Campaign life

I’m working on (not with) a state assembly campaign right now, traveling, meeting people, grinding. Two months ago, post-graduation from Chico State, I roadtripped to Portland and Seattle and above, burned out the last of my apartment lease — fighting one last Waterloo against a bedbug armada, dipped to San Jose, said why not and flew to Greece and Italy (just to strangle the guy directing the Suspiria remake), stayed in Athens, Mytilini, Eressos, Corinth, Olympia, had a disaster flight into Sicily, finished in Rome and returned to Silicon Valley, slept two nights and drove to Santa Barbara … got a call “Hey, can you be in Wisconsin on Monday?” … slept a night and drove back to San Jose, American Airlines’d to Green Bay and beat my feet for two weeks of calluses and drove to the swamp, YALCON for four days in Virginia, drove back and now it’s back to knocking doors until the mist rolls in.

Travel is fun. Campaigns are fast. Ringing doorbells in humid Wisconsin is the opposite of tutoring logic in an air-conditioned Californian college. I majored in political science and philosophy, and learned more about philosophy from reading independently than studying in university. I learned more about American politics from listening to Non Phixion than listening to a professor. And now, amidst all the blood, sweat, tears, pus and guts that go into a political campaign, I can learn more about how politicians win, and how power gets distributed, than generalizations about voting patterns, polls and platforms. Life is a lot of fun — sterile dreams of grad school seem very distant, if only for the moment. Redbull and protein bars look and taste and feel much closer. Greetings from the road!

Feyerabend: Westernization and culture

There is a short thought, quoted by Paul K. Feyerabend in “Notes on Relativism”, that I’ve been thinking about a lot recently. Paul, ever critical of Western rationalism, is commenting at length on the expansion of (Western, capitalist) industrial scientific society to the margins of the developing world and minority cultures. He quotes François Jacob from The Possible and the Actual:

In humans … natural diversity is … strengthened by cultural diversity, which allows mankind to better adapt to a variety of life conditions and to better use the resources of the world. In this area, however, we are now threatened with monotony and dullness. The extraordinary variety which humans have put into their beliefs, their customs and their institutions is dwindling every day. Whether people die out out physically or become transformed under the influence of the model provided by industrial civilization, many cultures are disappearing. If we do not want to live in a world covered with a single technological, pidgin-speaking, uniform way of life — that is, in a very boring world — we have to be careful. We have to use our imagination better.

Prima facie, I want to say, the general message is correct: the world is slowly homogenizing, and homogeneity is boring. People no longer just consult their local markets and preserve culture organically; we buy and sell all over. Although Dallas and San Francisco have very different cultures, to some extent Los Angeles looks like Seattle looks like St. Louis looks like New York City… looks like Athens looks like downtown Rome, etc. This doesn’t explain what we should do — neither Jacob as quoted, nor Feyerabend in his entire book explain how we should “use our imagination better” (which is what makes this paragraph so unsettling). Feyerabend offers some views in other writings, e.g., using the state to intervene with the success of the sciences.

Feyerabend can be interpreted in a plethora of contradictory ways. Though co-opted by the political left (perhaps to their own detriment), far-right nationalists, primitivists and humanists can all find theoretical support in his ideas. He seems to have written surprisingly little specifically about capitalism, although there are plenty of implications in his anthropology; maybe understanding his views on political economy could provide the path to extracting a substantive political philosophy. In any case, the concern of Jacob and Feyerabend is a consequence of, to a large extent, the West’s powerful free markets, globalizing trade, science and universalistic liberalism. And, I want to say, their concern is not only prima facie correct but a growing left/right critique of Western capitalism/liberalism, and therefore one worth addressing.

There may not be a market approach to preserving cultural diversity; maybe all we can say is that so long as homogeneity is a result of the free interactions of individuals it is not undesirable. Here are a few responses anyway, which may or may not be satisfying.

  1. The process of homogenization predates capitalism, and is really just a function of multicultural nations living side by side and competing and trading. Cultures grow, die and are subsumed ad nauseam, some survive well past the initial spawning phase and become hegemonic but eventually these too face extinction or subsumption.
  2. Homogenization in a free world means that the “best of the best” is accessible for societies which, though previously they may have maintained unique non-Western cultures, were far worse-off before the commercial tsunami. Firstly, the people in these societies didn’t consider the expatriate cultural elements “boring” when they arrived, and secondly, they would prefer “boring” Western/industrial culture than their previous dilapidated state. (We may want interesting tourism destinations, but does that take precedent over human well-being and free choice?)
  3. With the success of industrial, liberal society, science has grown and actually developed better preservation technology (and projection tech, like 3D modeling underground structures). Ancient artifacts from long dead cultures are able to survive longer to be appreciated, and living cultures are better able to create and preserve in the present.
  4. Globalization/Westernization means that we discover living cultures we would never have known otherwise. Under the eye of Western society they are opened up to the melting pot process, but discovery is mutual. We take and they take, and therefore,
  5. Another response could be to actually reject Jacob’s story. We are not trending toward a single McWorld, because although Starbucks can be found nearly globally, it functions alongside original cultural products and cuisine, and at the same time foreign cuisine thrives in the West and impacts our identity.

Evaluating the consolidation of cultural diversity sits at an uneasy crossroads between rights concerns, utilitarianism and aesthetics. I’m not sure these responses would be satisfying to those that buy Jacob’s argument, but it’s likely I’ll be returning to this subject at length in the future.

Some quick thoughts from Athens

I spent the last week and a half in Greece (mainly Athens and other historical sites in the Peloponnese) thanks to the Reason, Individualism and Freedom Institute, and explored ancient political philosophy in a modernly turbulent state. I’m writing this in Naples. Here are a few thoughts I had from the first couple days in Athens.

There is a strong antifa presence (at least judging from graffiti, small talk with some locals and the bios of Grecian Tinder girls). I can’t help but imagine the American antifa pales in comparison. Our black bloc — thrust into the spotlight in mostly superficial college campus debates — tends to be enthusiastic, whereas the antifa in Hellas, culturally sensitive to millennia of dictatorships, entrenched aristocracies, Ottoman annexation, great power puppeteering and a century of neighbouring fascist regimes, must be somber and steadfast. Our antifa crowd has so little targets to find Ben Shapiro a worthy protest, whereas Golden Dawn, the ultranationalist, Third Reich-aesthetics Metaxist party gets 7% in the Hellenic Parliament. Nothing here is spectacle. (Moreover, the extreme-right in Greece, according to our tour guide, has been known to worship and deify mainstream Christian figures as well as the ancient gods spawned of Uranus and Gaia. Umberto Eco’s immortal essay Ur-Fascism explained phenomena like this as the ‘syncretic’ element of fascist traditionalism.)

Moving past the fascists and antifa, in general Greece is left. The Communist Party of Greece, KKE, gets about 5% of the votes and displays a sickle and hammer. More telling still, plenty of the leftist graffiti is actually representing the KKE. Political parties tend to de-radicalize, or are supposed to in theory, and the fringe ideologues disavow the party for centrism or weakness (it’s funny to think of American socialists spray-painting the initials of the CPUSA). The graffiti stretches all the way to Lesvos, of Aristotle’s biology and Sappho’s poetry, and to Corinth of the cult of Aphrodite, but is most prominent in downtown Athens.

Athens has an anarcho-friendly district with a rich history called Εξάρχεια, Exarcheia. Antifascist tagging is complimented by antipolice, antistate, antiborders and LGBT designs, the Macedonian question is totally absent, and posters about political prisoners stack on each other like hotels on ruins. Our friends at KEFiM warned us about Exarcheia — it has a history of political/national xenophobia, and one member had been violently assaulted — but I had already visited on the first day. Aside from a recently blown-up car, it wasn’t too different from Berkeley — nice apartments and restaurants juxtaposed with street art and a punk crowd, drug dealing, metal bars on windows. Granted, this was in daylight and I saw only what was discoverable with Google maps. Still, I had the fading remains of a black eye and my usual clothing is streetwear, so maybe I wasn’t too out of place — even as an American and thus most hated representative of that target of so much antifascist graffiti, NATO.

Much of the larger politics of Greece were not easy to discover from our various tour guides. Just like the ancient myths of the country, they constantly contradict each other.

The Athens underground metro was incredibly clean and modern — infinitely more than in Atlanta, San Francisco, Los Angeles, etc. — while their roads are constipated and chaotic. Duh, the city itself is one of our most ancient settled, and so roads have proceeded in a particularly unorganized fashion. But it did cause me to consider the beauty that on a planet where our civilizations literally build on each other generation after generation — and, in an uncommon historical epoch where conquering is out of fashion — sometimes the only place to go is down. Humans have expanded our surface area in dimensions completely unfathomable to the diasporic colonizers from ancient Crete.

The syncretic chaos of the streets, though nauseating to the newcomer, lends itself to almost divine levels of flânerie, such that one can walk hours without reaching any particular destination and feel accomplished. Nothing much looks the same when Times Square melts into an ancient agora melts into a Byzantine church melts into the beach. Attica is wildly heterogeneous and beautiful; modernist adherents to classical Greek conceptions of precision-as-beauty should be humbled.

I should add also that my first impressions of Athens (and Catania) was how much it looked like something out of a videogame. The condition of 21st century man is that, upon visiting foreign cities for the first time, he will invariably compare them to Call of Duty maps.

On a few occasions, enough for me to notice but not enough for me to declare it a custom, my server (who sits me, takes my order and waits on me) gave me extra food on the side. This only happened at small restaurants that aren’t overly European and might be an orange juice, fruit bowl or something small and similar. Every time, of course, I left a larger tip. These actions put us in a sort of gamble. For the waiter to bring me something periphery, he might expect a grander gratuity. Then, when I notice the extra item, I have to assume that it’s not just a mistake — that he didn’t think I ordered something extra which will appear on my tab. He and I are both sort of gambling our luck. Of course, it’s not a real gamble — in every instance we were at least partially sociable prior and lose nothing substantial if it doesn’t work out. What is interesting is that we’ve removed ourselves just a little from the law — I am only legally obligated to pay for what I ordered; he is only legally obliged to bring me what I paid for. Still, without the legal backdrop, everyone leaves happy. Left-libertarians would like it.

(As everyone knows, the Greeks are very hospitable and friendly, and this is a testament to that. A counter-example: I went to a gay club for the first time in the rainbow district of Athens. I can’t speak enough of the tongue to talk to women anyway, and there is at least a chance that some guy will buy us drinks. Nobody buys us drinks. The only conclusions are that we’re not handsome enough or the Greeks are not as friendly. It has to be the latter.)

I should quickly add something about coffee. Where it not for the drought of drip coffee, I could easily stay in the Mediterranean forever. Alas, to literally order an “iced coffee” — kafe frappe — you are ordering a foamy concoction with Nescafé. To order a Greek coffee (known as a “Turkish coffee” before tensions in the 1960’s) means an espresso-type shot with grounds/mud at the bottom. But, the coffee culture is fantastic — the shops are all populated with middle-aged dudes playing cards, smoking rollies, and shooting the shit. I don’t think I need to describe the abominable state of American coffee culture. Entrenched in their mud, the Greeks resisted American caffeine imperialism. Starbucks tried and failed to conquer the coffee market: there were already too many formulas, and the Greeks insisted on smoking inside.

Law on the market: a debate

I’ve been reading through a great debate of sorts, first encountered in a C4SS anthology. I’m sharing it here, as it’s not everyday that one encounters a semi-live issue getting hashed out by giants in the field.

It starts with Robert Nozick. (Precious little starts with Nozick — we have Randians, Hayekians, Rothbardians, but no Nozickians, and no Nozickian tradition. Although he energized libertarianism as a respectable political philosophy for academics, his narrow scope and silent response to critics seem to have killed his staying power.)

Nozick famously claimed in Anarchy, State and Utopia (1974) that “Individuals have rights, and there are things no person or group may do to them (without violating their rights).” A first reading of Anarchy in the context of institutionalized philosophy makes it seem like a defense of libertarianism from big government, socialistic ideology. But, when Nozick’s connection to the Austro-libertarian anarchists is uncovered, the first part of Anarchy looks much more like a defense of small government from the anarchists.

Nozick tries to deal with the problem of law and police on the marketplace. In Chapter 2 of Anarchy, State and Utopia, he envisions a market model of competing rights-enforcement agencies. Eventually, in the service of their customers, two or more protection agencies will clash. They will fight. This results in the destruction of one (to the immediate monopoly of the other) or the relocation of the customers of each (to the territorial monopoly of each in different jurisdictions). If they choose not to fight because of the high expense, even arbitration can’t prevent a legal monopoly: consolidating to the top through voluntary contracts, government emerges anyway above the agencies. Thus, concludes Nozick, a purely free-market society will evolve into a state through an invisible hand process.

Collected in Free Markets & Capitalism?, published by C4SS, Roderick Long makes an argument against Nozick’s conclusion on the basis of different models of a post-state society (“The Return of Leviathan: Can We Prevent It?” (2013)).

Long points to another argument, this one from Tyler Cowen, that there is no way to save anarchy from collusion leading to monopoly (“Law as a Public Good: The Economics of Anarchy” (1992)).

David Friedman responded to Cowen’s argument the year afterward (“Law as a Private Good: A Response to Tyler Cowen on the Economics of Anarchy“), and Cowen responded back (“Rejoinder to David Friedman on the Economics of Anarchy“). Bryan Caplan, in an unpublished manuscript, critiqued Cowen’s position as well (“Outline of a Critique of Tyler Cowen’s ‘Law as a Public Good’“).

This is a showdown between Nozick and Tyler Cowen on the one hand, and Roderick Long, David Friedman and Bryan Caplan on the other. The whole extended debate is fascinating, but I’m not sure it has a conclusion. Was Nozick correct about the natural emergence of a state? Maybe it will take a NOL writer to finish it off…

 

Weed, and the Libertarian Party’s future

Last week, the Trump administration announced it would be pursuing a federalist approach to cannabis legislation, effectively allowing states to create their own rules about how the drug is classified and sold.

This is a big change in American drug policy. One common opinion of the Obama era is that the federal government took a relaxed approach toward policing states that were decriminalizing marijuana. The 2008-2016 administration shifted the financial language of the drug war from a law-and-order crackdown to a public safety effort, and placed a low priority on intervening in states with medical legality. Real reform was introduced like the Rohrabacher-Farr amendment which prohibited the Department of Justice from policing medical marijuana states with federal funds. However, DEA raids and reconnaissance missions continued — like in my home state, where counter-economizing Californians sold a whopping five times more weed than they consumed (often to states where it is illegal).

Under Obama, it looked like, with a president less enthusiastic about beating up stoners, American drug policy might start to approach the 21st century. Some skepticism was reintroduced when Senator Sessions was appointed Attorney General under President Trump. Jeff “Good People Don’t Smoke Marijuana” Sessions is explicit about supreme federal authority for drug laws, and supported overturning Rohrabacher-Farr. This, indeed, would be a return to normalcy. For the last half century, it has not been characteristic of the federal government to stay out of drug use — rather than the Trump administration being a Republican re-installation of the war on drugs, we would be witnessing a general return to the 20th century status quo. However, Trump’s announcement makes it seem like we can finally welcome the unexpected.

Trump’s representatives have positioned this move to give up cannabis regulation to the states in a philosophy of states’ rights. Whether or not Trump cares about dual federalism, the repeal of marijuana prohibition — medical, recreational and federal — sweeping across states the last decade is a big win for individual liberty, and, since neither Party has been particularly friendly to cannabis, would seem to point to mainstream party acceptance of libertarian ideas.

What is the Party’s track record on cannabis? The Libertarian Party explicitly opposed drug laws in its first 1972 national platform. Now, in our present day, drug decriminalization is not a radical stance but something more mainstream. Failed or ex-politicians from either party have made a habit of coming out in support of legalizing marijuana the last few years, and up north, the Canadian Liberal Party may now endorse wide-scale reforms. Just yesterday, Senate Minority Leader Chuck Schumer announced he would introduce a bill to directly decriminalize marijuana as a federally classified substance. We’ll see how it goes. But it is now clear that in the same way Libertarians supported gay marriage decades before either partisan establishment now does, one doesn’t have to seek out a minarchist anymore to find someone who opposes drug laws or mass incarceration. (One mainstream policy position that hasn’t budged — war.)

So although we see radically unlibertarian moves nearly every day in Congress and the executive (e.g., FOSTA and Syria), some of the ideas of liberty have spread and reached mainstream status.

This raises some questions about the state of the philosophy and the Party, and more than just drug policy. What does it mean when our more eccentric ideas gain traction in the bigger political world? This question is tied to the purpose of an embedded libertarian political party in the first place.

Economist David Friedman made the point in the postscript to Machinery of Freedom that the purpose of the Libertarian Party is to not have a Libertarian Party. David’s argument is not the same thing as Austin Peterson’s brand slogan, to “Take over government in order to leave people alone.” Instead, David’s argument was built around a public choice understanding of political institutions, but the same conclusion follows from several different premises about the nature of third parties and especially those with a goal of mitigating or eliminating politics.

For American institutional reasons — codified in law and practice — a third party is almost certainly never going to win an election. David thinks, therefore, the purpose of a fringe political party is aspire to the legacy of the Socialist Party of the early 1900s. The Socialist platform in 1928 has succeeded in infiltrating establishment policy, even if the Party last election drew less than a tenth of 1% of the vote. Fringe parties are more successful as beacons of alternative policy than legitimate political competitors. The Party does not pursue political success but influence; hopefully, we will one day not need it to affirm liberty.

So, let’s return to cannabis decriminalization, where we are seeing a libertarian idea achieve mainstream political support.

Legalizing weed is a victory for libertarian ideas and a defeat for the Libertarian Party. Part of the simplistic draw of Libertarianism is “fiscal conservatism and social progressivism,” which, as a one-liner, allows recruitment from both the Republican and Democratic Parties. Now, however, if the progressive leaders, and the Republicans, are co-opting drug decriminalization, there is a lot less draw for social liberals to vote for Party alternatives more aligned with their radical agenda. (I know this, for instance, because drug legalization as an issue first drew me from Democratism to libertarianism in high school.) Hillary Clinton could have partially avoided her image as a crony neoliberal if she adopted more social freedoms, which would only leave her smears on the Left as an imperialist and capitalist.

A recent, rather strange video by AJ+ took aim at libertarianism (read: the Libertarian Party) as “ultra far-right” and spent seconds noting that libertarians are, on the flip side, “anti-NSA, anti-intervention and anti-drug laws.” These are not the only policies that small government people have to offer to the Left if they properly understand themselves. But, as libertarians, we should actually hope this list grows smaller and smaller; the more it shrinks, the more it means that establishment parties are appropriating libertarian positions. Pretty soon, being “anti-drug law” may disappear from the elevator pitch. Subsequently, the “worthwhile aspects” of the Libertarian Party fade to the back, and the draw of the Party (to the left, or the right) decreases until it looks heavily status quo.

So, we could expect that the influence of the Libertarian Party shrinks with the increasing influence of libertarian ideas in general society, as the general electorate pressures establishment politicians to adjust their policy space.

However, a lot of things are being taken for granted here. Do politicians actually respond to the general public consensus and public desire? Is it the case that “libertarian” ideas are spreading to the mainstream, or is it more “progressive” or “traditionalist” ones that are moving it in ostensibly similar directions? Can the ideas alone move policy positions without backing money?

Screenshot_5

We also know that the power of the Libertarian Party has greatly increased since its humble beginnings (whether or not its reputation has improved). My hypothesis is that the influence of libertarian ideas in society at large pressures the estabishment parties to adjust their positions, which in turn makes the Libertarian Party more irrelevant. This is not disproved by an increase in Libertarian Party power. The ideas, even if libertarian, still need to be seen as “libertarian” for it to hurt the Party. For instance, Chuck Schumer said “Looking at the numbers” guided him toward decriminalizing cannabis at the federal level and cited the ACLU.  These “numbers” have been available for decades, from a potpourri of alternative political thinktanks. Citing them from the ACLU will not embed the bill — also faux-embedded in a philosophy of states’ rights — in libertarianism, but in the context of mass incarceration, criminal justice racial disparity and THC research opportunity. These are all good contexts. But the individual freedom element key to libertarianism will be missing, and of course it is, because Schumer says nothing about the other plethora of federal drug laws which prohibit freedom. Recognition of the libertarian aspect of ideas which are libertarian, I think, is essential for them to harm a Party which bases itself around the philosophy.

All of this means that there will be perverse incentives in third-party leadership. Politicians want job security like the next guy, and organizations in some sense want to “survive,” so the interests of libertarianism and the Libertarian Party are in one way opposed (or environmentalism and the Green Party). Liberty is more advanced by incumbent politicians (who are liberty-advancing, of course) than defeated politicians. And the mainstream parties are successful, the fringe parties are not. Thus, liberty is better spread when our ideas take off and get mainstream acceptance, but this will only serve to weaken the Libertarian Party itself, as its attraction as a political outlier fades. This must be obvious: no Libertarian Party candidate is going to claim the White House in our lifetime, and the best hopes of libertarian success are in influencing other parties. So, even when we gain more percent of the vote, the success is in getting people to hear about libertarianism, not in actually convincing people to vote Libertarian.

Conflicting incentives (working in the Party and advancing liberty) means that the Party could be taken over by bad actors like any other political organization, and indeed David predicts this with the increase of political clout. Parties with political power have plenty of favors to dish out, and it only takes a few non-ideological Party members to break ranks. As some of the ideas become more mainstream, this is one possibility. Another is disintegration: there might be no reason for the Libertarian Party to continue, given that its unique draw has suffused into larger bases. A third option is that more radical contingents, like the Mises Caucus, achieve ideological supremacy as the moderate libertarians leave for the newly-libertized Democrat and Republican parties.

In any case, libertarianism faces a conundrum in its Party format. Much of the problems apply to other third parties, but some are unique to libertarianism. One brutal confrontation is the acknowledgement that legalizing cannabis will advance liberty and simultaneously hurt the liberty movement. To this end, Saul Alinsky’s reflection in Rules for Radicals is potent.

The Woodlawn Organization in Chicago is trying to stop the University from bulldozing the black ghetto. The activists issued five demands for the city council, grew in power, and defeated the construction project. Eight months later, the city crafts a new policy on urban renewal to the frustration of the Woodlawn Organization, who barge into Alinsky’s office denouncing the policy statement. But “Through the tirade it never occurred to any of the angry leaders that the city’s new policy granted all the five demands for which the Woodlawn Organization began. Then they were fighting for hamburger; now they wanted filet mignon; so it goes. And why not?”

The solution to one problem creates a new problem, and there are always future problems to work on. Liberty will just have to keep trucking through the victories, and learn from our friends the Socialists of 1928 and Saul Alinsky, who never joined a political party.

Happy 4/20.

The President’s commission on opioids (2/2)

Here’s the second half of an abridged essay I wrote for a public policy course. First half is here, and next week I’ll write about the FDA’s new enemy, kratom.


 

Epidemic status

The DEA’s 2015 declaration of an opioid epidemic was the first sign of large-scale federal attention to prescription analgesics, to my knowledge. On the CDC’s official glossary, “outbreak” and “epidemic” are interchangeable: “the occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time.”

The classification of addiction as a disease is sometimes controversial. (See also Adam Alter’s Irresistible for a popularized form of the psychological takes on addiction.) For the opioid problem to be an epidemic, the focus must be the addition rate, and not the overdose or death rate alone. The federal government usually refers to the opioid situation as an epidemic or emergency (which presupposes a value judgment), and when media has covered it (as with the deaths of Philip Seymour Hoffman, Heath Ledger and Prince) they use the same language. One definitive media moment might have been last year, when John Oliver announced for a young progressive crowd that “America is facing an epidemic of addiction to opioids.”

Oliver was referring specifically to addiction — criticizing companies like Purdue Pharma (creator of OxyContin) for misleading or misinformative advertising about addictiveness. But usually it does not seem like the focus is on addiction. As stated, nonmedical usage of opioids is generally down or stabilized from the last couple years, and the problem is mostly overdoses. (True, these are intimately connected.) This might indicate that cutting the pills with other drugs or general inexperienced use are greater problems than general addiction. So, there is an epidemic in the colloquial usage — extensive usage of something which can be harmful — but only questionably in the CDC’s medical definition, as the usage rates are expected to be up as synthesized morphine-, codeine- or thebaine-based pain relievers diversified, and these have mostly stabilized except for heroin (thought as often beyond opioid status) and fully synthetic derivatives which get less attention (fentanyl, tramadol).

Why the standard of abuse fails

John Oliver — worthy to talk about because much of the public plausibly started paying attention after his episode — noted that the pills are assigned to patients and then, even if the patient doesn’t develop an addiction, they end up in the “wrong hands.” What happens at this point? The Commission recommends that companies design their prescription drugs for “abuse-deterrent” formulations (ADF). After spikes in opioid abuse, Purdue Pharma and other companies began researching mechanisms to prevent abusers from easily obtaining a recreational high by tampering with the pill or capsule. In a public statement, FDA commissioner Scott Gottlieb asserted that the administration’s focus is on “decreasing unnecessary exposure to opioids,” but, recognizing the real role that prescription opioids play in pain relief, Gottlieb continues that “until we’re able to find new nonopioid forms of pain management … it’s critical that that we also continue to promote the development of opioids that are harder to manipulate and abuse, and take steps to encourage their use over opioids that don’t offer any form of deterrence.” Some of these abuse-deterrent options are crush resistance or wax coating to make dissolving more difficult.

However, opioid abuse comes in two forms which are conflated by the legal language. The first is when a patient takes more than their recommended allocation or takes it in the wrong way. The second is when someone with or without a prescription consumes them purely for recreation. Many drug savvy abusers of the second variety have adapted methods to get a recreational high but avoid potential health risks, the most popular method being “cold water extraction” (CWE). Most opioid pills contain both a synthesized opium alkaloid (from morphine, codeine or thebaine) and acetaminophen: Percocet contains oxycodone and paracetamol; Vicodin contains hydrocodone and paracetamol. The acetaminophen or APAP has no recreational benefits (a pure pain reliever/fever reducer) and can cause severe liver problems in large quantities, so recreational users will extract the opium alkaloid by crushing the pill, dissolving it in distilled water, chilling it to just above freezing, and filtering out the uncrystallized APAP from the synthesized opium. This way a greater quantity of the opioid can be ingested without needlessly consuming acetaminophen. Other recreational users that want less of the opium derivative can proceed without CWE and insufflate or orally ingest the particular pills.

ADFs might be able to dent the amount of abusers of the second variety. If the pills are harder to crush (the route of Purdue’s 2010 OxyContin release) or, for capsules, the interior balls are harder to dissolve (the route of Collegium Pharmaceutical’s Xtampza), amateur or moderately determined oxycodone enthusiasts may find the buzz is not worth the labor. As the Commission observes, more than 50% of prescription analgesic misusers get them from friends and family (p. 41) — these are not hardcore aficionados, but opportunists who might be dissuaded by simple anti-abuse mechanisms. Abusers of the first variety, though, are unaffected: at least in the short term, their abuse rests on slightly-over-the-recommended doses or a natural tendency to develop an addiction or non-medical physical dependency. And, if the political core of the opioid emergency is patients that develop an addiction accidentally (those that stay addicted to pharmaceuticals and those that graduate to heroin), abuse-deterrent focuses are unlikely to create real change in addiction rates. It could even have the unintended consequence of higher overdose deaths for amateur narcotics recreationalists, who aren’t skilled enough to perform extractions and opt to consume more pills in one sitting instead.

And furthermore, ADFs can be incorporated into the naturals and synthetics that are usually bonded with APAP like codeine, oxycodone, hydrocodone and tramadol, but cannot for the drugs that come in pure form like heroin or fentanyl. And those are the problem drugs. The NIDA research on drugs involved in overdose deaths across the board, for one, shows that overdose deaths are on the rise as a whole (except for methadone), and also that the synthetic opioids are much more deadly than the naturals and semi-synthetics: fentanyl is the biggest prescription analgesic killer (it’s much more potent than morphine, and tramadol is not very good for recreation).

drugoverdosedeaths

(This graph also shows, however, that the natural/semi-synthetic usage rate was possibly leveling out but resuscitated in 2015.) So ADFs are useless for the drugs most massively causing the “opioid epidemic.” Making them harder to abuse only dents the second category of abuser, and does not limit their addictiveness for those prescribed them for postsurgical pain or otherwise.

Moreover, from a libertarian standpoint, the second category of abuser does not really belong in the “public health crisis” discussion. Those who knowingly consume opioids for recreation are not a problem, they are participants in a pleasure-seeking activity that doesn’t tread on others. So long as their costs are not imposed on other people, it might be better to separate them from the “epidemic” status. Blurring the lines between the groups that fall under “abusive” means that those with a side-interest in OxyContin on Friday nights are lumped in with addicts suffering from physical dependency. Someone who has a glass of wine each night is not “abusing” alcohol, but we can recognize someone who is an alcoholic; the same distinction should be applied medically to opioid users. By painting all consumers outside of direct medical usage as “abusers,” there can be no standard for misuse, and thus no way for a recreationalist to know how much is too much, when health problems might set in, if they are really trapped in their recreation, etc. Research and knowledge are threatened by the legal treatment and classification.

Conclusion

To summarize, the government terminology of “abuse” obscures a legitimate distinction that is justified on both medical-political and civil liberty grounds. Some of the approaches in the Commission report, like the market-based CMS package recommendation, will likely succeed at quelling opioid exposure (and thus addiction and overdoses), while other maneuvers like an education campaign or ADFs should be treated with cautious skepticism. The trends show that heroin and fentanyl are actually the biggest contributors to the opioid epidemic, although semi-synthetics are climbing again in overdose deaths after leaning toward stabilization two years ago. Evidence that prescription abuse and street use are linked, as well as testimony from former addicts, indicates that drug users easily swing between the legal and black market.

The President’s commission on opioids (1/2)

Given Zachary’s post on the drug war and opioid crisis, I thought I would share parts of an essay I wrote for a class last semester about Trump’s commission on opioids, which is the first policy step the new administration took in dealing with the issue. It’s edited for links and language and whatnot.


 

One of the more recent executive steps to combat the opioid crisis — the “abuse” of prescription and illegal opioid-based painkillers — was the creation of The President’s Commission on Combating Drug Addiction and the Opioid Crisis (hereafter, the Commission) two years ago by the Trump administration. The commission, led by Chris Christie, was instituted to investigate the issue further and produce recommendations for the government and pharmaceutical industry. It released its final report in November and seems set to work on opioid use with the same sort of strategies the federal government always treats drugs, except maybe a little more progressive in its consideration of medicinal users. Looking at the Commission’s report, I argue that a refusal to treat unlike cases dissimilarly will lead to less than effective policy.

The President’s Commission

The DEA first asserted that overdose deaths from opioids had reached an epidemic in 2015. In March of last year, Donald Trump signed an executive order establishing the policy of the executive branch to “combat the scourge of drug abuse” and creating The President’s Commission. The Commission is designed to produce recommendations for federal funding, addiction prevention, overdose reversal, recovery, and R&D. Governor Chris Christie of New Jersey served as Chairman alongside Gov. Charlie Baker (R-MA), Gov. Roy Cooper (D-NC), representative Patrick J. Kennedy (D-RI), former deputy director of the Office of National Drug Policy and Harvard professor of psychobiology Bertha Madras, and Florida Attorney General Pam Bondi.

Included in the final report is a short history of opioid use in the United States, characterized by a first crisis in the mid- to late-19th century of “unrestrained … prescriptions,” eventually reversed by medical professionals “combined with federal regulations and law enforcement.” A public distrust of opioids developed afterward, but this was “eroded,” and now the new crisis, traceable to 1999, has become more perilous by innovations since the 19th century: large production firms for prescription drugs, a profitable pharmaceutical industry, cheaper and purer heroin, new fentanyl imports from China.

Since the Commission’s report, several bills have been introduced in the House or Senate currently awaiting judgment (e.g., H.R.4408, H.R.4275, S.2125). Declaring widespread addiction and overdoses to be a national emergency in August, Trump fulfilled one of the interim steps proposed by Christie in an early draft of the report; since, the President has met with drug company executives to discuss nonopiate alternatives for pain relief. Within the next few months we should start to see large scale moves.

Through all of this, the treatment of opioids by the Commission and the US government uses a traditional framing. The National Institute on Drug Abuse (NIDA) defines drug abuse in the following way:

[Use of substances] becomes drug abuse when people use illegal drugs or use legal drugs inappropriately. This includes the repeated use of drugs to produce pleasure, alleviate stress, and/or alter or avoid reality. It also includes using prescription drugs in ways other than prescribed or using someone else’s prescription. Addiction occurs when a person cannot control the impulse to use drugs even when there are negative consequences—the defining characteristic of addiction.

This definition by the federal government does not discriminate between various levels of damaging consumption behavior. The weakness of this definition is that, because all illicit drug consumption is categorized as abuse, there can be no standard for misuse of a black market drug for recreation. An entry-level dose of heroin qualifies as equally “abusive” as a lethal dose because of the binary character of the definition. Other federal agencies give similar definitions; in its report on recommendations for abuse-deterrent generic opioids (see below), the HHS and FDA use a definition of abuse characterized by the “intentional, nontherapeutic use of a drug product or substance, even once, to achieve a desired psychological or physiological effect.” This terminology still characterizes any and all recreational consumption of opioid analgesics as abuse, and not misuse, regardless of dosage or long-term dependency. It will be seen that this is a problem for the success of any sort of policy aimed at quelling usage, and particularly hazardous for the opioid problem.

Legal Background

First, the legal background and a more extensive history. The category “opioid” covers much drug terrain both prescription and illegal. Opioids in the most expansive sense are synthetic derivatives of alkaloids in the opium of the West Asian poppy species Papaver somniferum. Opium resin contains the chemicals morphine, codeine and thebaine. Morphine is the basis for powerful pain relievers like heroin and fentanyl. Codeine is considered less powerful for pain relief but can be used to produce hydrocodone; it also doubles as a cough suppressant. Lastly, thebaine is similar to morphine and is used for oxycodone. 90% of the world’s opium production is in Afghanistan.

All opioids are criminalized under federal Drug Scheduling. Heroin is a Schedule I drug as part of the Controlled Substances Act. Several synthetic opioid drugs that contain hydro- or oxycodone are Schedule II (Vicodin, Dilaudid, OxyContin). Fentanyl is also a Schedule II drug. Heroin is just a brand name for the chemical diacetylmorphine (invented by Bayer), still used as treatment in plenty of developed nations like the United Kingdom and Canada; after heroin was completely criminalized in the United States (“no medical benefits”), synthesized opiate drugs became more popular for prescriptions.

The Pure Food and Drug Act of 1906 introduced labels on medicine containing codeine and opium in general after Chinese immigrant workers introduced the drug to the states. Through 1914, various federal laws restricted opium further until the Harrison Narcotics Tax Act on opium and coca products (which are not narcotics, and the colloquial language has been messed up ever since) effectively criminalized the prescription of opioid products to addicted patients. Shortly afterward, the amount of heroin in the U.S. skyrocketed. Only in recent decades have synthesized opiates occupied the public mind, however. Between 1999 and the present, deaths from overdoses of opioids and opioid-based painkillers like OxyContin, Vicodin, morphine and street heroin have risen almost fourfold.

The data on overdoses and deaths does not paint a straightforward picture, and the group “opioid” obscures the different trends between drugs. The CDC classifies data according to four varieties of opioids: natural/semi-synthetic opioid analgesics like morphine, codeine, oxy- or hydrocodone, and oxy- or hydromorphone; synthetic opioid analgesics like tramadol and fentanyl; methadone; and heroin. The last is the only completely illegal opioid. Overdose deaths that have included heroin and completely synthetic opioids have increased exponentially from 2010 and 2013, respectively, while deaths from natural/semi-synthetic opioids and methadone have roughly stabilized or gone down over the last decade. Taken altogether, the deaths from opioid overdoses per 100,000 from 2000 to 2015 have increased from three to eleven people. (As of 2016, natural/semi-synthetic opioid deaths have actually started to go up again, but its still recent in the trend.)

OpioidDeathsByTypeUS

In 2016, the CDC issued guidelines for treating chronic pain that warned physicians against prescribing high dose opioids and suggested talking about health risks. It also advised to “start low and go slow” — a slogan later mocked by John Oliver in a segment on opioids. And, according to a CDC analysis, prescriptions for the most dangerous opioids have dropped 41% from 2010 to 2015, and so have opioid prescriptions in general dropped. This has resulted in patients with physical dependency suffering withdrawal, often without programs to ease the transition to nonopioid pain relievers. Opioid dependants with withdrawal, or average citizens in need of pain relief, often turn to stronger street narcotics, since heroin is the cheaper and stronger alternative to oxycodone. For example, with the drop in first-time OxyContin abuse since 2010, heroin use has spiked. In Maine, a 15% decrease in opioid analgesic overdoses came with a 41% increase in heroin overdoses in 2012. The use of prescribed opioids, then, looks like it might be strongly connected to the use of street narcotics. The Commission, for its credit, notes that “the removal of one substance conceivably will be replaced with another.”

One fact lost in the discussion is that the use of nonmedical opioids has decreased but the amount of overdose deaths has increased. And “opioid epidemic” when discussing overdoses highly obscures that heroin is the major contributor alongside fentanyl — not merely prescription analgesics. We hear a lot about OxyContin and Vicodin, which are actually leveling out (or were until 2015), and less about the drugs which are already policed more, have been policed longer, and cause more physical problems.

What the Commission proposes

In its report, the Commission concludes the goals of its recommendations are “to promote prevention of all drug use with effective education campaigns and restrictions in the supply of illicit and misused drugs.” The President’s Commission doesn’t want to interfere too strongly, despite all of Trump’s suggestions of a revamped drug war. The report notes that coming down hard on opioids will hurt patients with real needs, as has already happened, and, in a way, has happened since 1924. Much of the Commission’s recommendations come from a market approach, e.g. the suggestion (Rec. 19) to reimburse nonopioid pain treatments. The current Centers for Medicare and Medicaid Services (CMS) policy for reimbursement for healthcare providers treats nonopioid, postsurgical pain relief treatments the same as opioid prescriptions, issuing one inclusive payment for all “supplies” at a fixed fee. Nonopioid medications and treatments cost more, and so hospitals opt for dispensing opioids instead. The Commission recommends “adequate reimbursement [for] a broader range of pain management” services, changing the bundle payment policy to accommodate behavioral health treatment, educational programs, “tapering off opioids” and other nonopioid options.

Trump himself suggested an educational approach in a public announcement, which triggered critical comparisons to the failed D.A.R.E. program and “your brain on drugs” commercials. Educational programs are a less coercive option than direct regulation of opioids, but their effectiveness seems to be hit and miss. The Commission cites the Idaho Meth Project from 2007 (ongoing), conducted by a private nonprofit to inform young adults on the health problems associated with methamphetamine use, as a success story: “The Meth Project reports that 94% of teens that are aware of the anti-meth campaign ads say they make them less likely to try or use meth, and that Idaho has experienced a 56% decline in teen meth use since the campaign began.” This meth project is one success story out of many failures. For instance, the Montana Meth Project from 2005, on which the Idaho project was modelled, “accounting for a preexisting downward trend in meth use,” was determined to have “effects on meth use [that] are statistically indistinguishable from zero,” according to an analysis by the National Library of Medicine. Then again, one large scale anti-drug educational campaign, truth, which encourages youth to avoid tobacco, might be having success. Their modern guerrilla tactics are a major improvement on the old model of Partnership for a Drug-Free America. 

In another market approach to help recovering addicts reenter society, the Commission recommends decoupling felony convictions and eligibility for certain occupations (Rec. 50). The report cites Section 1128 of the Social Security Act, which prohibits employers that receive funding from federal health programs from hiring past convicts charged with unlawfully manufacturing, distributing or dispensing controlled substances. Any confrontation with law enforcement is a barrier to landing a job — a protected area of discrimination — and government laws that specifically ban their hiring make it worse on ex-users and -dealers trying to get clean. Recommendations like these lessen the role that the state has in keeping ex-convicts out of work. 

Much of the funding requested by the President’s Commission is authorized by the Obama administration’s major contribution to combating opioid usage, the Comprehensive Addiction and Recovery Act (CARA), signed into law July 2016 and credited as the “first major federal addiction legislation in 40 years.” CARA helped implement naloxone (an opioid overdose-reversal nail spray) in firefighting departments and strengthen drug monitoring programs. 


 

I’ll post the second half soon, and then a bonus post on my personal favorite solution.