give you psychosis, slowly, with continued use. The sleep deprivation adds to that. Meth created via the P2P method is apparently considerably worse for you, and leads to psychosis at a much higher rate than ephedrine methods: https://www.theatlantic.com/magazine/archive/2021/11/the-new...

The long term mental damage from stuff like meth induced psychosis is not something that the state should be furthering, especially when the state isn't even picking up the ball for mental health treatment facilities. If we were serious about addiction, we would heavily crack down on users and send them to detox facilities where they will remain until they are clean and well rather than maintaining the status quo of tolerating increasing levels of open hard drug use on our streets.

"we would heavily crack down on user"

Learn some history. We tried this. It failed spectacularly, as if in slow motion, for decade after decade.

Nothing will stop trafficking since its a lucrative product and we live in a capitalist society, but crackdowns at least push drug use out of the open and cause people who get picked up to end up in jail or some facility rather than turned back out to the street where they often continue to commit more crimes. It keeps these chronic hard drug users out of public places like train stations where they are less likely to harm innocent bystanders. I've seen meth users on the train go off in racist tirades and start fights on transit just because someone happened to make eye contact with them. The status quo of not doing anything and shrugging our collective shoulders just leads to more people getting harmed, both the addicts and random other people.

I disagree. Alcohol, being legal, has very few of these problems, and it still causes immense damage to its users - more so than illegal drugs, by many measures.

Which is not to say there aren't humane reasons to fix these problems, especially if they aren't effective at reducing drug use anyway. But yeah, drugs actually are a huge problem and would be even if they were legal and free for all.

Alcohol is legal bc fermentation is easy so restrictions fail, not bc its harmless. Weed is by comparison harmless but easy and lucrative to enforce laws against. The reason for legalization isnt bc drugs are good, its abt the emerging economic dynamic with drug dealers and drug enforcement. drugs have become a profit center for the state and it has created perverse incentives that do not benefit the end user or society.

OP is saying most of the harms come from illegality.

I'm pointing out that alcohol causes immense harms despite being legal, so likely other drugs too would still cause considerable harms when legal (even though yes, it's likely some, like cannabis, would be less harmful than alcohol almost no matter what total consumption settles on under legalization).

I was not arguing about why things are legal or not, only challenging the assertion that drugs aren't very harmful when legal.

It's pride, not love.

And a pride that is essentially about avoiding shame; shame being the primary currency of those with an authoritarian bent.

> It's pride, not love. And a pride that is essentially about avoiding shame;

That has nothing to do with my rationale... I'm curious where you got that.

If I give heroin to an addict, the only shame involved to me would be the personal feeling of shame from having caused harm to another human...

So I think this response is a straw man that doesn't address my point.

What are the loving consequences of not giving them the drugs that you are hoping to achieve? Like, how is that making their life better? Or do you assume that (evidence to the contrary) without you supplying it they'll be unable to find it?

Free methadone isn't all that much better from that perspective. You come to your doctor and tell him, "I'm useless, my life's hardly worth living, I'll never amount to anything so I might as well take opiates to dull the pain" - is it then the doctors job to basically say, "yes, clinically your life is not worth living", even if it is a milder opiate?

It's writing people off as lost cases. And many addicts WANT to be written off as lost cases, because a) they already did so themselves, but feel guilty about it, an official confirmation would be nice and b) it will give them access to painkillers.

Which is why I'm very skeptical of involving doctors in the first place in free methadone programs, if such programs should exist. It shouldn't be anyone's job to validate you if you say you're a lost cause.

Plenty of people get on methadone maintenance and life productive lives. This keeps them from scoring dope in the streets and fueling the drug trade. Judges have demanded people stop taking methadone and some of these people have ended up dead from an OD soon after or in jail when they were fine on methadone. Demonizing methadone programs doesn't help anything.

I'm not demonizing it, sure it can help many, but it is not a panacea. In Norway, we have a problem that people in the methadone program ask for more than they need (due to tolerance, you pretty much have to just ask them) and sell the excess to people who don't qualify for the program. In some years there have been more methadone overdoses than heroin overdoses. Even in the legal program there are overdoses.

Its not loving to control another person with draconian measures that further harm them with criminal sanctions that cause economic stress and stigmatize the person socially. Love would be creating a social environment that is capable of providing safer options, therapy, and letting people make their own choice about their health instead of treating them like criminals.

I mostly agree. I was arguing against free heroin, not in favor of prohibition.

That's a pretty rudimentary analysis, and the "law of love" doesn't really hold much weight when you start looking at the prognosis for various treatment groups for people with opiate dependency.

It's really the abstinence only attitude I was talking about: why is it a big deal to give someone medication for the rest of their live if we know it will keep them alive, healthy, and allow them to live a fulfilled life? Addiction is just like any other disease, and it turns out medication assisted therapy is very effective.

Methadone works, and so do other medications, but it's only a partial solution. We need a rapid and massive expansion of these programs. We also need programs and medications to target people who go on Methadone, but keep going off. Why not give them Herion, if we can do it safely? What about if there is evidence they can become productive members of society?

Again, it's my view that although people OD from drugs, it's really the prohibition of drugs that are killing people through the incredibly unsafe and unreliable drugs people get. Supervised opiates are not dangerous, and unlike other drugs, cocaine, meth, benzos, you can safely be on them for years at a time nearly no long term effects. At least the long term effects of staying on them pale in comparison to the consequences of an OD.

60,000 people OD per year. What we are doing isn't working!

"...and the Sacklers just walked with no criminal liability."

The fact that they did, has to be amongst the top crimes of the century.

That justice can fail so spectacularly is treason against the citizenry. Not only does it undermine people's belief in rightful justice but it also brings law, order and governance into disrespect.

If you want to sow the seeds of anarchy then this is how to do it.

"Anyone that is addicted to drugs can get the drugs they want, they just have to already be addicted first"

All that does is create a perfect window for new users to use tainted black market drugs and die. It's also essentially a government endorsement of the black market and the violence that comes with it. I think we need to move past those cowardly policies and craft laws that respect the reality that drug use will always be part of society. Playing make-believe that we can stop drug production or sales is too expensive (in cash and life) and has been proven comprehensively ineffective over several generations.

It seriously harms the black market for these drugs. Opioids are an escalating addiction so new users are simply less profitable. Eventually illegal opioids can consume an almost unlimited budget, but shift heavy users to government supply and suddenly it’s a much less profitable business.

The Swiss are roughly 1/10th as likely to use opioids as Americans and of their users ~85% are in rehab. Relatively speaking it’s a tiny illegal drug market.

There is no drugs policy what can reduce drug usage. The only way you can make sure it's not getting out of hand is to have a rich, smart and healthy society.

>I'm a strong proponent of the US taking the approach the Swiss took to combat their opiate epidemic in the late 80s and early 90s.

I suspect you have your dates wrong, they didn't get a handle on their problems until the late nineties and early 2010s.

https://ssir.org/articles/entry/inside_switzerlands_radical_...

You could both be right. That would mean it takes 20+ years of consistent policy to remedy the situation.

Yes, I'm attributing the later successes to the early efforts. I did a quick google search when I posted the original comment and got the dates for the start of the program, which started as a mess, not much later when they finally introduced effective measures.

The aspects of the Swiss approach I wish the US would take the most are the willingness to try something fundamentally different. For the Swiss, it took a few tries to ultimately work out, but I don't see why the current solutions to the problem they use wouldn't work in the US.

It'd be interesting if there were any country wide experiments that are similar to the approach that has been taken with tobacco. Basically legalize it for those over 18, slap it silly with warning labels and then tax the heck out it to make it prohibitively expensive. And raise the tax every year. And then fund ad campaigns and social media campaigns which make it generally look dumb and unfashionable as well as treatments.

But perhaps the addictive qualities and treatment is much greater than tobacco.

I don't know. As a smoker, I m guilty of smoking, Im not really a victim even if one could argue it will be hard to stop - it's a lot of personal responsibility, a bit of laziness and a minority the product itself.

With heroin, I d argue people are definite victims. It's absolutely not like tobacco, the craving is physically painful for long, not just the mild annoyance of tobacco.

To give you a few exemples: it takes me 3 days to a week of being irritated to stop cigarets for a full year, cold turkey. For injected heroin, it's 2 weeks of extreme pain with possibility of hospitalisation, for Subutex, an alternative pill, it's around a month (so many addict complain it s easier to take a break from heroin than the progressively reducing alternative medicine).

My dad is a pharmacist in France where we treat drug addicts who want to recover as victims and help them get alternative subutex or methadone for free: he told me he never saw someone truly stop. They can reduce and live with it, but they cannot possibly stop.

Your increasing tax solution seems unfair, while it seems fair for me with cigarets: it's my fault and I can stop. Not an heroin addict. I dont have a magical solution, in France we focused on stopping the violence due to the craving with free Methadone in pharmacies and it changed the criminal landscape, but destroying the product supply at the source while keeping the last addicts on Methadone seems like the only path, if the goal is to free people from opioids in France.

In the US it's different: opioids became a for profit pharmaceutical entreprise, and most of the crisis there is due to opium sold hidden as painkillers totally legally on a large scale.

Thanks that's insightful.

> My dad is a pharmacist in France where we treat drug addicts who want to recover as victims and help them get alternative subutex or methadone for free: he told me he never saw someone truly stop. They can reduce and live with it, but they cannot possibly stop. In the US it's different: opioids became a for profit pharmaceutical entreprise, and most of the crisis there is due to opium sold hidden as painkillers totally legally on a large scale.

A refinement might be to tax legal painkillers that pharmaceutical companies, drug distributors and hospitals are prescribing to the populace from which they make profit from. The tax proceeds could then be used to pay for the inevitable rehabilitation of the certain percentage of the populace that is going inevitably get addicted to it.

The refinement is that the general taxpaying populace doesn't have to pay for this out of the general funds, its explicitly the people profiting from the negative externality.

It's a lot easier to be a hardcore smoker and still function though.

People on meth can have psychotic episodes and hallucinations. It's a common sight today to find shoeless people high on meth yelling incoherent things in traffic. That's the answer to your experiment. In my city in CA, meth is dirt cheap and enforcement on the side of the police is zero. I've seen a shirtless man smoke crystal meth right outside of the train station with metro security not reacting at all. BMWs appear by night to sell meth and pimp out people from homeless encampments, aid workers appear by day to feed people boxed lunches. That sort of environment doesn't lead to people picking themselves up by the bootstraps and stepping into a job and a $2000 1br apartment (going rate in LA). This situation of nothing checking drug use leads to them falling further and further into psychosis until they die in poor health in a bad situation with a necrotic limb or two, as I've seen play out before my own eyes in this city.

I'm a smoker. I have heard that the addictive properties of nicotine are more powerful than those of heroin. As the old joke goes:

"It's easy to quit smoking. I've done it scores of times."

I'm not so sure about this. The most recent, and best, evidence we have on getting folks addicted to substances better is to put them on a coordinated treatment overseen by doctors and implemented by a variety of different healthcare professionals.

Interestingly, I think if hard drugs were legal, very few people who don't already use them would go out tomorrow and give them a try, "just because", so its' not like we would have a complete societal meltdown if it happened.

I just think the US should look to other countries, and start off by implementing what works there. Even that is radical!

> The US is really grappling with diseases of despair, and heroin/fentanyl addition is on of the biggest ones impacting the wellbeing of our society.

This is a false narrative. Tobacco use kills 7-8x more every day, week, and month in the USA. That's a legitimate industry, though, so that's not pushed on the news.

Opiates aren't that big an issue, they're just the one the media tells you to care about.

Absolutely ludicrous comparison. The people dying of opiate overdoses are much younger than cigarette deaths, and the smokers don't have their lives debilitated by their addiction.

Really? COPD is an incurable and debilitating illness, almost always caused by smoking. Also, smoking causes death, which I would put in the "debilitating" category.

Well, there's limb loss due to ischemic peripheral vascular disease, lung carcinoma, various other upper airway malignancies, ischemic heart disease, obstructive pulmonary disease...

Plus, I don't think you can really overdose Heroin, people mostly die from contamination.

https://en.wikipedia.org/wiki/Median_lethal_dose

I stand corrected.

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