You cannot solve a problem if you don't understand the problem.
Silicon Graybeard has a long and information rich post about how the war on drugs is simultaneously keeping patients from being able to control chronic pain while making no headway at all in reducing opioid overdose deaths:
The problem, as usual, is that the Government regulators are starting from a bad assumption. They assumed today's junkie shooting contaminated fentanyl is yesterday's patient who started out on prescription drugs and got addicted that way. Only about 8% of people who receive prescription opioids develop addictions. 80% of addicts get started in other, less legal, ways.In my field of computer security there's a saying: sometimes its easier not to do something stupid than it is to do something smart. Issues are complicated, and data are often sparse. Fortunately, there's still a sense here that we don't know as much as we'd like to.
As the Journal of Pain Research points out, the government’s campaign is based on a false premise: “Today’s non-medical opioid users are not yesterday’s patients.” Medical users usually do not become addicts.Wrong assumptions lead to wrong law, and doctors are being threatened with their livelihoods by new regulations.
But not in the realm of public policy:
A study by Harvard’s Jeffrey Miron and others shows the government’s anti-opioid crusade has backfired and actually increased opioid addiction and overdose deaths:Again, issues are complicated and data are sparse. It is, once again, easier not to do something stupid than it is to do something smart. And yet here we are, mired up to our necks in stupid.
Opioid overdose deaths have risen dramatically in the United States over the past two decades.… The opioid epidemic has resulted from too many restrictions on prescribing, not too few. Rather than decreasing opioid overdose deaths, restrictions push users from prescription opioids toward diverted or illicit opioids, which increase the risk of overdose because consumers cannot easily assess drug potency or quality in underground markets. The implication of this “more restrictions, more deaths” explanation is that the United States should scale back restrictions on opioid prescribing, perhaps to the point of legalization.
What SiGraybeard does not venture into is motivations. How is it possible for all of the Organs of the State to have produced a result that is not just worse than doing nothing, but probably worse than any other policy conceivable? After all, overdose deaths are skyrocketing, opioids are for sale on ever street corner in the land, the prisons are packed to overflowing, and patients are forced to live in excruciating pain for years. It's hard to come up with an outcome worse than this, and yet the War on Drugs persists.
I think that the explanation is summed up in Jerry Pournelle's Iron Law of Bureaucracy:
Pournelle's Iron Law of Bureaucracy states that in any bureaucratic organization there will be two kinds of people":
First, there will be those who are devoted to the goals of the organization. Examples are dedicated classroom teachers in an educational bureaucracy, many of the engineers and launch technicians and scientists at NASA, even some agricultural scientists and advisors in the former Soviet Union collective farming administration.
The Drug Enforcement Administration has a bunch of folks who are trying to keep people from killing themselves with narcotics. They're in the first group. But the Iron Law says that they will not be the ones who end up running the Agency. Those will be from the second group - those who work to increase the power, scope, and budget of the DEA.Secondly, there will be those dedicated to the organization itself. Examples are many of the administrators in the education system, many professors of education, many teachers union officials, much of the NASA headquarters staff, etc.The Iron Law states that in every case the second group will gain and keep control of the organization. It will write the rules, and control promotions within the organization.
Note that keeping patients out of excruciating pain is not going to increase the power, scope, or budget of the DEA. And so it does not happen.
The idea that really smart policy, implemented by smart and dedicated public servants is one that we scoff at when it is proposed for gun control. It's right that we scoff, because it's no more plausible than Unicorns. It's a tale to comfort small children.
And so with the stupid War On Drugs. We're not going to get smart policy implemented by smart and dedicated public servants. The Iron Law explains everything that you need to know about why. It's long past time to declare victory and bring the troops home.
12 comments:
Bad initial assumptions lead to bad policy. QED
And then you do the exact same thing, but in reverse.
The reality is, "Legally prescribed Norco and Percocet good; heroin and crack and meth bad."
Not "Government bad, therefore heroin and Everything Else good."
Government has always been a necessary evil, and frequently more the latter than the former.
That truth, at no time, confers acceptability on any level of heroin use in the general population. For the same reason that even if every member of the Board of Public Health is both corrupt and incompetent, I still don't want people crapping on the sidewalks and making meals at restaurants with feces-encrusted hands.
Police are frequently corrupt too, as five minutes in any newspaper will confirm, but I still want them to chase rapists and murderers.
You're still trying to justify throwing out the baby with the bathwater, on whatever ideological grounds.
There is no amount of filth in the bathwater that excuses throwing out that baby.
Nice try.
Tell the troops to go back to harassing street corner pharmaceutical merchants, and leave the physicians alone.
The DEA is doing to doctors what the BATFE does to FFL gun dealers: harassing the people they can, who they know won't shoot back when they come in the door, because they're a bunch of gutless chickenshits.
Fire everyone in both those agencies above street-level direct enforcement, and try it again. If you have to, fire everyone, and start from scratch.
The suggested "cure" of laissez faire is worse than the disease.
What Aesop said, in multiples.
Pain Management Doctors, real PM docs, are becoming scarce as hens' teeth out there, between the combination of the DEA jackbooted thugs and lawyers (it always comes down to the lawyers...) I'm seeing the same round of regulatory and lawsuit bullscat that killed off so many docs dealing with births.
I've seen my wife's doc get swamped by people who have lost access as other docs pull back, to the point that if an emergency occurs and we have to miss our appointment for the 30 day supply of drugs, then we stand the very real chance of running out way before we can get an emergency appointment. The front staff is overloaded, and only by going to the doc's nurse and forcing it have we been fitted in, sometimes having to wait 3-4 hours for the 10 minutes it takes to ask, "Anything change yet?" and hand us the scripts. Insane. Worse than trying to schedule a teeth cleaning. Every month.
Tell the troops to go back to harassing street corner pharmaceutical merchants, and leave the physicians alone.
The DEA is doing to doctors what the BATFE does to FFL gun dealers: harassing the people they can, who they know won't shoot back when they come in the door, because they're a bunch of gutless chickenshits.
Aesop, I don't have any problem at all with this.
The difference between your attitude and mine is the street level enforcement. I don't think that this works, after decades and a trillion dollars of trying. Maybe it could, but I'm skeptical that success is in the offing. A plan for a new approach that seems like it might plausibly work is something that I might be able to get behind. But I don't see anything more than "do it again only harder".
I'm at a complete loss as to why I should care if a junkie assumes ambient temperature from whatever cause.
I do care that patients who had no control over the condition or event that caused it are suffering excruciating pain because of the drug war flustercuck.
BP makes a good point: We've expended billions of dollars and man hours (oh, sorry, 'scuze me all to heck, "person hours") trying to eradicate illegal distribution and use of both illegal and pirated medical drugs, and failed miserably in every way it's possible to fail.
It's past time to change the tune. Shift some money from police to public works, buy a couple more garbage trucks and staff them. Two new trucks per city ought to do it, 2 guys per truck, 2X 10 hour shifts daily (0100-0500, it'll keep for the day shift). The cops find a body, do an on-scene go/no-go blood test, if it's drugs, print the corpse, heave it in the truck, visit the landfill at end of shift. Done.
Notification postcard to last identifiable next of kin, if they need a death certificate they can request and pay for one.
Someone needs (or wants) rehab, the cops and bleeding heart social workers can tell them where to find it. If they want to keep doing drugs, no problem. We no longer give a damn whether you live or die; if you don't care about you, neither do we.
Druggie gets arrested, into the cell. You'll either survive withdrawal or you won't. Make it through, you'll get your court date. Make it through whatever sentence you get, you're released with the necessary information on how to seek help statying off drugs. If you do, fine. If you don't, fine also. We no longer care, we have our own productive lives to manage, we're tired of trying - and consistently failing - to help you manage your non-productive one.
Oh, yes - the mid- and high-level distribution personnel whose activities keep druggies connected to the stuff. Commercialize them with a licensing procedure, let the free market handle the pricing structure. Make detailed, exhaustive and complete drug education a mandatory part of the education-industrial complex so the teenage know-nothings no longer have an excuse when they try the stuff.
How is it possible for all of the Organs of the State to have produced a result that is not just worse than doing nothing, but probably worse than any other policy conceivable?
Isn't that the normal state for every agency of the Fed.gov you can think of? I want to believe there are exceptions, and maybe we don't notice the ones that seem logical because they don't stand out, but it sure seems like good, logical decisions are a tiny minority of policy decisions.
Which is not to say that Pournelle's Iron Law is the wrong diagnosis.
One of the doctors I quoted said, “We have less mercy for people who have chronic pain and are on chronic opioids than we do for somebody who’s using heroin in the streets right now,” and that's the part that gets me. It's the diametric opposite of what the policy should be doing.
In the never ending discussion of legalize vs. not, I simply see no good alternative. I'm completely with Aesop when he says that it's not a victimless crime, and that we're not actually fighting a "war on drugs", we're just going through ineffective gyrations. His argument is to make it effective. If you're going to fight a WOD, fight to win. Your argument is to simply stop doing the ineffective stuff - all of it.
I'm sympathetic to Noname Smith's argument but at some point, someone (and in my mental image it's me) will have to step over someone dying, begging "help me!" and let them die. The thing is, we won't know any of that: we won't know that they're dying of an OD, just that they're in need of help. My personal ethical system is going to scream like hell at me.
The only way to cut off drug sales is to cut off demand, and we don't know if that's even remotely possible. We just know you want no part of a government with the power to mess with our minds (personalities, genomes) to that degree.
I agree - but with the caveat that we should eliminate law enforcement as a federal function PERIOD. I think that the feds should have to bring in local cops when they want it done - and they shouldn't be able to force them; they should have to convince them the work they ask for is needed and also pay for the help they want. It would essentially be extending the Posse Commitatus (sp?) from just the military to prohibiting any federal armed force from operating in the US.
P.S. You need to fix "Pubic" in your title. I assume it should be "Public".
I know some folks who have constant and unremitting pain from conditions like scoliosis. They have had increasing problems with getting pain relief, because their doctors are scared shitless of getting into trouble with the DEA.
That is fucked.
"The only way to cut off drug sales is to cut off demand, and we don't know if that's even remotely possible."
NOT possible. All of human history shows that there are always people who crave an alternative to reality. In a nutshell, that is drug use, whether alcohol or some other drug.
Want to know why the DEA went after pain clinics? Look up the old news about Florida pain clinics where each "doctor" saw at least ten "patients" per hour, and gave them all 90 day prescriptions for multiple pain meds. And they would see the same patients day after day after day, writing new scripts for them every time they came in the door. And the pharmacists at the CVS next door filled the scripts, no questions asked. They received a semi-truck load of drugs every day.
That's why we can't have nice things. Yes, the reaction was overkill. That's how government works! Congress told the DEA to do something about the problem.
You want to fix this mess? Talk to your Congressthing. Tell them to change the law. It's their job.
@McChuck
The 10 patients per hour is not limited to pain docs. I have heard my PCP and orthopedist complain about it. It is in Medicare and Obamacare rules. And seen a lot of on-line complaints across the board.
That is fucked.
Comrade Misfit, that's the best three word summary of the War On Drugs that I've ever seen.
Will, I think that you can learn everything that you need to know about "cutting off demand" for drugs by reading the text of the 21st Amendment. This is not our first rodeo.
McChuck, IMHO this isn't reason enough to condemn hundreds of thousands of people to decades of agonizing pain. And yes, this is exactly how Government works (which was kind of the point of my post).
"The difference between your attitude and mine is the street level enforcement. I don't think that this works, after decades and a trillion dollars of trying. Maybe it could, but I'm skeptical that success is in the offing. A plan for a new approach that seems like it might plausibly work is something that I might be able to get behind. But I don't see anything more than "do it again only harder."
Define "works" in the second sentence.
For reference, Cain killed Abel way back when, "Thou Shalt Not Commit Murder" is the VIth Commandment, and 3500 years later, laws against murder "work" as well as laws against drugs.
Yet I hear no drumbeat alleging that the war on murder is a failure, and we should thus legalize and tax that.
I repeat: what is the recidivism rate for drug dealers in Saudi Arabia and Singapore?
That's not doing "it" harder, it's doing it right.
As a distant second place option, first dismantle the entire welfare state, most especially including the federal EMTALA Act, then make any OD - drugs, alcohol, Skittles, whatever - a mandatory "Do Not Resuscitate" response by 9-1-1. They find you, they leave you. Suck it, loser. No ambulance transport, no hospital effort whatsoever (unless you paid for it, in cash, in advance).
And if you do drugs, you have to carry mandatory insurance minimums, just like driving a car, to include life insurance, at the expected exorbitant market premiums, to cover burial, and the support of any spouse and children, should you die from your habit.
If you fail to do that, or doing drugs impinges on anyone else in any way whatsoever, they throw the book at you.
Then (and only then) would drugs be a (mostly) victimless crime.
Start by enacting all of that, first, and once you do it, we can discuss legalizing drugs - last.
Doing it any other way is like giving illegals an amnesty, and putting off building a secure border until some future date.
And we know how that one turned out.
I am also now an official victim of the 40-Year Slap Fight On Drugs:
I had a tooth blow up on me. Waited literally all day for an appointment at the dentist. Got a scrip for pain meds. Took it to pharmacy. But he'd neglected to check one irrelevant box on the scrip, and had gone home, so no pain meds for me and my abscessing tooth in excruciating agony. Had to go back to the doc the next day, have him check the missed box in the exact color ink he'd used the day prior, or they'd throw the entire Rx out, then take the scrip back to get it filled.
Time from pain to med: 30 hours. With a valid, legal order for same written for obvious medical necessity, after seeing a board-certified Doctor of Dentistry, and having a signed prescription, with heat-sensitive watermark and serial numbered Rx in hand.
After that, I'm willing to help out, and go hunting for drug dealers myself, for free.
And then, for the DEA @$$holes who terrorized an entire chain of pharmacies into denying me the medication a practicing doctor determined was medically necessary, because f**ktards in the Rust Belt are shooting up heroin laced with carfentanil imported from China to Mexico, and then smuggled up here across the border where the Democrats in power swear there's no national emergency.
Only respect for federal law keeps me from actually adding worthless federal drug agents and idiot congressweasels to my hit list, and notching them on the pistol grip.
They still deserve it, mind, it's just illegal to do anything about that.
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