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Legalization and the Opioid Epidemic

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By Fvasconcellos (talk · contribs) – Own work, Public Domain.

Curious what folks think of this:

By the time I began as a drug policy reporter in 2010, I was all in on legalizing every drug, from marijuana to heroin and cocaine.

It all seemed so obvious to me. Prohibition had failed. Over the past decade, millions of Americans had been arrested and, in many of these cases, locked up for drugs. The government spent tens of billions of dollars a year on anti-drug policies — not just on policing and arresting people and potentially ruining their lives, but also on foreign operations in which armed forces raided and destroyed people’s farms, ruining their livings. Over four decades, the price tag for waging the drug war added up to more than $1 trillion

…Then I began reporting on the opioid epidemic. I saw friends of family members die to drug overdoses. I spoke to drug users who couldn’t shake off years of addiction, which often began with legal prescription medications. I talked to doctors, prosecutors, and experts about how the crisis really began when big pharmaceutical companies pushed for doctors and the government to embrace their drugs.

If I could sum up, the case would be something like this: The idea of drug legalization runs aground on the shoals of American capitalism.  While marijuana has proven too harmless for the pharmaceutical industry to weaponize, the combination of corporate marketing and the political influence of large companies has helped create and extend the extremely destructive “opioid epidemic” that we now find ourselves in. Done carefully (as has generally been the case in Europe) legalization can yield better social outcomes than prohibition, but given extant US political economy it’s as likely as not to yield tremendous human misery.

I can think of two caveats off the top; first, any public policy done badly is likely to have bad effects, and so of course drug legalization needs to be approached with care and caution.  Second, however awful the opioid epidemic has become, it’s not obviously worse than the prison industrial complex that prohibition has created (although it distributes costs differently).  That said, there may be a middle ground between legalization and prohibition that minimizes human misery.

Thoughts?

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  • I’m inclined to think legalisation will be beneficial overall for a number of reasons:

    1. A lot of accidental overdoses happen either because the lack of consistency in black-market opioids means people don’t actually know how much they’re taking or because they’re laced with hazardous substances (most often, fentanyl). Regulation would solve both of these problems, and it obviously can’t be done with a black market.

    2. If drug use were legalised, problem users would be less afraid to seek treatment, because they wouldn’t be afraid of being arrested for doing so.

    3. Incarcerating people for a medical problem doesn’t help improve their medical problem; addiction is a disease, and treating it that way makes addicts likelier to recover.

    4. Incarcerating addicts also makes them likelier to associate with criminal figures when they get out, because they will have a criminal record and can’t obtain legitimate employment as easily, and those criminal figures are likelier to be associated with the drug trade, which will make recovery harder.

    I can see the American pharmaceutical industry being uniquely horrible, so legalisation would need to be done carefully, but an approach like Portugal’s still seems like it could lessen opiate abuse in this country. (Portugal doesn’t imprison people for drug offences, but people are brought before panels for drug use, and repeat offenders may be given counselling, opiate substitution therapy, or other treatments.) The approach we have right now, at least, obviously isn’t working.

    • nkh

      A lot of accidental overdoses happen either because the lack of consistency in black-market opioids means people don’t actually know how much they’re taking or because they’re laced with hazardous substances (most often, fentanyl). Regulation would solve both of these problems, and it obviously can’t be done with a black market.

      A lot of accidental overdoses occur during usage of legally prescribed opioids by the patient to whom they were prescribed, especially for older patients. Just want to remind that this isn’t all an issue of legalizing something or not. The opioid problem was and still is, significantly, a problem of something that is already legal.

      • I didn’t say legalisation would stop all accidental overdoses, just that it would stop the ones I described.

        I do suspect that significant number of the accidental overdoses you describe, however, may also occur from users being given unclear or simply wrong instructions. After watching John Oliver’s piece on opiates, I no longer possess much trust in doctors to give their patients good advice on opiates.

        • nkh

          Well, doctors aren’t always the best at managing opiate prescription, but tolerance/addiction are perfectly capable of leading patients to misuse all on their own. There are relatively easy ways to help with that, like significantly restricting the number of doses in a prescription, simply not using opiates for long term pain management (because, you know, there’s no evidence that it works), etc. But opiates gonna opiate. They have their uses, but they can be bad news no matter who’s doing the prescribing.

          Basically, legalization isn’t the problem in this case, as I see it. Regulation combined with prescriber ad patient education is.

          • Right. Unrestricted use has its own problems; that’s why I suggested an approach like Portugal’s to managing addictions. I think part of the problem is that people simply aren’t properly educated on how opiates work, and so they assume that more = better. That isn’t really the case. The body does build up its own tolerance, so usage has to be managed carefully, but the carefully part is key here, and I see no sign that a lot of users are ever given the education necessary to understand how to do this. (I do think you’re right that shorter prescription lengths would help, though.)

            That said, the black market status definitely creates its own problems that wouldn’t exist with legalisation. But there’s a middle ground between “remove all restrictions on use” and “ban everything”, and it’s pretty clear to me that the approach that will most reduce opiates’ harm is somewhere in the middle ground.

            Basically, people with expertise in addiction should be the ones helping opiate users with their problems. Right now, they’re not always doing that, either on the medical side or on the law enforcement side.

            One additional note is that legal marijuana and medical marijuana seem to have greatly reduced the number of opiate deaths in states that have them, because it appears that marijuana is also a pretty good pain reliever, so a lot of people who can use it to treat their pain problems never turn to opiates in the first place.

            • nkh

              I agree with the management approach. I think opiates fit awkwardly into this conversation, to be honest, especially if the other side is primarily, “should we legalise marijuana”. I have my own opinions on that. But the opioid epidemic is not particularly related to that discussion. There’s a pretty sharp divide, at least in some sense, between prescription opiate abuse and, say, heroin abuse. For reasons you already brought up, if people can get opiates via legal prescriptions, they are perfectly happy to abuse them. But there’s a pretty sharp age divide in who can more easily get long-term prescription opiates. Older people can. Younger patients have trouble getting continuing prescriptions and legitimate prescription opiates are expensive on the black market. Heroin in cheaper. But, to a large extent, the initiation dependence was fostered by poor prescribing practices to begin with, so there’s a difficult interplay with legally prescribed drugs leading to dependence that we then don’t treat which creates a market for illegal substitutes, etc. But just legalizing heroin doesn’t fix the dependence/use disorder problem. There are tradeoffs. I guess the issue I’m having here is that this post gave rise to a legalise-it/don’t-legalise-it thread relating in part to what really is a medical/public-health issue without enough discussion of it as such. That said, I don’t think you lock up (well, not in jail, at least) people with a medical problem. That doesn’t help anyone. But that leads to policies that can be implemented whether drug X is legal or not.

              • Right. People present it as a choice between legalisation and criminalisation as though legalisation means everyone can use whatever drugs they want without restriction and as though criminalisation means lock everyone up. Criminalisation of any sort isn’t going to help; I think that’s obvious now. But at the same time, I don’t think anyone who’s seriously studied drug abuse thinks that allowing completely unrestricted use is the way forward.

                There are serious problems with an unregulated, black market supply of any drug. That’s why I favour legalisation rather than simple decriminalisation. Even with intrinsically rather safe drugs like marijuana, I’ve heard stories of black-market weed being laced with cocaine or other drugs. So that’s why I favour legalising, because you can control what goes into the drug supply by having oversight and restrictions on the manufacture process.

                But at the same time I definitely don’t favour removing all restrictions on use. There are drugs that cause serious problems even when they’re regulated to the fullest extent possible, and managing their users can help mitigate the damages they cause them. We’ve seen that criminalisation doesn’t stop people from abusing drugs. So we need to take some other approach to drug use that focuses on harm mitigation rather than punishment. And that’s where the middle ground comes in.

                Basically, the whole guiding principle of the drug debate should be “how do we reduce the harm of drug use as fully as possible?” And I think at this point that it’s pretty clearly legal, regulated use, with regulations on both the supply end and the demand end. Right now, we’re not really regulating either side.

                • ColBatGuano

                  Has anyone studied how all those prescriptions for Oxycontin got written in West Virginia? Sure, the drug manufacturer pushed for it, but it required doctors and pharmacists to go along. Someone refilling their prescription 3 times in a week should have set off alarm bells.

                • Michael Masinter

                  One reporter wrote a story on how those pills found their way to southern West Virginia coal counties and won a Pulitzer for his work.

          • percypercy

            I’m intrigued at the comment

            There are relatively easy ways to help with that, like significantly restricting the number of doses in a prescription, simply not using opiates for long term pain management (because, you know, there’s no evidence that it works)

            Which I’ve seen before, and have no idea where it comes from because, believe me, opiate based painkillers are an astonishingly good way of managing chronic, severe pain, and there are thousands and thousands of people whose lives are livable because of them. There is nothing on the legal market that comes anywhere close (even here in Colorado) and anyway, insurance companies wouldn’t pay for it.

            • bender

              A member of my family who had been in robust health through their sixties acquired neuropathy from a case of shingles and was in constant pain. This person was provided with lidocaine skin patches and a prescription for methadone. The combination managed the pain well enough to enable them to live independently for another fifteen years or so.

            • nkh

              You see it because there is no evidence that it’s an effective long term treatment for chronic non cancer pain. Acute, sure. Otherwise, no. And unfortunately, just because someone says their life would be unlivable without opioid, that doesn’t actually mean that they are the appropriate or most effective treatment for their condition. It just means it’s the one they’re using and they don’t want to stop.

              • percypercy

                I’ve been on opiods for 6 years, and they’re still the best way of controlling my pain. What’s your standard for long term?

          • Captain Oblivious

            doctors aren’t always the best at managing opiate prescription

            My GP will no longer prescribe any opioids. If she has a patient who needs (or say they need) that level of pain medication, she refers them to a pain management specialist.

            • bender

              If a pain management specialist is available to the patient, that is probably a good idea, because those specialists can also refer them to non-drug based techniques.

      • L2P

        There’s a huge difference between “legally prescribed opiods” and “legally prescribed opiods used as actually allowed by law.” Almost all “legally prescribed” opiate overdoses happen because the patient was overprescribed, getting multiple prescriptions and so on.

    • If only we had an AG who saw things the way you do.

    • StellaB

      Portugal didn’t legalize drugs, they decriminalized drugs. Getting caught with drugs results in a referral to rehab, not a criminal sentence. Drug abuse is a medical problem, not a legal problem.

      Just because marijuana isn’t particularly toxic, it doesn’t follow that there are no people who abuse it and need rehab too.

      • Well, yes. I discussed this downthread. The reason I specifically prefer legalisation rather than decriminalisation is that, from my understanding, decriminalisation doesn’t actually make the supply legitimate and leaves it essentially unregulated. I may be misunderstanding the terminology, though.

        Legalising and regulating means that you can regulate on both ends – from the supply end, where you can prevent toxicity and maintain a specific consistency, and from the demand end, where you can refer problem users to treatment.

        I don’t think we should use the same approach we’ve used for weed for every single drug; I agree that weed can cause problems in extreme cases but they seem to be fairly rare compared to most other drugs. But there are definitely drugs that cause serious public problems, health-related or otherwise, which is why I favour the regulations on both ends.

        • L2P

          It depends on what you decriminalize. If you decriminalize possession, marketing, sales, and production are still illegal. You can also decriminalize possession and sales, and criminalize production and transport. And so on.

          But generally, when people talk of decriminalization they are talking about decriminalizing possession. It’s very, very hard to regulate these sorts of drugs. We have ridiculous regulatory burdens with cigarettes, for instance, and with marijuana everywhere it’s been legalized. Nobody even really knows how to regulate meth, for instance, which anybody can make at home.

          • SIWOTI

            Here’s how to regulate meth: require a prescription for legitimate medical use, as is allowed under current law. Methamphetamine, aka Desoxyn, is an effective treatment for ADHD, and is a good second-line stimulant treatment option for some whose symptoms aren’t relieved by first line treatments like Adderall or Ritalin.

            That said, methamphetamine is a drug that nobody should be taking recreationally. It is neurotoxic at high doses and is incredibly addictive at doses above the therapeutic range.

            And they certainly shouldn’t be making it – most methods of making meth at home are dangerous, environmentally toxic, or both.

            We shouldn’t be throwing people in jail for being addicted to meth or even possessing it for use. But making it, or selling it? Sure. A short stint in the pokey could help deter making additional meth addicts. But we can’t even regulate tobacco effectively – there’s no way we could ever regulate meth well.

      • Jordan

        Almost nobody needs rehab from majijuana.

        They might well need in-patient care for various reasons. But its not because of the actual marijuana use.

        • Origami Isopod

          Yeah, I raised an eyebrow at that claim, too.

    • L2P

      A lot of accidental overdoses happen either because the lack of consistency in black-market opioids means people don’t actually know how much they’re taking or because they’re laced with hazardous substances (most often, fentanyl). Regulation would solve both of these problems, and it obviously can’t be done with a black market.

      This isn’t true at all. As long as there’s enough arbitrage between the market price and the regulated price you’ll see all sorts of hazardous things for sale. It happens right now with cigarettes.

      Meth and opiates will be extremely tough to regulate. The regulatory load can’t be anything less than like 1000% (it’s virtually free to make if it’s not illegal). Almost all of the cost is going to come from regulatory compliance.

      Where there’s tons of money to be made bypassing those regulations, it’ll happen.

      • …huh? There are significant aspects of cigarettes that are almost completely unregulated. Particularly e-cigarettes. That’s not a problem of regulation – that’s a problem of almost the exact opposite.

        Anyway, again, I think Portugal’s experience is instructive here: they seem to be able to direct problem users away from more dangerous substances to less dangerous ones, which is one of several reasons their overdose statistics and deaths and the like have dropped. Regulating things at the demand end would make it possible for us to do the same thing.

        And if you have a legal, regulated market, you can also punish the black-market suppliers who flout the regulations harshly. I would probably have no problem doing that; the regulations would be there to protect public health, and flouting them would be a blatant disregard for public safety.

        I really don’t see the problem here. Almost all of this can be managed by keeping close tabs on both sides of the market. Eliminated completely? Maybe not. But it can certainly be brought down from the crisis levels it’s currently at.

        (had a break for a moment; probably won’t have tons to say for awhile though)

  • NewishLawyer

    Heroin was sold by Bauer as a non-addictive substitute for Morphine. That worked well.

    I think marijuana, cocaine, LSD, Shrooms, Peyote, Mescaline, and Ecstasy should be legalized. I hesitate at heroin and meth but addicts should never be put in jail.

    Interestingly Slate had an article today arguing that marijuana legalization could be a winning issue for the Democrats but they won’t use it. The basic answer seems to be that too many elected politicians are from the time when saying this would destroy a career in a second.

    • Murc

      I hesitate at heroin and meth but addicts should never be put in jail.

      One of the problems there is that we’ve legally defined amounts that get you charged with “intent to distribute” as being well within the bounds of stuff that’s clearly for personal use.

    • I’m inclined to agree with Slate’s piece. IIRC, marijuana legalisation polls at 60% approval or thereabouts consistently these days.

      Heroin and meth are bad, bad drugs, but you can legalise them without making their usage completely unrestricted or whatever. A lot of the danger of heroin, as I pointed out above, is because of the lack of regulation. It would still be a bad drug if it weren’t legal, but it wouldn’t be as bad.

      Furthermore, you can legalise them without actually taking away attention from problem users; Portugal’s approach actually puts drug users before a panel, as I said, but it just takes imprisonment off the table as an option. If someone obviously has a problem, they can be given help that way.

      The biggest problem with our current system is that it seems purpose-made to make problem users less likely to receive help. And that may actually be the intention: the prison-industrial complex is so absolutely sinister that Hanlon’s Razor can’t really explain some of its actions.

      • wengler

        Remember when the government deliberately poisoned the non-potable alcohol supply during prohibition which ended up killing tens of thousands of people? We are governed by cruel people that want people who are doing bad things(according to them) to suffer and die.

      • Pat

        I believe that one of the biggest problems with our system lies in the widespread belief that over-use of drugs or alcohol is a moral issue, and that abstinence is the only appropriate solution.

        With this belief, addicts stop using entirely for short lengths of time, and then binge. This pattern of behavior drives overdose deaths.

    • John F

      Gallup poll from late 2016 had those in favor of marijuana legalization at 60%, age breakdown as:
      18-34: 77%
      35-54: 61%
      55+: 45%

      by partisanship:
      Repubs: 42%
      Dems: 67%
      INds: 70%

      Basically GOPers over age 50 overwhelmingly are against legalization and EVERYONE else (including younger Repubs) are for it.

      • ASV

        I had a chance to talk to both Dick Durbin and Democratic Illinois gov candidate JB Pritzker about this today. Durbin supports rescheduling and FDA research on marijuana, but he’s lukewarm on legalization. Pritzker supports full legalization, implemented prudently. FWIW, I asked them about it because another Dem gov candidate, Ameya Pawar, came out for full legalization yesterday.

    • Joe_JP

      addicts should never be put in jail

      I’m not sure about that “addicts” line. Non-addicts who use heroin or meth probably shouldn’t either.

      Can understand Democrats thinking a national program regarding legalization marijuana was perhaps a bridge too far. State by state legalization seems to be getting some real support & Democrats should at least be on record saying the feds should not go after those who follow state law.

    • tsam

      Heroin absolutely doesn’t belong in a category with meth. Not even close to the same level of destructive danger.

      A LOT of people are using heroin to avoid Oxy/hydro opioids, which they seem to think puts them in a better place. Feels like jumping out of the frying pan and into another frying pan to me, but I’m not a using addict.

      Part of the problem with discussing heroin is that everyone thinks of a strung out, starving person shooting up in an abandoned house somewhere. The vast majority of heroin users don’t mainline it, and they have every chance of functioning (in a relative way) in life that an alcoholic does.

      • Yes, from what I understand, large numbers of heroin users are even able to maintain consistent employment. If not for the risk of overdose (mostly due to black market factors I mentioned above), it apparently wouldn’t be a huge health risk apart from long-term use damaging either, IIRC, the liver or kidneys. (One thing I left out from my first comment is that needle exchange programs would obviously vastly decrease HIV/AIDS infections.)

        That said, as a person whose usage of recreational drugs (including alcohol) is limited to caffeine and smoking weed a couple of times, I don’t really possess an understanding of what the subjective experience of addiction is like.

        • tsam

          The best way to describe a functioning addict is like this.

          For normal* people, using a drug is a diversion, and while they enjoy the experience, they’re fine with and even a bit relieved to come down and return to a normal state.

          The addict (speaking for myself), the effect of the drug is like coming home. For just fucking once, things FEEL good, and you feel the way you perceive happy people are feeling. So it’s an experience I enjoy, and then miss it desperately when it’s over.

          * I hate this word in this context, but I don’t really have a better or less insulting one.

          • brad

            Doesn’t that gloss the difference between habit and addiction, however? They are, of course, very closely linked, and in fact can be found together in many forms of drug abuse, but there is a neurological difference. At least in my understanding, and semi-limited experiences.

            • tsam

              Possibly–I’m not really sure what the functional difference between addiction and habit is.

              • brad

                My own relevant experience is comparing quitting smoking and having to go any extended period without smoking pot, of which I’m otherwise a relatively heavy user. Both are a habit, but even with me having a relatively lucky draw in terms of how nicotine withdrawal hits me there’s a very, very noticeable difference. Cigs I would feel the physical lack of, pot I don’t really notice aside from a slight change in sleeping patterns.

                • tsam

                  Ah–ok. So I probably fit more into the habit column than the addict. Sometimes I think I use the word addict to remind myself that a few bad choices could do a lifetime of damage to myself and that I always need to be aware of what I’m doing.

              • Dennis Orphen

                Addiction is physiological (your caffeine withdrawal headache); habit is psychological (the basketball games you’ll be watching this weekend).

                • SIWOTI

                  This is just wrong. Addiction is often psychological as well as physiological. While many drugs create changes in the body that upon cessation create withdrawal symptoms, the physiological changes like caffeine withdrawal headaches are only a part of the picture. There are also neurotransmitter changes that occur with these drugs, regardless of whether they cause any later physiological withdrawal symptoms.

                  And these neurotransmitter changes are often expressed, most vividly and succinctly, as psychological symptoms: the longing for the drug, depression, anxiety, rapid mood swings, lack of motivation, etc.

                  So the real difference between habit and addiction is often blurry, but it often comes down to a question of conscious control of the behavior. Habits are things that one often does subconsciously or unconsciously, and most often, are things that with a sustained application of time, changes in the environment, and other work, can be changed through conscious control of the behavior. With addiction, conscious control of the behavior is often incredibly difficult to control, or even impossible to control.

              • nkh

                Strictly speaking, addiction is continued use regardless of negative consequences.

                • tsam

                  This would indicate that there’s a rather fuzzy line between the two? That would certainly line up with my experiences.

                • Pat

                  If you can put it down, you’re not an addict.

          • That makes sense. That also makes me wonder if part of the problem many addicts have is that they simply weren’t happy before they started using, and then they found that drugs made them feel happy for a time.

            • tsam

              For me there’s a social anxiety and dread that are always nagging at me like a rock in my shoe. Opiates (at least inside my head) relieve that for a little bit. It’s hard to describe the value of that reprieve to someone who hasn’t experienced it, but it makes all the other risks totally worth it.

              • I’ve always experienced social anxiety for my entire life, so I can partially understand what you’re talking about. Just leaving the house makes me feel a bit nervous. Probably a product of being on the autism spectrum. I don’t experience the dread, though.

                I’ve read some articles on how psychedelic therapy has made some people’s social anxieties completely vanish. The inaccessibility of these kinds of therapies, as well as the fact that they’re still not completely understood, is a particularly horrible consequence of the drug war. There are a lot of populations that could stand to benefit from therapies like this substantially, but because they’re expensive and difficult to gain access to due to the drug war, many poor and minority communities will be unable to use them for as long as the drug war continues.

                • tsam

                  Based on what you say here, you’re probably a good candidate for developing a habit without realizing it until it’s too late. I don’t think people without social anxieties quite understand what a hindrance and psychologically draining problem that is.

                • That’s a major reason I’ve avoided hard drugs entirely. I certainly can have an addictive personality, and I often don’t notice changes in my psychological outlook until others point them out.

                • tsam

                  You done good in avoiding that trap. It’s an easy one to fall into.

                • Thanks. And yeah, it seems hard to notice. And there are a lot of psychological ailments that seem to work much the same way – also depression, for example. Which I’ve also suffered for long periods of time. (And because I’ve suffered depression, that probably makes me even more vulnerable to addiction.)

                • guthrie

                  I suppose I used to be socially anxious (great difficulty speaking to groups of people, fear at going into rooms with strangers in, inability to talk to them), but was able to train myself out of it over a number of years. I also think I have a habitual personality, and realised that if I got into the habit of snacking mid-morning like some people do, I would probably put on weight and eat more than I needed to. So I never started doing that.

                  But many people have greater problems than me, and just because I managed to get over some of mine doesn’t mean they can too and I can’t look down on them for having such problems.

            • nkh

              Well, there are genetic predispositions. Self-medication for underlying psychiatric illness is a reasonably common cause. So, hey, better mental health care would be a big help! Who would have thought? Also, happiness isn’t necessarily the way to describe what a user is looking for. “Relief” might be better. Treating, e.g. bipolar mania/hypomania with alcohol is more like tamping down too much “happiness”.

              • Yep, the benefits to better mental healthcare would be legion and solve a number of other societal problems that people often don’t think of as related. It would definitely also reduce the number of unemployed and vastly reduce the number of suicides, for starters. And as a member of a population that frequently needs particularly intensive mental healthcare – those with autism-spectrum disorders – this hits particularly close to home for me. It’s one of the reasons Clinton’s loss affected me personally as badly as it did, since she’d proposed a mental healthcare program of unprecedented comprehensiveness in our country’s history. If we took mental health more seriously, a lot of people would still be alive today.

            • bender

              When I was younger, I had many friends and acquaintances who consumed a variety of illegal substances. Some were recreational or social users, some had habits, and some were drug dependent.

              A few of the more drug dependent ones combined drugs frequently and would switch to alcohol or another illegal drug if the supply of their preferred drug dried up. I came to a similar conclusion to yours–those people simply couldn’t stand being sober for long and would do anything to alter their consciousness.

              • vic rattlehead

                I came to a similar conclusion to yours–those people simply couldn’t stand being sober for long and would do anything to alter their consciousness.

                There’s a shadow just behind me,
                Shrouding every step I take,
                Making every promise empty,
                Pointing every finger at me.
                Waiting like a stalking butler
                Who upon the finger rests…

                • tsam

                  Ayyyy Tool lyrics. Yesssssss

                • vic rattlehead

                  I want to see them at Governors Ball but I have a work commitment. There’s a rumor that a new album may be coming out later this year (sound familiar? ha)

                • Q.E.Dumbass

                  Do you know how many of your friends had definite problems with rumination?

                • vic rattlehead

                  @QEDumbass

                  I definitely have problems with that. Cognitive behavioral therapy has helped me recognize destructive thought patterns, but substances sure are easier.

                • Q.E.Dumbass

                  I also have that tendency, and while I’ve never used them they would be much easier.

        • Jordan

          I don’t really think much of this is true.

          The risk of ODing isn’t just because of unknown quantity/quality intakes. Its also because people build up a tolerance and thus up their intake. Eventually, that increased intake leads to an OD. This is the reason to move people to suboxone, subutex, or methadone.

          One of the long term things for heroin is the risks caused by withdrawal. While not really as bad as alcohol (withdrawing from that will kill you pretty easily and pretty fast).

          Withdrawing from any opiate is *terrible* and often basically impossible outside of a medical situation. Thats pretty terrible, and a thing that sets it apart from non-alcohol, non-benzodiazapene drugs.

          • Accounts I’ve read have actually suggested that heroin users regularly detox to build up their tolerance levels. I’m not sure how accurate this is, however, but in any case, detox from opiates doesn’t appear to be anywhere near as dangerous or excruciating as delirium tremens. It’s not fun, but if the accounts I’ve read are accurate, it sounds like you’re overstating how unbearable it is. If it were that horrible, I find it hard to believe people would willingly go through it repeatedly.

            Tolerance does cause a serious issue, though, which is why opiate use needs to be carefully managed (and it’s one reason I’m fine with the suggestion of requiring prescriptions for opiates which can only assigned for short intervals; this can hopefully ensure the involvement of an addiction specialist who understands how the body builds up tolerance and what safe dosages will be). And it’s also a major reason that people who have relapsed after a long period of sobriety are particularly likely to overdose: they may simply assume they can tolerate more than they can.

            • Jordan

              Really bad alcohol detoxes *are* worse than opiate detoxes, yes. But that is only because really bad alcohol detoxes are basically the worst thing in the world and not infrequently kill you.

              I actually work at an in-patient behavioral health hospital which is psych/detox/dual diagnosis. And heroin detoxes are terrible. You don’t want any part of that, believe me. You can *survive* it, which you can’t always do for alcohol detoxes (or, to a lesser extent, for benzo detoxes), but you feel worse than you’ve ever felt in your life when you are doing it, usually.

              Here are the “accounts” I see every day: nausea, diarrhea, vomiting, sweats, shakes, restless legs (which is actually much, much worse than it sounds), basically whole body pain, confusion, irritability, and just the general “fuck this” feeling of withdrawal. I’ve not withdrawn from opiates so I don’t have the subjective experience to tell you about, but you are seriously off if you think its not all that big a deal. It really, really is. Its really, really bad. That people might go through it repeatedly tells you about the depth of people’s desperation to be off the shit. Its still really terrible (but less terrible when you do it in a hospital!)

              Your tolerance proposals are fine for very new people, but if they interfere with people getting buprenorphine presciptions/access, then its a terrible idea. So it depends.

              You are right about people relapsing on opiate being at particular risk for ODing, though, which is yet another reason that naloxone needs to be as prevalent as epipens.

              • The accounts I’ve read don’t make it sound like the people who detox regularly actually intend to quit for good. They apparently just don’t want to spend so much money on it.

                I’ll take your word that some people feel the worst they’ve ever felt while detoxing, though. I suppose it’s also entirely possible that people’s experiences detoxing vary widely.

                I’m also not aware of opiate withdrawal regularly killing people, which alcohol withdrawal has been known to do.

                That said, I definitely agree that whatever can be done to mitigate harm/pain should be done. (And there are serious problems with epi-pens as well, notably the price jack-up from the other year.)

                • Jordan

                  First: I hope I didn’t give the impression that I was saying that opiate withdrawal regularly kills people. Because, as you say, it almost always doesn’t. It makes you feel like absolute shit, but it doesn’t kill you (unlike alcohol sometimes, and benzos less often).

                  I guess I am not sure which type of people you are familiar with who are detoxing. Heroin, or opiates in general, have a lot of different ways to use those drugs. If you use them every so often, or maybe a little more often than you should but now you are stopping … ya, you don’t really need to detox at all (other than maybe kinda feeling like crap for a little bit)

                  Maybe you use more than that, but haven’t done it for a while or something. Ya, your detox isn’t all that bad.

                  Maybe, you are using 20 bags each day. Ya, your detox is going to be pretty crappy.

                • Yeah, I didn’t mean to imply you were saying it’d kill people; just wanted to be clear that it almost always doesn’t. It might feel like you’re going to die, but you probably won’t.

                  The people who detox regularly seem to be fairly functional users, so my guess is that they’re probably not using dosages as high as the people you’re treating. That would probably explain a lot of it: the detox would feasibly be a lot less severe if you’re not at the point where you need to seek outside help for it, since your tolerance would also be not as high as problem users’ would be. I think they still need a day off or something to deal with it, but their accounts don’t make it sound like the worst experience of their life. It sounds like a flu that goes away after a day or something.

                • Jordan

                  Cool.

                  And ya, that makes sense. And generally tracks my experience with light-dosage opiate users.

              • PunditusMaximus

                The shitty part of detox wasn’t the weeklong flulike symptoms. That was unpleasant, but whatever — you take your Tylenol and decongestants, and you try to sleep as much as you can.

                The shitty part was the two months of anhedonia. That was genuinely awful and it persuaded me fully that I wanted no part of going back on.

          • rhino

            Opiates are among the easier drugs to quit, actually. The success rate is far higher for opiate addicts than cigarette smokers, for example.

            The problem is not how hard they are to kick, it’s that normally the lifestyle of an addict is such that they have no access to help, and are surrounded by forces conspiring to create failure (like all their friends are users, for example)

            • Jordan

              Nah, that has much more to do with the different natures of the addictions and how they work than anything else.

              Trust me, detoxing off opiods is something you never, never want to do.

      • brad

        Agreed. Meth is a different level of destructive, only a few unpopular things like PCP can have a comparable effect on someone. Amphetamines in general can do real damage to someone, I’m not certain they, including ecstasy, should be granted simple legalization.
        I would essentially legalize addiction to heroin, but not dealing. Which is to say I would make heroin addiction a medical problem, as it truly is, and have addicts forced to register via a doctor to be allowed to purchase state sold and regulated heroin. Which would also allow them to be targeted for treatment, if they are open to it.

      • L2P

        I disagree. Heroin is so addictive that it needs so much regulation it might as well just be banned. Heroin, meth and cocaine all are very different addictive substances than marijuana and alcohol.

        Nobody ever became a pot whore. Coke, crack, and smack whores are a cliche. Those are very, very different drugs.

        • The problem with the “ban it” approach is that it obviously doesn’t work. People still use it and die from it all the time. Meanwhile, management has been proven to work – when you stop treating addicts like criminals and treat them like people with diseases, more of them actually recover.

          And people turning to sex work as a result of these drugs is in large part a result of their lack of other employment opportunities combined, in many cases, with the drugs’ cost. The fact that anyone turns to sex work as a result of economic circumstances strikes me as a condemnation of our economic system, but curiously, a lot of people who cite sex work in a negative fashion never seem to make the connection. And, indeed, the fact that anyone is forced into any job they don’t want by economic circumstances also seems a condemnation of our economic system.

          There are also plenty of people in sex work who, for some reason, enjoy it and don’t see themselves as exploited in any fashion. Because sex is enjoyable. (Of course, just because it’s enjoyable doesn’t mean everyone will enjoy sex with every possible partner, but some people enjoy it enough that they can enjoy it with anyone, so it logically follows that they can enjoy sex work.)

          And of course, creating a black market for sex work further worsens the problems with addiction by increasing sex workers’ risk of sexual assault (they’re more vulnerable due to their legal status), making it more difficult for them to obtain justice when they’re victims of crimes (harder to find witnesses willing to step forward due to the criminalisation, not to mention it makes sex workers less likely to step forward themselves), further contributing to criminal records making it more difficult for them to obtain legitimate employment if they want to leave, and so on. Of course, simply legalising sex work without restriction isn’t the answer either (in particular you have to implement strict regulation to prevent human trafficking) but as is often the case we’re not even listening to what sex workers want, which is usually having their work legalised and regulated.

          …and with that, I’ve got to head off for several hours. May come back later.

        • tsam

          Coke, crack, and smack whores are a cliche.

          And occur much more frequently in the movies and our fevered imaginations than in real life. They’re a cliche because pop culture made them that way. That’s not to say they don’t exist, but their numbers are far from what could be called cliche.

        • bender

          I don’t think heroin is terribly addictive across the board. It may be very addictive for some people. By all accounts, the withdrawal process is unpleasant, but it’s the way the drug dulls emotional pain that draws users back. I knew a vet who, by his own account, picked up a smack habit in ‘Nam and kicked it cold turkey when he came back to the States because he didn’t want to be an addict here. He had a good steady job and was a pot smoker when I knew him. We went to a nude beach; no tracks on him unless they were between his toes.

          Anecdotal evidence says that heroin users who have a reliable supply of predictable strength often manage their habits and are able to control their highs well enough to hold down jobs. Obviously for public safety it matters what the job is.

          I have had brief experiences with several of the poppy derivatives, some out of medical need and some out of curiosity. Didn’t get dependent, haven’t sought them out since.

          • SIWOTI

            I’ve never tried heroin, but I had a history of abusing prescribed opiate medication in my younger years. The only thing that really stopped me from further abuse was the fact that I quickly built up tolerances, and it would cease to be fun and/or I would run out of the prescribed drug. I’ve since been very wary of opiates, knowing my own particular risk factor for them.

            Heroin, like all opiates, is addictive across the board. If anyone takes a high enough dose for long enough, they will become physiologically dependent on it, to the point of having withdrawal upon cessation. But whether someone becomes an addict is influenced by a person’s biology (their genetics), a person’s individual biological development, and a person’s social, cultural, and economic environment. All else being equal, people with support systems, good mental health, and decent economic circumstances are less likely to become addicted than people who lack those things. But everything else isn’t equal, so mileage will vary.

            Heroin is not inherently more dangerous than other opiates: codeine and morphine have similar physiological effects on the body. Heroin is more likely to be abused, because it passes the blood-brain barrier faster, and users get higher faster. And you get two problems with heroin from that: the first is that a smaller dose is needed for an overdose, and the second is that it makes the drug that much more likable (we all like highs within 10 seconds of an intravenous injection). Being more likable does mean that it is more addictive.

            The real dangers of heroin often have to do with dosage. For any opiate, if dosage isn’t controlled, the risks of an overdose increase dramatically. Because less is needed for effect, it is easier to overdose on heroin, much like is true of fentanyl and other opiates with effective low doses.

            We’ve tried to regulate legal opiate use – the current heroin crisis demonstrates that the US has failed at even properly regulating medical use of opiates. I am pessimistic about the realistic possibility of anything more than the decriminalization of opiates.

  • Tzimiskes

    At a minimum advertising of these drugs should be banned as part of any legalization effort. Even better would be a government monopoly on sales and distribution. The profit motive exists uncomfortably with addictive substances, best make them look as boring and unsexy as possible, and few things say boring and unsexy as well as bureaucracy.

    Note, political reality did nothing to inform this comment.

    • I completely agree that advertising should be banned, though I don’t fully understand how that squares with the First Amendment, but since cigarettes haven’t been allowed to be advertised on television for decades, there’s obviously some room to restrict advertisements on public health grounds. I’d probably even ban advertising for cigarettes and alcohol outright if I thought it would fly, but it obviously won’t. (I could probably even been persuaded to support banning advertising of everything, since ads are basically never, ever truthful, but there’s definitely no way that would ever fly.)

      • rea

        though I don’t fully understand how that squares with the First Amendment,

        Commercial speech has always been subject to regulation in the interests of honesty, health and safety.

        • L2P

          It always WAS. We’ll see if it will be, which is very troubling for legalization.

  • cleek

    i don’t see why it should be all or nothing. some things are actually quite dangerous.

    legalize the things that aren’t dangerous. prohibit the rest.

    • pillsy

      It also doesn’t have to be all at once. Start with stuff that’s relatively safe and uncontroversial, and go from there.

      If you legalize pot, and you’re a bit lucky, some people might start smoking instead of drinking or using Oxy. Pot isn’t like magically great for you, but it’s not gonna fucking kill you the way booze or opioids will.

    • njorl

      So ban alcohol and tobacco?

      • SIS1

        Those substances are:

        A. Heavily regulated and have several forms of specialized bans around them…

        B. Neither has the same terrible physiological effects some of the more potent drugs have.

        • nkh

          Well, be careful with what you mean there. Long term abuse has some pretty awful physiological effects. And alcohol withdrawal can actually kill you. Opiate withdrawal won’t.

        • Warren Terra

          Alcohol and nicotine are, in their different ways, each at least as dangerous (in the former case more dangerous) as marijuana. But, as you say, we’ve developed a lot of regulation to make them less dangerous: public intoxication laws, and licensed premises not permitted to dispense to the inebriated. Rules about operating heavy machinery. Etcetera.

          Opioids have particular problems of lethality, though. If we could somehow make a non-lethal version (noting though that we almost certainly can’t!) we could probably build the social constructs to regulate and make relatively safe their legal use, much as we do with alcohol.

        • Aardvark Cheeselog

          Neither has the same terrible physiological effects some of the more potent drugs have.

          You’re dead wrong about this. Tobacco and alcohol addiction both cause horrible physical diseases. Tobacco is distinctive in that there basically is no safe way to consume it.

          • bender

            Safety is relative, not absolute. Like most toxins, dosage and frequency of exposure make a difference in whether the body can handle it. If you want to ingest a substance that is both potentially addictive and hard on the body, take good care not to get addicted. My rule of thumb (yours might be different) is that if I’m not already habituated to something and I don’t want to be, I don’t ingest it more than three days in a row and then I lay off for awhile.

            Native Americans grew (and still grow) tobacco for ceremonial purposes. They did not smoke tobacco daily and they did not develop tobacco habits. They did sit around wood fires and inhale particulate matter often.

          • postmodulator

            Tobacco is distinctive in that there basically is no safe way to consume it.

            Look up “snus.”

            • JR in WV

              Look up oral cancer, tongue cancer, cancers of the head, neck and throat, etc.

              Snus is no more safe than Mail Pouch chewing tobacco.

        • njorl

          If some failed chemistry major just invented fermentation a decade ago and started selling alcohol to pay off his gambling debts, it would be considered the third most dangerous drug on the market, behind coke and heroin, but ahead of meth.

          • rhino

            It would probably be number one, and it would certainly be well ahead of cocaine.

          • Jordan

            It would be easily, easily way ahead of cocaine.

            Possibly tied with heroin. Possibly ahead.

      • cleek

        no.

    • SIS1

      Yes…some things are simply not safe for human consumption.

    • bender

      Why does the government get to decide that adults can’t do things that are dangerous to them? Are you going to ban hang gliding and free diving for abalone?

      If somebody’s idea of a good time is different from mine, he doesn’t need my permission unless it affects me directly.

      • SIWOTI

        Because things that are dangerous to individuals often become dangerous to others. Hallucinogenics aren’t my thing, but I have no problem with people taking them if that’s what they want to try. I do have problems with people whacked out on PCP running into the street naked with a knife cutting themselves and attacking others. Most of the problems with certain illegal drugs aren’t just the problems they pose to their users, but the problems their use impose on others. Drunk driving is a problem caused by a legal drug, and we continue to have huge problems with it.

        And most of these drugs, you can’t just make by yourself. Someone has to synthesize it from precursors, or manufacture it from its natural producer. Then you have manufacturing, transportation, marketing, and sales. Pretty soon, you have an entire empire built on the addictions and problematic use of individuals.

        Granted, not every illegal or recreational drug is like that. But the answer to the first question is pretty much the same: the government gets to decide because these things effect others both directly and indirectly. And the government is us. Which is also the other answer to the question, being that we are prudish and racist and puritanical country, meaning we try to ban all sorts of good times are somebody else’s idea.

        • GeorgeBurnsWasRight

          If someone is attacking me with a knife, I don’t care what his reasons are.

          IMO, behavior which hurts another person is what should be restricted or prohibited, depending upon the circumstances. If someone drives drunk, they’re likely to hurt others. That doesn’t prove drinking is always bad, and blaming drinking for their behavior ignores the fact that many other people drink but don’t drive drunk.

      • PunditusMaximus

        Because we live in a society, and we look after each other or we all die.

  • Joe_JP

    The first comment is a good one.

    Bottom line, alcohol and cigarettes cause a lot of problems, but oppose criminalization. Did that for first, didn’t work well. This is so even though companies promoting the drugs have had a big role in causing these problems. The government itself too, including by subsidizing tobacco, encouraging cigarette usage etc. Can address that in various ways.

    Criminalization causes various problems and legalization will not on a cost/benefit basis be worse. I’m sure legalization will bring forth certain problems. But, that’s the case with lots of things. The devil also might be in the details, including with prescription drugs. Medical practice there would be a major influence, not merely the fact the drugs were legal. etc.

  • howard

    i favored total legalization before i read the article, and i continue to favor it after reading the article.

    otherwise, we continue to have two problems: public health and crime.

    i’d rather reduce it to a public health problem only.

    • witlesschum

      This is the bottom line to me.

      • Derelict

        Indeed. And as with so many such things, bringing it into the light can only do good. Keeping these things illegal prevents us from getting any real understanding of the dimensions of the problem, and fosters the underground economy that makes can only use violence to enforce “contracts” and marketing disputes.

        We also need to start cracking down in the manufacturers of opioids. When one company is shipping nearly a million doses to a single pharmacy in town of under 1,000 there’s something really wrong.

    • pillsy

      You have a problem because people are deciding to do something dangerous for fun.

      You make it illegal.

      Now you have two problems.

      • Were you thinking of the old programmer joke about regular expressions there?

        Regardless, that’s a good way of putting it.

        • pillsy

          Yeah, I was.

          • It’s a good phrasing. Probably applies to a lot of different cases.

            (I’ve actually found regexes highly useful in certain circumstances, but they certainly have their limits and, if misused, can cause more trouble than they solve.)

      • njorl

        There are three uses for opiates – ease pain, get high , service addiction. If the third use is the most common, I think it’s perfectly reasonable for big brother to get involved. It’s no different than going after loan sharks. The patron gets their benefit and is forced to pay beyond all reason for it in the long run. I don’t think it’s reasonable to treat the victim like a criminal, though.

        • forced to pay beyond all reason for it in the long run.

          You have put me in mind of Philip K. Dick’s note at the end of A Scanner, Darkly.

          ===begin quotation (copyright by Philip K. Dick, 1977)===
          This has been a novel about some people who were punished entirely too much for what they did. They wanted to have a good time, but they were like children playing in the street; they could see one after another of them being killed—run over, maimed, destroyed—but they continued to play anyhow. We really all were very happy for a while, sitting around not toiling but just bullshitting and playing, but it was for such a terribly brief time, and then the punishment was beyond belief: even when we could see it, we could not believe it.
          […]

          Drug misuse is not a disease, it is a decision, like the decision to step out in front of a moving car. You would call that not a disease but an error in judgment. When a bunch of people begin to do it, it is a social error, a life-style. In this particular life-style the motto is “Be happy now because tomorrow you are dying,” but the dying begins almost at once, and the happiness is a memory. It is, then, only a speeding up, an intensifying, of the ordinary human existence. It is not different from your life-style, it is only faster. It all takes place in days or weeks or months instead of years. “Take the cash and let the credit go,” as Villon said in 1460. But that is a mistake if the cash is a penny and the credit a whole lifetime.

          There is no moral in this novel; it is not bourgeois; it does not say they were wrong to play when they should have toiled; it just tells what the consequences were. In Greek drama they were beginning, as a society, to discover science, which means causal law. Here in this novel there is Nemesis: not fate, because any one of us could have chosen to stop playing in the street, but, as I narrate from the deepest part of my life and heart, a dreadful Nemesis for those who kept on playing.
          […]

          If there was any “sin,” it was that these people wanted to keep on having a good time forever, and were punished for that, but, as I say, I feel that, if so, the punishment was far too great, and I prefer to think of it only in a Greek or morally neutral way, as mere science, as deterministic impartial cause-and-effect.

          […]
          These were comrades whom I had; there are no better. They remain in my mind, and the enemy will never be forgiven. The “enemy” was their mistake in playing. Let them all play again, in some other way, and let them be happy.
          ===end quotation===

          Even when they saw it, they could not believe it.

    • N__B

      Yes.

    • L2P

      Consider this. How legal do you want heroin to be? Do you want a week’s supply on the shelf at 7-11? Otherwise, you’re going to have a ton of crime.

      • bender

        Well, why not? As long as they aren’t selling to minors.

      • GeorgeBurnsWasRight

        I don’t see the difference between selling heroin and selling liquor at a 7-11.

        It’s been quite a while since I was in a 7-11, but IIRC they just sell beer, which was a business decision. They could sell all types of alcohol, just beer, or nothing, and for reasons that made business sense to them they chose one of those options. I would assume that if all drugs were legalized they’d make a similar choice as to which, if any, they would sell.

        • GeoX

          When I was studying in Ohio, you could buy wine in convenience stores. It’s not a matter of what the business “chose;” it’s just state regulations.

  • tsam

    Opioids themselves? Bad idea.

    Another synthetic that mimics the brain responses without the deadly side effects? (Think methadone vs heroin) Sure. I don’t know of another way to curb the deaths. Enforcement isn’t working, never has and never will. Enforcement of these kinds of things has always been a joke–and racist.

    ETA: For context, if opioids were legal in their current form, I’d be dead.

    • Legal and unrestricted? I can believe that. I can believe a lot of people would be. But then there are a lot of people who die because of our current approach, too.

      If you’d been put before a panel like Portugal’s, would you still be dead? There is a lot of middle ground between “legalise everything, no restrictions on use” and “criminalise everything.”

      • tsam

        If I had easy access to them, I don’t know that I could stop myself. But then when I was using, I had strict pill/day limit that I NEVER broke, so maybe I could have gone along.

        Just from the time of using them almost daily, however, there were noticeable, painful side effects. The pills alleviated the side effects and…well you know where this is going.

        From what I know of Portugal’s approach to the problem (not very much), I feel like they’re certainly on the right track. The criminalization of everything inarguably contributes to the downward spiral of addiction (losing jobs, getting a criminal record, stigma, etc…)

        • Right. I think an approach like Portugal’s can provide a form of structure that addicts may need. If you can manage your addiction, it might not actually be that harmful overall. The problem is that a lot of addicts won’t be able to manage that.

          Keith Richards said in his autobiography that one of the reasons he’s still alive is that he had a strict regimen that he never allowed himself to exceed. The question, of course, is whether everyone who uses opiates can do that. Apparently some people manage it. But some people may not possess that kind of discipline or self-control.

          The side effects definitely sound extremely annoying, and, apart from the risk of overdose with opiates in their current state and the addiction factor, are a major reason opiates never once appealed to me. I definitely don’t have as much self-control as I’d need to manage an addiction, either, so that’s another reason I’ve stayed away.

    • kateislate

      Worth flagging – methadone is not particularly safe or good for you. Dosage is tricky, side effects can be huge, FDA warns that its use for pain management can kill you.

      • tsam

        Yeah–but it seems to have a positive effect on addicts where dosages are controlled…? I may have old information here too. This seemed to be a big deal back in the 90s or so, and I thought there was a general consensus that it was a somewhat effective way of dealing with heroin addiction.

        Maybe controlling opioids the way methadone is controlled is a partial answer…

        • kateislate

          It is absolutely considered an effective way of dealing with heroin addiction, and the rise in methadone deaths is probably not linked to formal treatment programs. Just wanted to note that it isn’t like methadone is the safe version of heroin.

          If you could control dosage of opioids the way you do with methadone the risk of opioids might go down … but then you end up with illegally obtained opioids just like we have illegally obtained methadone, which kills people. (The same way illegal opioids can kill people just like legal ones right now). And its worth considering the views of those who consider methadone to be a tool of social control (introduces a lot of hoop-jumping into the lives of people who use it). So we might still have the problem of ensuring that people who need pain control not being able to access it in a non-life-wrecking way.

          As you note, tricky! And unfortunately not a lot of safe ways to feel the way these substances apparently make one feel.

          • tsam

            And unfortunately not a lot of safe ways to feel the way these substances apparently make one feel.

            Yeah–this is definitely wishful thinking on my part. But then I could see it happening if the research was focused at that particular goal maybe. I do realize that nothing that alters brain chemistry that way is going be as safe as a food or something, but I feel like they could probably reduce the dangers quite a bit if they tried. I’m actually kind of surprised something like this doesn’t already exist.

        • Warren Terra

          My understanding – from reports in the news quite some time ago, I’ve not researched this – is that controlled administration to addicts of heroin, or of methadone, is pretty good at keeping those addicts alive, healthy, and even gainfully employed.

          Of course, handling the issue this way requires that heroin addiction be treated as an almost-socially-acceptable health problem, in a society where the state covers health problems.

      • bender

        Anecdata: Didn’t kill the member of my family. Extended their life and quality of life. That person was career military and had enough self discipline to go to the gym regularly even when in pain.

        I knew this person well and shared a house with them for a while. Other than constipation, the methadone made them drowsy, not all the time, but more than before. As far as I observed, the dosage problem they had was forgetting to take the pill and then wondering a couple of hours later why they hurt so much.

    • tsam

      I should clarify that with opioids–legalization without restrictions is a terrible idea.

      Decriminalization with a focus on treatment and control–I’m way down with that. Probably our best hope for containing the damage. I’d still like to see a drug developed that hits the pleasure center the way an opioid/opiate does that can be made safer for consumption.

      We’ll call it an anti-depressant. That’s more or less how I got snared by them.

      • Origami Isopod

        We’ll call it an anti-depressant.

        ? Anti-depressants don’t work like that at all. In fact, they take quite a while to work.

        • tsam
        • NBarnes

          Actually, opioids are fantastically effective treatments for clinical depression, as are the more powerful stimulants. They’re just banned for that use, because, well, right.

          Certainly in my case, Adderall is far and away the most effective part of my anti-depression regime, even though it’s actually for my ADHD and not the depression.

          • tsam

            They sure wipe out my anxiety and depression for short, blissful periods of time. Always with a hefty price though.

          • Dennis Orphen

            Are amphetemines good then? (I like em, but use sparingly at most, 10 times a year or less). If we as a society go around demonizing meth but giving children aderrall (a trade name for benzedine/dexedrine), then maybe we deserve Trumpism.

            I’m fine with you having aderrall, why is it bad for me?

            • tsam

              I love meth. It’s another thing I have to be extremely careful with.

              One thing about the Aderrall and other stimulants–I don’t know about the pharmacology, but it was explained to me that for kids with ADHD or other forms of hyperactivity, amphetamines have the opposite effect–a calming effect that helps them focus. I don’t know why, and I’m not even sure if they know why, but that’s generally why they’re indicated for that sort of thing.

              • Pete

                One thing about the Aderrall and other stimulants–I don’t know about the pharmacology, but it was explained to me that for kids with ADHD or other forms of hyperactivity, amphetamines have the opposite effect–a calming effect that helps them focus.

                That’s absolutely correct — and not just for kids.
                I don’t take Adderall, but do take another controlled stimulant daily plus a non-stimulant co-therapy. For me, the stimulant was like magic in terms of calm and focus. It does not wire me up at all. the first day I took that pill was the first day I really believed I had ADD (the more preferred term because H is just a subset).

              • searcher

                The short answer is that some parts of your brain inhibit other parts, and the net effect of a stimulant can be to stimulate those inhibitory parts.

                It’s basically the opposite of the way alcohol, as a depressant, can make people feel jubilant or excited – the alcohol is quashing the inhibitory part of your brain that’s whispering “don’t jump on the table”.

                For a non-drug example, a fun one is that arousal tends to inhibit the parts of the brain that handle feeling disgust – things are judged as less disgusting when someone is aroused.

              • postmodulator

                One thing about the Aderrall and other stimulants–I don’t know about the pharmacology, but it was explained to me that for kids with ADHD or other forms of hyperactivity, amphetamines have the opposite effect–a calming effect that helps them focus.

                As an adult, if they suspect ADHD, they’ll ask if you’ve ever done coke or speed, and then try to figure out if you had the atypical calming reaction to them.

                • Q.E.Dumbass

                  Interestingly enough, ISTR that ADD is pretty much the extent of teratogenic cocaine exposure (at least isolated from other factors).

                • Origami Isopod

                  Interesting.

                  Is there any connection at all to having an atypical reaction to pseudoepinephrine? Or are we talking about completely different pathways?

              • rhino

                Most people who use meth get bored of it and stop. The ones who get addicted are frequently people who have undiagnosed anxiety, depression, or ADHD and are actually self medicating.

                Most people simply aren’t interested in being high for the continual periods required to create an addiction.

                I favour the harm reduction model when dealing with substance use and substance abuse. I believe we will have addicts and drug users no matter what, and that we can do almost nothing to prevent it. What we can do is make sure the substances people want to use (and abuse) can be acquired safely and legally. That if necessary the price should be subsidized to the point that it is impossible for a black market to compete. That users should be able to buy their substances easily, in pure form, and precise doses to prevent accidental overdose and poisoning by adulterants like fentanyl. Finally, the kiosks in which the substances are sold should feature easy access to treatment, counselling, and rehabilitation.

                Most addicts don’t want to steal or whore for drug money. They are forced to because black market pricing means that is the only way they can afford their drugs. Lower the price, and you eliminate all that crime. Opiates are *cheap*, you can keep an addict happy for a couple dollars a *day* at cost. Meth is no more expensive. Cocaine has been farmed on an industrial level for centuries, minus the black market I doubt it would be more expensive than coffee.

                Most addicts, in fact, don’t want to be addicts at all. They simply have no real access to treatment. Their dealers certainly aren’t helping, but walking past all the friendly free help available every time they buy from that kiosk? The vast majority will soon be in treatment.

                Some people, of course, will just buy their subsidized drugs, and slowly kill themselves. This is unfortunate, but measured against the vast majority who are no longer committing crimes, no longer squatting in fetid drug houses and burdening the health care systems, no longer selling their bodies or injecting with dirty needles and feeling the HIV epidemic? I can accept a few failures.

                ESPECIALLY SINCE WE WERE FAILING THEM ALREADY!

                • I do suspect a lot of people who are diagnosed as addicts are actually self-medicating for other problems they’ve never been able to get help with. If I’d never been diagnosed with an autism-spectrum disorder, I wonder what would’ve happened to me. I could’ve gotten desperate enough that I’d have resorted to chemical aid to see if that would solve my issues. I was extremely, extremely desperate for almost a year before I found out about my diagnosis. I was certainly depressed and I might even have been entertaining suicidal ideations. I’ve long wondered what would’ve happened to me if I hadn’t been diagnosed and, eventually received treatment for the disorder. I could’ve wound up institutionalised, homeless, addicted to drugs, dead, any number of things.

                  We’re very, very bad as a nation at treating psychological disorders. Part of this is because we stigmatise them so badly (employers openly admit to being less likely to hire people with histories of psychiatric diagnoses, even though this directly contravenes the ADA; mental illness is still popularly linked with violence, even though sufferers of almost every mental disorder are likelier to be victims than perpetrators of crimes), and part of it is because we are so bad at providing treatment for them. It’s difficult to know how many addicts are self-medicating for these disorders, but I suspect it’s an awful lot of them, and not just for meth.

                  Your proposed solution seems pretty logical and includes a few steps I hadn’t thought of.

              • SIWOTI

                Both Pete and searcher are right, and here’s a slightly longer answer for those interested.

                ADHD is a developmental disorder of the brain. By that, I mean that the brain of those with ADHD follows the normal pattern but develops at a slower rate than those without ADHD. This developmental delay is seen primarily in the prefrontal cortex of the brain, largely responsible for things like suppressing inappropriate actions and thoughts, focusing attention, remembering things from moment to moment, and fine control of movement. These functions are often disturbed in people with ADHD. And it is the prefrontal cortex that develops last, or never completely develops in those with ADHD.

                So why the hyperactivity? The motor cortex is the one area of the brain that develops faster in those with ADHD, so the current theory is that a lot of the hyperactivity is due to an overactive motor cortex being insufficiently suppressed by an underactive prefrontal cortex. So you get a lot of the fidgeting and restlessness, and a lack of inhibition.

                The way stimulants work to remedy this is by increasing the activity of the brain. Adderall and other amphetamine derivatives increase the amount of dopamine in the brain, while Ritalin and other methylphenidate drugs keep dopamine around by being inhibiting dopamine reuptake. This increases the activity of the prefrontal cortex, or makes it more efficient, calming the overactive areas of the brain, and allowing the person with ADHD to focus. Now, this is a simplified view, and there are debates as to how and what other neurotransmitters are implicated, and how these imbalances in the brain play out, but it is the dominant theory at the moment.

                For much of my life, I wondered why it was that caffeine calmed me down, rather than made me jittery, as it did to many others, but I came to realize that it was because of my ADHD (and my genetically increased caffeine metabolism). I have the stereotypical ADHD reaction to stimulants: they tend to calm me, and small doses can actually make me sleepy rather than awake. But without them, I wouldn’t have been able to write half this paragraph.

            • SIWOTI

              Amphetamines, at therapeutic levels, have few long term side effects, and are mostly good. They helped us win World Wars, and then were overused on a recreational basis after the Wars. The basic dextroamphetamine/Dexedrine, at low doses, is overregulated as a Schedule II drug, IMO, but it is an addictive drug, and if people chase highs with amphetamines, they can really eff themselves up.

              Meth, unfortunately, is different creature than regular amphetamine. I’m not okay with demonizing meth, or meth users, but it isn’t safe to take without medical supervision. Meth is more effective at dopamine release than dextroamphetamine, meaning it is more likable and more addictive. It is also much more dangerous, being neurotoxic at much lower levels than dextroamphetamine.

              Adderall, btw, is not a trade name for Benzedrine, but is actually a mixture of dextroamphetamine (75%) and levoamphetamine (25%), giving it a larger sympathetic nervous system and norepinephrine boost than Dexedrine itself. This has a synergistic effect for many with ADHD, since deficiencies in dopamine and norepinephrine in the brain are theorized to be at the root of the disorder. That’s also why it is bad/ineffective for someone without ADHD. It has more prominent cardiovascular side effects, and it is more active outside of the brain. It also ends up being less potent, dose for dose, than dextroamphetamine. So you’re better off with Dexedrine than you are with Adderall for recreation.

          • SIWOTI

            The reason why opioids aren’t prescribed for clinical depression is because they aren’t fantastically effective at treating depression. They’re no better at treating depression than the drugs that replaced them, the tricyclic antidepressants and MAOIs, and they have addiction issues to boot. Electro-convulsive therapy was better than opiates at relieving depression without remission.

            The more powerful stimulants aren’t fantastic at treating clinical depression either: what they are good at is treating an often coexisting/co-morbid disorder. Treating the co-morbid disorder leads to the resolution of the depression. ADHD has many co-morbidities, many mental disorders that are often seen with it, depression being the most common.

            I’m in the same boat, ADHD and depression. I had sought treatment for the depression first, then eventually was diagnosed with ADHD. Eventually, I realized that treatment for the ADHD alone was sufficient to relieve my depression, and that many of the root causes of my depression stemmed from my ADHD symptoms.

            Opiates and stimulants aren’t banned for treatment of depression, but if someone is dealing with clinical depression, they aren’t the first line treatment for very good reasons, largely due to side effects and addiction potential. Bupropion, an NDRI, also a stimulant, is a first-line treatment for depression. Buprenorphine, an opiate, is currently being tested in clinical trials for treatment resistant depression and has showed some promising results. But don’t overstate the case – opiates and amphetamines aren’t a good first line treatment for depression.

            • In my case I’m fairly sure the co-morbidity with depression was an autism-spectrum disorder; I have ADHD but I’ve had it under treatment for most of my life so it hasn’t affected me in anywhere near as profound a degree. That said, it also appears that ADHD is closely correlated with depression; it’s possible that there are common genetic predispositions to both or simply that the increased incidence of depression is a result of societal norms affecting those with ADHD.

              My depression was almost certainly at least partially brought on as a result of societal norms, but it’s mostly ones that affect autistic people. Society is coded to favour the social interactions of people who don’t possess autistic brain types, so those of us who have them are often marginalised in ways others don’t think about or even notice; for example, American society codes aversion of one’s eyes as rude, but eye contact with strangers causes many of us discomfort. At the same time, other autistic people are incapable of communicating with people who aren’t at least looking in their direction, because they can’t process words without a face to go with them. Neither of these communicative preferences or needs are normalised in society, but we’re often blamed for miscommunications with others, when it’s a simple problem of ignorance.

              Communication is a two-way street. You don’t blame someone who speaks only Spanish for not being able to communicate with someone who speaks Spanish; they have no mutually intelligible forms of communication. Similarly, if a non-autistic person hasn’t learned how an autistic person communicates, it’s a problem of ignorance. Yet we’re blamed for it. It’s rarely considered that others might be misinterpreting us, but we’re almost always blamed for misinterpreting them. And we’re commonly asked to change how we communicate to suit others, but they’re rarely asked to change how they communicate to suit us. (Indeed, not changing our form of communication can get us fired from jobs. And our employment rates are terrible.)

              Depression and other mental disorders are also strongly correlated with other marginalised populations (for example, queer people are vastly likelier to suffer mental disorders, which almost certainly isn’t due to genetic predispositions), which is another reason I think societal marginalisation is probably a major contributing factor to many people’s depression.

              That said, while outside factors can cause depression, their improvement doesn’t always cure it. This may be another reason so many people with mental illnesses self-medicate: they can’t find anything else that alleviates their issues.

              In any case, this relates back to a comment I made earlier about how improving mental healthcare would help society in a large number of ways: many addicts very likely need both medical and psychological help, and the system we have now makes them far less likely to receive either.

              • SIWOTI

                Mental healthcare is healthcare. Without the ACA, I wouldn’t have been treated for ADHD, and I wouldn’t be writing here today.

                Mental healthcare also improves drug abuse statistics. People with ADHD who are under medical treatment are much less likely to abuse drugs than those with ADHD not under treatment, and people with ADHD are at much greater risk for drug abuse. Early intervention with depression and anxiety are also effective at reducing the risk of drug and alcohol abuse. And we’re only recently recognizing the increased risk of drug abuse that people with autism face. And knowing that the risk is there is important, because it hopefully allows for earlier intervention or avoidance of risk.

                And sometimes, treating a substance abuse problem also requires treating underlying mental health issues. And getting all of that together is a problem in the US. Even if substance abuse help is available, it doesn’t always treat the mental health issues, and vice versa, or there’s a lack of communication between mental health professionals and substance abuse professionals. So I agree: better healthcare would continue the mandates for both mental health and substance abuse care.

  • Murc

    Done carefully (as has generally been the case in Europe) legalization can yield better social outcomes than prohibition, but given extant US political economy it’s as likely as not to yield tremendous human misery.

    Second, however awful the opioid epidemic has become, it’s not obviously worse than the prison industrial complex that prohibition has created (although it distributes costs differently).

    I think these are your two money quotes, Robert.

    With respect to the first one, the question isn’t “will legalization yield tremendous human misery.” It absolutely will, in the same way that the legal status of alcohol and tobacco yield tremendous human misery.

    You pose this question yourself, in the second quote, and I think the answer has to be that legalization is far superior to the prison-industrial complex. People whose lives are being destroyed because of an addictive illness have a massively better chance to get well then people whose lives are destroyed by the state, which is essentially what a prison sentence is for anyone not already wealthy.

  • LeeEsq

    It depends on whether the drug companies are going to behave like tobacco companies or alcohol companies. The alcohol industry isn’t great but they seem to approach the downsides of drinking with greater care than the tobacco/pharmaceutical industry. Maybe they learned the lessons of Prohibition. Perhaps the right to sell previously illegal narcotics should go to the brewers, vinters, and distillers of the United States rather anybody involved in tobacco or pharmaceuticals.

    I think any drug legalization program needs to deal with the fact that not all narcotics are equal and some do more havoc on the body and mind than others. You can’t do a blanket legalization.

    • NeonTrotsky

      “The alcohol industry isn’t great but they seem to approach the downsides of drinking with greater care than the tobacco/pharmaceutical industry.” I don’t know, my impression is that they are mostly forced to by regulation, which despite loosening on the production side have remained fairly strict relative to other industries, probably due to the weird conversion of influences that is religious conservatism/Mormons, parents not liking their kids drinking, and people in general not liking being killed by drunk drivers.

      • Domino

        Yeah, I get the vibe that if not for regulation, the big alcohol producers would behave in the same seedy, shadowy way casinos and tobacco companies do.

      • LeeEsq

        You have a point.

      • njorl

        Yeah, alcohol is unusual in how often it kills people who are not abusing it. The way it’s high boosts confidence while it detracts from abilities and judgement, combined with our auto-centric society is a bad combination. I don’t know of any other drug like that. Speed maybe, but speed probably doesn’t cause as much impairment.

    • Alcohol is significantly less addictive than cigarettes, not to mention most illegal drugs. Probably the only commonly-known drug that is less addictive than alcohol is marijuana. The problem with alcohol is people hurting others under the influence, mostly through drunk driving. Which, unlike drug addiction, is not a problem that can be corralled and described as afflicting only Those People (as many have noted, who drug addicts are strongly affects how a drug epidemic is seen; black and brown heroin addicts are shiftless criminals, while white pill addicts are victims of a predatory system who need help). If your average middle class person can be killed by a drunk driver, that makes drunk driving a social problem – which was, of course, the spin that MADD put on it. The motivation for the alcohol industry not to seem hostile to that formulation is thus obvious in a way that doesn’t exist for the cigarette industry.

  • Matt

    “Big Pharma will always bribe politicians to let them make mad cash killing people” is not an argument against the drugs, it’s an argument against the lobbyists. For that matter, the lobbyists, the overprescription of pain medication and the existence of “pill mills” are all signs that treating healthcare like a profit-making business is a fuck-stupid idea that leads to terrible outcomes.

    • Domino

      Well if you know of a way to ban lobbyists for the pharmaceutical industry, I’d love to hear it.

    • ColBatGuano

      What is the status of liability for pharmacists or doctors for over-prescribing? Would tightened enforcement have a significant effect?

      • bender

        I don’t know but I do know there is a trade off. The greater the penalties for over-prescribing, the more reluctant doctors are to prescribe at all.

        • DocAmazing

          I’m having a 1990s flashback. For a long while, docs were terrified to prescribe opioids, because the DEA would take notice and start reviewing every prescription you’ d ever written. Then in the ’90s, patient groups agitated for more attention paid to pain as a problem–“pain is the fifth vital sign” (after respiratory rate, heart rate, blood pressure and temperature) became a standard refrain in hospitals, and a high-profile case in California set the precedent that a physician could be imprisoned for failing to treat pain adequately. So: do patients get to suffer because we fear creating addicts, or do we accept that opioids will be abused and continue to use them to treat severe and chronic pain?

          • Surely there’s some kind of middle ground where we can recognise the danger of addiction without avoiding prescribing pain medication to people who need it. I’m not sure how you get there, but it seems like it’s worth trying to reach, at any rate.

            (It’s also worth noting that African-American patients are apparently still often underprescribed pain medication, because it appears that there are widespread beliefs either that African-Americans can more easily tolerate pain or that they are more genetically susceptible to addiction, both of which are pseudoscientific bullshit.)

            • Q.E.Dumbass

              Funny: I had my wisdom teeth removed in December 2014 and pain mess proved completely unnecessary, but a sore throat will incapacitate me for one to two days.

  • Warren Terra

    To what extent is the “opioid epidemic” about the prevalence of drug use, and to what extent is it about the overdose risk with opioids, compared to other recreational drugs? If it’s the latter, if opioids are an especially dangerous recreational drug, could we lessen the casualties by legalizing other drug options and penalizing opioids, to redirect users to safer alternatives? By legalizing and regulating opioids so the dosage would be more predictable, and adulterants disallowed or at least clearly identified?

    • kvs

      There seems to be some data suggesting opioid use has decreased in states with legal marijuana. At a minimum, that means that that any analysis of the consequences of legal opioids has to control for the effects from prohibitions on other drugs.

      And remedies have to take that into account.

    • Warren Terra

      Adding: I’m very much not an expert, but it’s my understanding that opioids are unusually dangerous – that it’s especially easy to overdose on them, for a whole bunch of reasons: a sharp dose-response curve to begin with, the differing varieties of opioids and adulterants making dosage unpredictable, and a really tricky one: adaptation. Regular users acquire a resistance and need higher doses and/or different opioids; this both means their pursuit of an efficacious dose is likely to kill them and even worse means that if they do manage to get clean and reduce their resistance, a relapse is likely to kill them as they are likely to take a dose appropriate to their previous resistant addict physiology, but that’s much too strong for them after months away from the drugs.

      By contrast, it’s reportedly difficult to impossible to kill yourself with Marijuana. That isn’t to say that sustained and heavy use of pot is completely safe, even if you avoid operating heavy machinery – but reportedly at least some of the cognitive impairments associated with sustained heavy use of weed are reversible.

      • kvs

        Yes, speaking specifically of LD50 toxicity as opposed to other harmful effects, cannabinoids require a relatively large amount (between about 900-1200mg/kg) relative to what would produce intoxication. Aspirin (200mg/kg), ibuprofen (650mg/kg), nicotine (6.5-13mg/kg) and even caffeine (200mg/kg) all have lower lethal doses, for example. But you’re probably not going to overdose on caffeine from coffee when you’re getting about 95mg per cup, or nicotine when a cigarette has about 8mg/kg. Likewise you’d have to be doing some pretty stupid stuff with cannabinoid extracts to overdose on them.

        Opioids have much less margin between effective and lethal doses. Which, as you say, is a problem when combined with how the body develops tolerance.

  • Dilan Esper

    The error that is being made (and it gets made all the time on our side of the political spectrum) is assuming that consumer demand is an almost completely manufactured byproduct of whatever our corporate overlords want to sell us.

    Obviously advertising and promotion and marketing have effects, but they are only a small part of what causes consumer demand. And the reason this is important to this issue is that there is a demand for psychoactive substances that wasn’t created by big corporations. Drinking and drunkenness have happened for millenia. So has the consumption of opiates. It isn’t as though before corporations came around to promote it, there were no mass epidemics of opiate abuse.

    Prohibition can work on the margins. It even worked on the margins with alcohol. (The oft-told story that during Prohibition everyone violated the law is quite wrong. Many people obeyed it. Liver disease statistics show this.) But when you have so many people who want to get high, the social costs associated with Prohibition are simply enormous.

    And in the end, that’s why this is an area where I think you have to hold your nose and be something of a libertarian.

    There are strong arguments on the libertarian side of this issue– people enjoy getting high, and that should actually count for a lot. It really is a significant impingement on freedom for some stranger to come in and say “you can’t take this substance that you enjoy and which makes you feel good because I disapprove of it and know better than you as to what is good for you”. The fact is that pleasure is a fundamental human freedom, and the fact that we don’t count it at all as a society when striking the balance on issues like that is probably something that goes all the way back to the Puritans.

    So you have substances that people want to take, that make them feel good, and that have horrible societal effects. But Prohibition also has horrible societal effects. Seems to me the best route is to hold your nose and let people use the stuff, while pouring a ton of money into treatment programs.

    • LeeEsq

      Outside the big immigrant and their children dominated cities and what can be called the moonshine belt, most Americans seemed to have tried to obey Prohibition. Getting decent to good alcohol was a big issue unless you lived near a coast, big city, or close to a non-American country or could make it yourself.

      • Dilan Esper

        Right.

        One of the mistakes people make in thinking about this issue is thinking that alcohol is basically harmless compared to the various illegal substances. (A lot of people for many years even thought booze was not as bad as pot.)

        If you were looking for a substance to prohibit based on the harm that it caused, it actually would be alcohol. Alcohol causes domestic violence, assaults in public places, lost jobs, suicides, and drunk driving deaths and injuries. It is also at least a catalyst to the sexual assault epidemic on college campuses. It interferes with labor productivity. It causes people to fail classes and drop out of school. It breaks up relationships and families.

        So Prohibition’s accomplishment of cutting the drinking rate really was no small feat. And yet we all agree, myself included, that it was a terrible idea.

        And part of the reason we agree on this is not simply all the side effects, but also that we think there’s something wrong with telling someone they can’t enjoy a drink.

        But yet when it comes to other drugs, people suddenly want to totally ignore the fact that they are pleasurable or treat that pleasure like it is an awful, sinful thing. And that is truly puritanism.

        • LeeEsq

          There are plenty of criminal judgments that have the sentence “defendant was drunk” before he did an act of violence. There are no criminal cases that have the phrase “defendant was high on pot when he got into a fight.” Prohibition was not a dunder-headed decision when it first appeared. Many intelligent people examined the facts and thought it was the only rational and logical position based on the sheer damaging power of alcohol.

          Alcohol benefits a lot from being one of the oldest drugs humans used. We learned how to brew beer before we could bake bread by all accounts. It might be the devil of drugs but its the devil you know. Many other narcotics are newer and appear less natural than alcohol. That allows people to justify banning them in their minds.

          • brad

            There are, in fact, species of monkeys which allow certain fruit to get overripe and ferment. I’ve seen nature documentary footage of them plain drunk on it.
            Alcohol predates humanity, basically.

            • LeeEsq

              Henry David Thoreau would do that with apples from what I’ve read.

            • MidwestVillager

              There was an NPR segment about moose getting drunk off of fermenting fruit.

              • GeorgeBurnsWasRight

                Bullwinkle was despondent when the show ended.

                • mikeSchilling

                  He started acting really squirrelly.

            • bender

              Cedar waxwings get drunk off pyracantha berries, fly into windows and kill themselves. Not clear whether they do this to get drunk or just because the berries are good to eat.

            • Q.E.Dumbass

              IIRC it’s partially because alcohol is both calorie-rich and sterile.

        • L2P

          If you were looking for a substance to prohibit based on the harm that it caused, it actually would be alcohol.

          I hear you on alcohol. We joke that you never read a police report saying “He beat up his wife after two bong hits” but you always see “After heavy drinking…”

          But still, for me it’s cocaine and meth. Far worse than alcohol in almost every measure. That’s where the legalization arguments lose me. Coke and crank are nightmares.

          • bender

            Alcohol is a preservative, is handy for sterilizing things, can be burned in lamps and is the best medium for extracting many medicinal compounds from herbs. Alcohol is very useful.

            • Dilan Esper

              So are most narcotics.

              • Origami Isopod

                They are, but they don’t have the same range of uses.

    • LeeEsq

      I think your spot on about our side not understanding consumer demand though. Its one of the parts of Far Left thought that wormed its way into liberalism. Many people on the liberal-left side are genuinely non-materialistic and really don’t understand why people like their creature comforts.

    • JBC31187

      So you have substances that people want to take, that make them feel good, and that have horrible societal effects. But Prohibition also has horrible societal effects. Seems to me the best route is to hold your nose and let people use the stuff, while pouring a ton of money into treatment programs.

      I came here to say this. The problem, of course, is that treatment costs money even if it’s cheaper than punishing people. You see the same bullshit with guns- a school or movie theater gets shot up, and the bastards come out and say, “well, it’s not guns it’s the mentally ill.” But we can’t treat them because those same bastards are cutting funding. And god forbid we restrict access to guns.

  • NeonTrotsky

    Total legalization strikes me as a position very few people hold outside of some hardcore libertarians and hard leftists. The more common position to see among liberals/leftists and the left on meth/heroin type drugs is decriminalization which seems entirely consistent with addressing the opioid epidemic, because locking up addicts is not helpful, probably even harmful when you consider that going to prison makes it harder to get a job and makes people more likely to commit crimes in the future.

    • Steve LaBonne

      Yes. I have a front row seat working as a forensic chemist, and tightly controlled decriminalization seems to me to be the least worst approach to the really dangerous drugs. Marijuana doesn’t even have the destructive potential of alcohol and should be legal.

      • L2P

        Agreed. I don’t know why people go straight from where we are to legalization.

        Allowing unfettered access to meth would be a nightmare. Decriminalizing possession, with enforcement for sales, marketing, and production, is a no-lose proposition compared to here.

  • Robespierre

    These things were criminalised for a reason. Don’t be stupid.

    • Warren Terra

      How about arguing your position instead of dispensing insults?

      • Robespierre

        The position stated is ideologically motivated and completely irresponsible.

        • Warren Terra

          Did I really ask for more of the same?

          • N__B

            Arguments are down the hall.

            • Origami Isopod

              I’m sorry, but this is Abuse.

              • Warren Terra

                I think you mean: This is Abuse, you vacuous toffee-nosed malodorous pervert!

                • Ivan Pavlov

                  Excellent.

            • Aardvark Cheeselog

              This is contradictions.

        • tsam

          Only to a stupid asshole who doesn’t know what he’s talking about, but with that qualifier, you’re totally right.

    • JKTH

      Well I’m convinced.

    • PunditusMaximus

      Weed was criminalized to get Nixon reelected. So . . . mission accomplished? We can stop now?

      • rea

        I seem to remember it being illegal before that, although those years are somewhat hazy . . .

      • bender

        I think I remember a flight back from Israel where the announcement over the loudspeaker amounted to, “We are descending, smoke it if you’ve got it.” Young passengers were in the aisles smoking up their stash before we landed. We entered the airport and (this I remember distinctly) were greeted by signs in Customs that said:

        Patience Please
        A Drug Free America Comes First

        Somehow America has not become more drug free since 1971.

    • LeeEsq

      Giving the FBI something to do after Prohibition ended?

    • Origami Isopod

      These things were criminalised for a reason.

      O B E Y

    • kvs

      Yeah, racism.

      • brad

        This. Marijuana prohibition began as an excuse for police to target, harass, jail, and deport Mexicans in New Mexico. Then other states realized it could be used against black folk.

    • tsam

      Gosh, mister, I sure am glad you stopped by with this insightful and thoughtful comment.

    • John Revolta

      We must trust our leaders. They know things and have our best interests at heart.

    • Hogan

      Iraq was invaded for a reason.

      Tanks rolled into Tiananmen Square for a reason.

      Eric Garner was killed for a reason.

    • Aaron Morrow

      To make legal pharmaceuticals more profitable.

  • Nobdy

    Criminalization doesn’t stop use (though it prevents some usage by some people) and has massive and far reaching costs.

    The current opioid epidemic was not caused by legalization but by advertising and claims that the newer formulations were not addictive.

    If we actually prosecuted fraudulent advertising we could do more to stop drug use than prosecuting drug use ever could.

    The bottom line is that prohibition doesn’t work and has greater costs than benefits. Our current politics makes it harder to do the stuff that does work better (education, treatment, regulation) but decriminalizing would do more good than harm in and of itself.

    • This strikes me as correct.

      There are certain drugs that I would almost certainly use more often if they were legal (marijuana, most notably; I’d probably smoke it a couple times a month instead of my current record of once every several years). But the legal status of opioids isn’t what’s stopped me from using them; they simply don’t appeal to me, full stop.

      The way opioids have been marketed overall, particularly to doctors, is a major contributing factor to the current opioid crisis, and in any decently run country, the companies that were responsible for this would be prosecuted for the many wrongful deaths they’ve caused as a result to the fullest extent of the law. Advertising absolutely should be regulated to a much stronger extent than it currently is, because, as you point out, it is literally a life-or-death matter in many cases, and in many cases it simply isn’t taken seriously.

      • Steve LaBonne

        Doctors and pharma companies definitely have a big share of responsibility. Both promoted opioids for treatment of chronic pain, for which they actually are much worse than useless.

        • koolhand21

          Well, that’s not been my experience nor that of the pain management doctors I’ve been seeing and who have been prescribing for me for the last 13 years. I’ve talked to VA docs, been to every type of alternative, including the utterly uselessness of hypnosis, acupuncture and assorted homeopathic remedies. I always end up on some variety of opioids to get through each and every day.
          I’m required to visit the doctor every 2 months to get my scripts ($76/visit with insurance) regular blood work and a series on conversations with them just to see how life is. Seems to work for me.
          So, how many doctors in West Virginia whose names are on the scripts for all these millions of pills have been investigated and or lost their license to practice? I would guess/bet it’s single digits if not zero. Here in PA, you can be convicted of Medicare fraud and not lose your license.

        • DocAmazing

          In some patients, opioids are quite effective for chronic pain. In some patients, cannabinoids are effective. In some patients, surgery to cut the nerves that transmit pain (like radiculotomy) is effective. One size has never fit all.

          • Steve LaBonne

            The odds are very much against an agent that induces a massive amount of tolerance being of value for long-term use. Limited value plus great danger of addiction = strong contra-indication. More here.

  • witlesschum

    I think first we need to establish that opoid use is in fact some sort of new, terrible thing we should freak out about. The media and law enforcement types were shouting similar things about meth 10 years ago and I’m beginning to detect a pattern here, so I’m skeptical to begin with. The obvious argument is to cite the deaths, but all drug deaths are still less than alcohol deaths per the article despite the article’s emotionalism on the subject.

    • Origami Isopod

      The media and law enforcement types were shouting similar things about meth 10 years ago

      And crack, back in the ’80s.

      • bender

        And heroin in the ’70s.

        To some extent, people buy whatever’s available and dealers deal whatever’s profitable. However, new products and delivery systems do come on the market from time to time.

        Also, racism.

    • Steve LaBonne

      No, the new and ever more potent synthetic opioids are genuinely scary. In my lab we wear a particulate respirator when handling unknown powders.

    • The new, terrible thing is mostly that it’s become a problem affecting large numbers of white people.

      • Ronan

        Drug induced Morality rates for African Americans and Hispanics have also increased(just not at the same rate)

        https://www.cdc.gov/nchs/products/databriefs/db273.htm

        “In 2015, non-Hispanic white persons had a higher age-adjusted rate of drug overdose deaths (21.1 per 100,000) than non-Hispanic black (12.2) and Hispanic (7.7) persons (p < 0.001) (Figure 3).
        From 1999 to 2015, the age-adjusted rate of drug overdose deaths among non-Hispanic white persons increased from 6.2 to 21.1 per 100,000, an average increase of 7% per year.
        Rates also increased for non-Hispanic black persons from 7.5 in 1999 to 12.2 in 2015, an average increase of 2% per year.
        Rates for Hispanic persons increased from 5.4 in 1999 to 7.7 in 2015, an average increase of 2% per year."

        • Right, but I strongly suspect that if it were only affecting minorities, our media wouldn’t care. We’ve had other drug epidemics before, and none of them were covered this way. Indeed, some of them were subject to absurd hysteria (remember crack babies? Almost every claim there has unravelled, as have most of the claims about freebase versus powder cocaine generally). The fact that this epidemic is affecting middle-class white people, I suspect, is a strong reason it’s received this kind of coverage; if it had been affecting only minorities, or even minorities plus poor rural whites (e.g., meth), it would’ve been given a different kind of coverage.

          • Ronan

            Attitudes towards drugs have changed in most western countries over the past two decades, i think this shows up in polling in the US aswell? Plus you dont have the crime rates of the 80/90s that crack etc was often linked too.
            Race is probably a factor, but not the only Id guess?

            • That could be some of it, but the peak of media attention to the meth epidemic was fairly recent and the coverage was a lot more different than one would expect if changing attitudes about drugs were the main cause.

              Crime could be a fair point, though, I suppose. Then again, a lot of Republicans think the crime rate is way higher than it is, so maybe not.

              I still think it’s mostly racism.

    • cleek

      19,000 people died from opioid overdoes in 2014.

      http://www.pbs.org/wgbh/frontline/article/how-bad-is-the-opioid-epidemic/

      that’s almost twice as many as were murdered with firearms.

      meth killed under 4,000

    • Warren Terra

      There are a couple of features new to the opioid phenomenon (note this doesn’t make it worse than previous phenomena like crack; any particular phenomenon is likely to have unique features):

      1) Lethality. It appears that opioids are just more dangerous than most alternatives, because the effective dose is too close to the lethal dose, because the dose needed varies from user to user depending on acquired resistance, because of different formulations and adulterants. This appears to be real, and to have a disturbing trend line – though a lot more people die of cocaine overdoses than I’d have guessed (which is however complicated as more than 2/3 of overdoses involving cocaine also involve opioids).

      2) Pharma. Weed, coke, and heroin are plant products made in various places and smuggled around. Meth and LSD are produced chemically, but illegitimately. It’s shocking how much of the opioid phenomenon is driven by the licensed manufacture and sale of pharmaceuticals.

      3) Demographics. Unlike the previous crack and heroin phenomena, this isn’t – or isn’t being portrayed as – a scourge linked to urban minorities, or even to rural white losers as was the stereotype with meth. If violent gangs are a feature of the opioid trade, it’s not a heavily emphasized feature as it was in the cocaine, heroin, meth, and even marijuana phenomena. Instead, opioids are described as affecting bored suburban white kids, who are basically the media’s sweet spot.

      • tsam

        because the dose needed varies from user to user depending on acquired resistance, because of different formulations and adulterants.

        Right–the acquired tolerance is really dangerous. I have witnessed a person eating 6 hydrocodone in one fistful. I was fucking stunned. I’d probably die from that.

    • nixnutz

      I gotta say completely anecdotally that back in the 90s close to half my friends were addicted to heroin at one time or another but none of them died until the last few years when two of them have. I don’t know the details of either of those overdoses, I think they were relapses after pretty long spells clean but I don’t know what they were using. But it’s easy for me to believe that things are more dangerous right now for whatever reason.

      • The Temporary Name

        In my area it’s more or less an epidemic. Fentanyl’s in everything, and you hear people talking about taking a bump of what they thought was cocaine and being grateful they didn’t do a line because they’d be dead. We’re at around 1000 deaths-by-Fentanyl over the last few years. People assume it’s only needle-users but the people putting it on the street seem to use it to add kick to whatever’s in stock.

        Much harder to OD on a clean and measured supply of heroin (or cocaine).

        • Right. It looks like an awful large number of overdoses these days are caused by fentanyl, because it’s really cheap, it’s really potent, and it’s really easy to overdose on. Since it’s so cheap and potent, people lace their supplies with it, and, well… overdoses.

          • Steve LaBonne

            Fentanyl and the steady stream of new fentanyl derivatives, many even more potent, that keep coming out of China.

        • Ronan
  • Origami Isopod

    The opioid crisis IMO would be mitigated greatly by fixing the underlying social problems: dangerous jobs with minimal worker protections, lack of access to health care (including mental health care, as addiction is often an attempt to self-medicate), and various other forms of oppression that increase stress. Legalizing marijuana would be helpful, in that it would give people an option other than the “hard stuff.”

    I’d like a pony, too.

    In this reality, where we’re unlikely to get any of that any time soon (except maybe piecemeal marijuana legalization, and with Beauregard at the DoJ there are no guarantees), I agree with Howard and Murc: Legalization is problematic, but far less so than the prison industrial complex.

    • PunditusMaximus

      See also: Rat Park.

    • Steve LaBonne

      Absolutely right.

    • Sev

      Of course many societies have serious drug use problems, and many of them share some of the same contributing pathologies as ours, such as poverty, discrimination and lack of opportunity, along with religiously inspired moral authoritarianism. It does seem a heavy lift to challenge those things here- we loves our Daddy State much more than we loves our Mommy State; at least the folks with power do, and the idea of investing for a social payoff instead of private payoff might as well be a criminal alien in Jeff Sessions gunsights.

    • tsam

      Yeah, this all makes sense. I think decriminalization to some degree is really the only sane answer here.

      Sessions is a perfect embodiment of every fucked up, backwards, racist view of drugs this country and way too many others hold. “good people don’t smoke marijuana”… You know what? FUCK YOU, ASSHOLE.

      • I’ve smoked marijuana, and I’m a much better person than Jefferson Beauregard Sessions III. For starters, I’m not sympathetic to the fucking Klan.

        His statement makes me half tempted to start smoking marijuana again simply out of spite.

        • tsam

          His statement makes me half tempted to start smoking marijuana again simply out of spite.

          HA! If only you could do it and be there to blow smoke in his fucked up little mug. Then smack him SO HARD with a fish. A great big, stinky fish. No, I’m not high right now. Why do you ask?

          • I would definitely love to do that if I had reason to believe there wouldn’t be legal consequences for it.

          • Dennis Orphen

            Why do we ask? You’ve mellowed out. Usually you would call for a lumber massage. Of course the fish and the 2×4 aren’t mutually exclusive.

            • DocAmazing

              Planked shad?

      • PunditusMaximus

        I can think of no greater endorsement of my decisions than Jefferson Beauregard Sessions denouncing me as not “good people”.

        • tsam

          I’d feel better about it if he wasn’t in charge of the DoJ, where he can actually DO something about people smoking weed. But your larger point stands–anytime you’re crossed up with a dumbfuck redneck racist, you’re doing it right.

    • epidemiologist

      Yes, basically. Related to lack of access to care, there is a generalized lack of access– for almost everybody– to coordinated and multidisciplinary care that can provide appropriate monitoring of use and referral to other types of treatment.

      Many people who use opioids for real pain might also benefit from physical or occupational therapy, mental health care, social work or case management, and having a specific plan to manage their health condition of which pain management is just one part. Many don’t realize that opioids may not be effective for their type of pain, especially long-term, and could even increase perceptions of pain. Lack of sleep, lack of exercise, boredom, mental and emotional distress all could too.

      A perennial ethical issue in medical practice is how to refer and treat patients who may not be able to comply with the prep or follow-up for a treatment of choice. When I worked in a clinical setting, I rarely saw the same type of soul searching regarding whether the medical team was capable of a safe level of compliance. IMO both the prescription and its abuse in some cases come from the same source: organizational inability to get people appropriate preventive services and monitoring. To me the clearest indication of this is that many of these overdoses are accidental poisonings caused by mixing with e.g. alcohol or other medications. Most people would never, ever mix those with pain medication if someone had made sure they understood how incredibly dangerous that is. What other counseling about their chronic medical condition weren’t they getting?

      • DocAmazing

        If we can get beyond a system in which a provider is expected to see four patients an hour, in which we rely on photocopied handouts to convey instructions to patients because we don’t have time to, y’know, talk to people, we might see some improvementin outcomes. That might cost money, though.

  • Rob in CT

    This seems like a stronger version of Mark Kleinman’s take (which is legalize, yes, but you have to be careful about it – regulate, tax, treat, etc.).

    I still think that it’s worth trying even if we think we’ll probably do it suboptimally.

    • Steve LaBonne

      Except that I think he greatly exaggerates the danger of marijuana.

  • njorl

    Second, however awful the opioid epidemic has become, it’s not obviously worse than the prison industrial complex that prohibition has created

    It’s not even as bad as the alcohol abuse epidemic. Alcohol still causes over twice as many deaths and 2.5 times as much economic impact as all opiates combined. It’s catching up remarkably fast, though. If it were as cheap and easy to get opiates as it is to get booze, I think things would get much, much worse.

    • cleek

      the opioid stats i’ve seen only count overdose. but the alcohol stats include things like DWI, long term problems like liver failure, etc..

      alcohol overdose deaths average 2,200/year. that’s a bit over 1/10th the opioid overdoes deaths.

      https://www.cdc.gov/media/dpk/alcohol/alcohol-poisoning/dpk-vs-alcohol-poisoning.html

      if opioids were legal OTC, we’d be able to get numbers for long-term abuse and opioid-related deaths (DW-opioid’ed). they wouldn’t look good. opioids are way too strong for people to handle.

      • cleek

        one of these days i”l learn to type ‘overdose’ correctly.

        those ‘overdoes’ is almost a workable synonym .

  • xq

    Done carefully (as has generally been the case in Europe) legalization can yield better social outcomes than prohibition, but given extant US political economy it’s as likely as not to yield tremendous human misery.

    What country in Europe has legalization? Isn’t the US West coast already ahead of almost all of Europe in actual legalization?

    • Portugal hasn’t completely legalised most drugs, as I understand it, but it’s completely decriminalised everything and focuses entirely on treatment rather than punishment for addicts. All measurable addiction statistics as well as new HIV/AIDS and hepatitis infections have plummeted since they implemented their policies (in 2001, IIRC).

      • xq

        Yeah, the Portugal model looks pretty good, but it’s not legalization.

        • Right. The main reason I favour legalisation specifically is due to the consistency factor I mentioned in my first post: the inconsistency of black-market opiates leads to accidental overdoses that wouldn’t happen if users knew for certain how much they were taking. This still doesn’t mean I favour completely removing restrictions on usage, though; it just means the drugs could be controlled to reduce the harm they cause to the fullest extent possible. I basically favour Portugal’s approach, but modified to have a legal, regulated supply.

    • PunditusMaximus

      I think this is in reference to the harder stuff than weed. Weed legalization is one of those weird policies that seems to have almost no downside.

      • bender

        I’m in favor of it since forever. Two caveats. Commercial grade marijuana these days is often as strong as hashish used to be. And money needs to be spent on developing a quick, cheap, reliable test to assess whether a person is too stoned to safely operate machinery.

        Some byproducts of marijuana use linger in the body after the drug’s effects on reflexes, concentration, sense of time etc. have worn off. Rather than test breath or bodily fluids, I think it would make sense to design a performance and cognition test on the lines of a computer game. (No doubt if such a test existed, people would practice it to improve their scores while stoned.)

        BART is required by federal law to randomly drug test both train operators and the mechanics and techs who repair the trains, which would be reasonable except that lingering traces of marijuana in a urine test is a disciplinary, and on the second strike, firing offense for a person who does not come to work high, or who can maintain well enough to do their job safely, or who thinks they are maintaining but actually aren’t.

        • And money needs to be spent on developing a quick, cheap, reliable test to assess whether a person is too stoned to safely operate machinery.

          Oh, I can think of plenty of such tests. One (or more) for each kind of machinery that can be operated unsafely. Very quick; very cheap (not counting sunk costs); completely reliable.

          …What? You’re not interested in destructive testing?

        • Warren Terra

          I heard a talk the other day by someone with cerebral palsy, and she mentioned that because of her lack of coordination she cannot pass a field sobriety test (she’s Muslim and doesn’t drink, but does get pulled over; whether that’s because of profiling or bad driving, I don’t know). On the assumption she can drive safely (I don’t know a lot about cerebral palsy in general, nor her in particular), some thought would have to be made regarding reasons people would fail coordination tests other than pharmacological impairment.

          • DocAmazing

            This also touches on something that has bugged me for years: concentrating on drunk drivers often results in bad sober drivers skating. On more than one occasion, I’ve seen people who drive erratically and stupidly let go by cops because they passed a Breathalyzer.

            • I definitely often feel that standards for drivers should be higher, but at the same time, given that it’s almost a requirement to be able to drive in many parts of the country given the almost complete lack of public transportation in them, I don’t know if that would actually be feasibly possible. I sort of feel like half the solution to problems like this is to focus on creating better public transit. Of course, there are probably structural reasons in our political system that explain why this hasn’t happened, and why we’re such a car-focused nation. (To be fair, we’re a much more spread out country than other parts of the world like Europe are; Europeans are often amazed how physically big this country actually is when they visit. But I don’t think our size can explain the car thing entirely.)

              Still, yeah, many sober people are terrible drivers.

              • JR in WV

                Back when every little town had electric trolleys and buses, when GM came to town the bought those transit systems and junked them. Now everyone has to buy cars, and some of those folks will buy from GM.

                And that’s why people drive drunk, there are no trolley systems any more. In Europe, we stayed in a tiny French farming village, and the hotel manager/owner told us they hoped we wouldn’t be bothered by the trains. We of course thought of 150 car unit trains hauling bulk freight.

                They were talking about the passenger trains that came through town every two hours until midnight. The loudest part was the bell ringing at the crossing when the bar came down. That lasted 90 seconds as it was a two-car electric train.

    • JR in WV

      And the Swiss treat heroin addiction with prescriptions – for heroin, much as the British do in part.

      Because it’s expensive, the Brits are doing less of it, also because of the “immorality” of using drugs which seems to affect the Torys quite a bit.

  • petemack

    When something like this comes up, compare it to other lethal compounds. Alcohol kills 90,000 people per year, out of roughly 150,000,000 regular users and 15,000,000 heavy users (AUD.) The average age at death is around 60. So, that’s around 2,000,000 person-years of life lost. For opioids, it’s crazy. Out of roughly 600,000 addicts, 50,000 die in any year. That’s a 9% annual chance of death by OD. Nothing else is remotely in this league–the really big killers–tobacco and sugar–have something closer to a 2% annual chance of death for heavy users, and a life expectancy roughly the same or longer as that for alcohol addicts. I suspect marijuana is in the same ballpark as tobacco.

    So yes, opiates are in a very different place from more ordinary legal poisons. When you pick your poison, pick something else.

    (Note that other drugs are down in the noise. And even cocaine use is only around 1/3 as deadly as opiates.)

  • Aardvark Cheeselog

    There’s a pretty good description of the Portuguese model in Chasing the Scream.

    The short version is, never bust anybody for getting high, try to get people who won’t quit to get their drugs from the State, and provide lots of social services to help people live lives that don’t suck so bad that they want to be whacked out on opiates all the time.

    It would require huge changes in American social policy to get anywhere near this.

    • Steve LaBonne

      That a much poorer country can do this and we “can’t” is a good example of how fucked up this country is.

      • AMK

        Well that’s just the thing–it has absolutely nothing to do with money.

        • I suspect it actually has rather a lot to do with money: too much of it going to the wrong people to increase the odds that the current distributions of it remain as they are.

          • AMK

            Sort of like a chicken-egg question–did the racism come first, or did the profiteering?

            • To be Scrupulously Fair, not all of this is racism. Some of it is also classism. There may be some other bigotries involved as well.

        • Aardvark Cheeselog

          Au contraire, it has everything to do with reluctance to give money to the undeserving poor. And blah people. Doing in the US what the Portuguese are doing would require spending a huge fvckton of $$ on things intended to help junkies. Who are maybe the only group more despised in the wider society than atheists and Muslims.

  • AdamPShort

    I find this attitude toward opioid policy very strange. For many decades drug hysterics tried mightily to convince people that opioid overdose was this huge public health problem and that the solution was harsher control measures.

    It wasn’t a huge public health problem. It was a small to moderate public health problem, on the order of, say, household accidents. But the anti drug people got their wish and now opioids are much more tightly controlled.

    The result is that opioid overdose is now a huge public health problem, on the order of car accidents or gunshot wounds. And this now is the reason that opioid controls can’t be loosened. These drugs are dangerous!

    The solution to bad drug policy is always, it seems, more bad drug policy.

    • petemack

      The issue at hand is (largely) *legal* opioid use. Doctors are getting kickbacks from pharma companies for pushing addictive drugs–there’s clearly no interest in addiction treatment shown among actors like this. Doctors are prescribing opioids for chronic pain–which essentially is a guaranteed path to heavy use, as tolerance builds up fast.
      The issue here isn’t whether the drugs should be legalized: most of them already are.

      • AdamPShort

        Yes, I guess I actually an inelegantly trying to make your point. The point is, what benefit exactly is there to the harsh laws criminalizing these drugs? There are lots and lots of people in jail for heroin possession, possessing other people’s prescription painkillers, etc. Why? What on earth has that accomplished?

        It’s just weird to me that there’s this presumption that drug prohibitions must automatically have some salutary effect, because the drugs being prohibited are dangerous. Opioids are indeed quite dangerous! So what?

        I think sometimes we get too far ahead of the facts when we try to talk about all the benefits of drug legalization. The point is to prevent the harm of harsh drug prohibitions, militarization of police, etc. The point isn’t to solve the opioid overdose problem. That’s a weird, high bar to hold legalization/decriminalization to.

        • This is a good point, especially since addictions often have other underlying contributive factors (poor living conditions, undiagnosed mental disorders, untreated medical problems, etc.). A lot of people can use these drugs without ever having problems with them, even heroin. Why? Is it entirely genetic? There isn’t much evidence to suggest that it’s all genetic, but even if it is, why should people who are never likely to develop problems be incarcerated? It’s not actually solving the problem.

          I can see why people expect the government to intervene to help drug abusers, because they aren’t always just harming themselves. But the problem is that prohibition doesn’t do any of that. It doesn’t stop them from getting their hands on the drug, and it doesn’t mitigate the drug’s harm to society when they do.

          There is a middle ground between banning all opiates and allowing unrestricted usage, just as there is a middle ground between banning all guns and allowing unrestricted usage. Most people on the left seem to be able to accept a solution along the latter lines for guns, but some of the same people have difficulty doing the same with drugs or sex work. And yet exactly the same principle applies: an unregulated market has problems, and a black market has problems, but a tightly regulated market can solve problems that neither of the others can solve.

          (Meanwhile, people on the right often have extremely black-or-white thinking with guns and abortion, as though they can’t accept that you can have a restricted market for guns that doesn’t involve government grabbing law-abiding citizens’ firearms, and don’t seem to realise that women aren’t having late-term abortions for funsies. But, of course, there’s probably no helping these people.)

          Anyway, as with many issues, there’s a lot of shades of grey here, and the appropriate course to take seems to me to be one of harm reduction, which means neither a complete ban nor completely unrestricted access/ability to produce. Yet a lot of people always seem to gravitate towards the extremes with issues like this, as though they’re the only two options. Humanity often seems to be prone to black-and-white thinking.

  • LifeOntheFallLine

    It’s interesting how much this discussion is a mirror image of right wing response to the idea of gun control, right down to the “People will still get their hands on guns/drugs if they really want them!”

    Aren’t opiods already legal with a valid prescription? Do we need to define our terms here? When people say legalized do they mean OTC? Are there age restrictions? If prohibition is on the table, what goal is it trying to achieve?

    Because prohibition absolutely does work when applied relatively rationally and humanely – the drop in drunk driving deaths since 1984 shows that much. Did it eliminate them entirely? Of course not, but I bet if the legal age was raised again from 21 to 25 the amount of deaths would drop even further (and I assume the amount of lifelong alcohol addicts would drop as well, but the evidence I would use to support this is beyond my grasp to find currently).

    I don’t think we need OTC opiods to dial down our current levels of prohibition. For people seeking them for physical pain, the answer is lower doses on a cycle of opiate rotation. For people who use them to respond to mental pain, an answer is methadone clinics with outpatient mental health counseling. No answer includes tossing them in jail or prison. Other people have mentioned how do you differentiate between a dealer and a stockpiler – and I think at least one solution (for opiate users) is to do a 24-hour hold in a medical facility and watch for withdrawal symptoms; I grant that it’s not perfect, but it’s better than a hard red line based solely on weight of product.

    Marijuana, peyote, shrooms, LSD…fine, just for the love of God chose a reasonable legal age and keep the people using them from getting behind the wheel of a car (a robust public transportation network would do wonders here, but we’ll see heroin possession dropped to a simple misdemeanor before we see that).

    Cocaine, methamphetamine…the medical benefits versus the potential for harm are completely upside down. I still favor decriminalization and lowering of possession penalties, but I can’t get behind full scale legalization.

    • xq

      Because prohibition absolutely does work when applied relatively rationally and humanely

      Yep. The research on alcohol and tobacco suggests that raising barriers to access generally has substantial public health benefits. I think the optimum for most high-risk drugs would be to raise barriers as high as possible without creating a large black market.

  • vic rattlehead

    Opioids terrify me.

    I was prescribed Percocet a couple years ago after getting my wisdom teeth out.

    Apparently I have the Osbourne gene. Because I just didn’t have any real side effects other than a little constipation. Absolutely no nausea. And it didn’t seem to fog up my brain that much. Just made me feel really really good.

    I’m just glad I ran out. If it were any easier to get, I shudder at the thought.

    That being said, there’s just no fucking reason for cannabis to be illegal.

    • PunditusMaximus

      I’m pretty much the same way. Over time the side effects pile up and you decide it’s not worth it. It was a shitty month, but otherwise no worries.

  • RPorrofatto

    In the 80’s, the government succeeded in shutting down the production of one of the best drugs ever: Quaalude (methaqualone). It was not only one of the best recreational drugs (IMO – old hippie that I am) but it was a terrific tranquilizer and sleeping aid. A comparison:

    — The number of deaths from prescription opioids in the last few years has been hovering around 14,000-18,000 per year.

    — According to JAMA, there were 246 methaqualone-related deaths reported in the ten years between 1971 and 1981.

    I guess it just wasn’t a big enough money maker, or something.

    • Bill Cosby sort of ruined the brand, though.

  • Gwen

    This dovetails with an idea I’ve had recently, which is that anyone calling for prohibition of something needs to be very careful that what they are proposing to ban, is really the root cause of the problems they claim to be addressing.

    Alcohol prohibition is the obvious example of this. Throughout the 19th century, temperance was pushed as a way of:

    * protecting women from abusive drunkard husbands
    * protecting parents from neglectful drunkard parents
    * protecting employers from lazy drunkard employees.

    Of course, Prohibition did not solve these problems at all; domestic violence is rooted in a number of other problems (including patriarchal domination of the household) and banning alcohol was only going to make a difference at the margins – if that. Similar observations could be made about the issues with child abuse and employee shiftlessness.

    When it comes to opioid abuse, banning them probably isn’t a facially horrible idea; but obviously the epidemic has roots in much bigger social problems, including a growing sense of alienation and impotence in Middle America.

  • royko

    Any time the idea is expressed that capitalism is too dangerous and irresponsible to be trusted with drugs, it makes me think that the question isn’t what should we do about drugs, it’s what should we do about capitalism.

    • PunditusMaximus

      Nice.

  • MacK

    I’m you to say something that people probably don’t like. But I regularly point it out to Republicans so I can say it to the Democrats.

    Unless you’re willing to put users of illegal drugs in jail, even isolate them on prison islands you are not going to solve the problem and a drug dealing. As long as there is a demand for addictive substances, there will be a vendor-and the more you trying to do to target the supply side, the more criminality, murder etc. will be associated with illegal drugs. As I put it more bluntly actually, doing a bit of a right wing nut imitation, I announce and “it’s a war on drugs, and if you buy drugs, use drugs you’re committing treason-we should hang them, shot them, execute all the users…..” They usually blanche at the idea of executing some middle class yuppies (who may be related) for scoring some coke.

    My point is that there is an intellectual dissonance in the approach to drugs. As a society we are not willing to impose the consequences on illegal drug users that would be necessary to dry up demand. We’re not willing to do it because we recognize the drastic consequences for users is socially unacceptable, and given their numbers, and frequent white middle-class status, quite possibly completely uneconomic too.

    But as long as we recognize that imposing sufficient consequences on the users of illegal drugs is economically societally and socially unacceptable, there’s no point in continuing with the current policy of illegality.

    Does anyone really think the Donald never did cocaine, or his kids. We can all be pretty certain that W did… But Republicans have not imposed consequences on them. And that’s the big issue, criminalizing use would move too far into the white middle-class base of the Republican Party, not to mention wealthy yuppies. However if you can’t target demand, then there is really no point in a war on supply.

    • Steve LaBonne

      Feature, not bug. Selective enforcement of laws is a powerful tool for social control. This is why the system vigorously resists decriminalization.

  • pseudalicious

    I’d be interested in hearing a perspective on this from someone with chronic pain issues, especially a woman dealing with that. Every so often, over the years, I’ll hear frustration with the framing of the Opioid Epidemic in various internet spaces, usually from women dealing with chronic pain. Their argument seems to be that the underlying issue here isn’t Big Pharma or Addicts Gone Wild but an inability on the part of doctors to deal adequately with pain management. And apparently race complicates this; I know there have been studies that white women get over-prescribed pain medication, including opioids, and black women (and black people in general) get under-prescribed.

    I mentioned this to a doctor I know (though this area isn’t her specialty), and she said that pain management is difficult because pain is subjective, difficult to quantify.

    ETA: Now that I think about this, I remember hearing stuff about this from female fans of the show House — people arguing that it was wrong to portray that character as an addict, that people don’t understand how difficult it is to manage pain, etc.

    • It’s been awhile since I watched House, and I don’t think I finished the last couple of seasons, but my recollection is that the show was fairly ambivalent about portraying him as an addict. It pretty conclusively demonstrated that he literally couldn’t function without pain meds because his pain was so severe. That’s a bit different from the normal presentation of addiction in media. However, he was still treated as an addict by those around him.

      I guess how you interpret the show’s message depends on whether you think the writers intended us to sympathise with others’ perception of him as an addict or not. His Vicodin use did cause him trouble at times, but he literally couldn’t even function without some sort of pain medication. (There was a subplot where he began using methadone for awhile, but I don’t entirely remember how it was resolved.) That’s… a bit different from the usual perception of addiction, where people are just chemically or psychologically dependent upon drugs. In this case it isn’t chemical or psychological. It’s literally biological: opiates seem to be the only thing that actually relieve his pain.

      Then again, addiction is commonly misunderstood anyway; many people still don’t realise how much of a medical problem it is (and the fact that there are also often underlying psychological disorders worsening it). I think I agree that simply classifying House as an addict without any further explanation is oversimplifying things a bit, but I also think the writers may have intended us to feel that way. After all, most of the time he’s able to do his job without much trouble, and he wouldn’t be able to do so without opiates. It’s a fairly complex portrayal overall, and I don’t think we’re really supposed to think there are really easy answers here – because, in reality, there aren’t any. When an individual’s chronic pain can only be mitigated by drugs with rather unpleasant side effects, there aren’t any easy choices. It’s not simply a question of addiction; it’s also a question of a medical necessity. And eliding the latter when dealing with the former is not actually going to solve either problem. I think that may have been an intended message from the writers.

      That said, I’m classifying “the writers” as though they’re a monolithic entity when in reality different writers probably had different interpretations of the character. Plus, it doesn’t even really matter that much, because as the Death of the Author school of criticism points out, authorial intent isn’t the only valid interpretation of an artistic work, anyway.

      Anyway, heading off for dinner – back later, maybe.

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