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.

Midweek Reader: The Folly of Trump’s Tariffs

With stocks plummeting this week upon an announcement of retaliatory tariffs by China in response to a recent spate of steel and aluminum tariffs from the Trump administration, it seems a midweek reader on the situation is appropriate.

  • At the Washington Post, Rick Noack explains how Trump is going into unprecedented territory since the WTO was founded, and why existing trade norms probably can’t stem a trade war. A slice:

    But while China has used the WTO to accuse the United States of unfairly imposing trade restrictions over the last months, Trump does not appear interested in being dragged into the dispute settlement process. In fact, Trump appears to be deliberately undermining the legitimacy of that process by saying that his tariffs plan was based on “national security” concerns. WTO rules mandate that a member state can claim exceptions from its trade obligations if the member’s national security is at stake.

    That reasoning has long been a no-go among WTO member states, because they understand  that triggering trade disputes under a “national security” framework could eventually render the WTO meaningless.

  • Last month at the Chicago TribuneSteve Chapman had a good op-ed showing why Trump’s justification of steel and aluminum tariffs on national security grounds is bogus:

    But putting tariffs on all imports to prevent dependence on China or Russia is like throwing away your library card to avoid bad books. It would make more sense to focus on the guilty countries rather than deploy a sprayer that also soaks the innocent.

    The national security risk is minuscule, though. Imports make up only one-third of the steel we use, and the Pentagon requires less than 3 percent of our domestic output. No enemy has us over a barrel, because we buy steel from 110 different countries.

    Most of what we import comes from allies and friends, including Canada, South Korea and Mexico, which would have no reason to cut us off in a crisis. If China stopped shipping to us, friendlier countries would leap to grab the business.

  • Also at the Washington Post last month, historian Marc-William Palen gives numerous historical examples of how nobody wins in trade wars and how they can threaten our national security by arousing populist resentment of the US abroad. A slice:

    The trade wars that followed the Republican passage of the protectionist Smoot-Hawley Tariff Act of 1930, which raised duties on hundreds of imports, similarly contain illustrative lessons for today. Canada responded with tariff increases of its own, for example, as did Europe.

    In a widely cited study from 1934, political economist Joseph M. Jones Jr. explored Europe’s retaliation. His study provided a warning about the trade wars that can arise when a single nation’s tariff policy “threatens with ruin” specialized industries in other countries, arousing “bitterness” throughout their populations.

  • At Cato’s At LibertyDaniel Ikeson explains how Trump’s tariffs establish a dangerous international precedent that will threaten US interests elsewhere:

    By signing these tariffs into law, President Trump has substantially lowered the bar for discretionary protectionism, inviting governments around the world to erect trade barriers on behalf of favored industries.  Ongoing efforts to dissuade China from continuing to force U.S. technology companies to share source code and trade secrets as the cost of entering the Chinese market will likely end in failure, as Beijing will be unabashed about defending its Cybersecurity Law and National Security Law as measures necessary to protect national security.  That would be especially incendiary, given that the Trump administration is pursuing resolution of these issues through another statute—Section 301 of the Trade act of 1974—which could also lead the president to impose tariffs on China unilaterally.

  • The Independent Institute’s Robert Higgs reminds us that citing trade deficits is misleading:

    In reality, individuals, firms and other organizations, and governments trade with other such entities, some of which are located in the same country and others of which are located in other countries. The location of the trading partners has no economic significance whatsoever. Trading entities enter into exchanges voluntarily, each one in each transaction anticipating a gain from the trade. Hence, in expectational terms, every such trade entails a gain from trade, or in other words an addition to the trader’s wealth.

  • At American Greatness, Henry Olsen tries to give a communitarian justification of protectionism:

    So-called populist movements around the world are gaining strength because their voters no longer feel like valued members of their nations. They do not believe their worth should decline because the owners of capital say so, nor do they think their life dreams or values should be denigrated simply because the most educated have different visions.

    Populists like Trump address this spiritual yearning and fulfill the deepest need every human has, to be valued and to belong to a group that values you. In this, and perhaps in this need alone, all men are truly created equal. Tariffs are simply an economic means to fulfill this spiritual need. Tariff opponents can only win if they first recognize this need and promise a more effective way to fulfill it.

  • At Bleeding Heart Libertarians, Jason Brennan explains why communitarianism cannot justify protectionist policies:

    Second, if tariffs don’t actually succeed in helping these workers, then the symbolic argument falls flat. Imagine an artist said, “I’m so concerned about the plight of people living in tenements, I’m going to do a performance art project where I burn down all their homes and leave them on the street. Sure, that will make them even worse off, but my heart is in the right place, and I thereby express my concern for them.” This artist would be…a contemptible asshole.

  • Finally, given its relevance at the moment, it’s worth revisiting Paul Krugman’s classic essay “Ricardo’s Difficult Idea” which remains the best account of why non-economist intellectuals have a hard understanding free trade:

    (i) At the shallowest level, some intellectuals reject comparative advantage simply out of a desire to be intellectually fashionable. Free trade, they are aware, has some sort of iconic status among economists; so, in a culture that always prizes the avant-garde, attacking that icon is seen as a way to seem daring and unconventional.

    (ii) At a deeper level, comparative advantage is a harder concept than it seems, because like any scientific concept it is actually part of a dense web of linked ideas. A trained economist looks at the simple Ricardian model and sees a story that can be told in a few minutes; but in fact to tell that story so quickly one must presume that one’s audience understands a number of other stories involving how competitive markets work, what determines wages, how the balance of payments adds up, and so on.

Can Elizabeth Warren help turn the populist tide?

During her recent visit to China, a Democratic Senator from Massachusetts, Elizabeth Warren (perceived by many as a potential Presidential Candidate of the Democratic Party in 2020), came down heavily on US President Donald Trump’s approach towards foreign policy, arguing that it lacks substance, is unpredictable, and does not pay much attention to liberal values and human rights, which according to her has been the cornerstone of US foreign policy for a long time.

Trump’s unpredictability

Commenting on Trump’s unpredictable approach towards Asia, Warren stated:

This has been a chaotic foreign policy in the region, and that makes it hard to keep the allies that we need to accomplish our objectives closely stitched-in.

Critical of US approach towards China

Warren met with senior Chinese officials including Liu He, vice-premier for economic policy, Yang Jiechi, a top diplomat, and the minister of defense, Wei Fenghe, and discussed a number of important issues including trade and the North Korea issue.

Warren criticised China for being relatively closed, and stated that the US needed to have a more realistic approach towards Beijing. She also spoke of the need for the US to remain committed to raising Human Rights issues, and not skirt the issue, while dealing with China.

Said the Democratic Senator: Continue reading

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.

Trump’s personal game might work in China

In spite of all the economic and strategic differences between the US and China, personal relationships play an important role in bilateral relations between Washington DC and Beijing.

Trump’s Ambassador to China 

One of the first appointments made by US President Donald Trump was that of Terry Branstad as US Ambassador to China. The key reason was Branstad’s personal rapport with Chinese President Xi Jinping. This began in 1985, when Branstad was Governor of Iowa, while Xi Jinping an official from Hebei was visiting Iowa. In 2011, Branstad visited Beijing, and met with Xi at the Great Hall of the People. In February 2012, when he was vice-president, Xi stopped in Muscatine, Iowa, where he met not just with Branstad but with big industrialists and farmers from the states.

The US President, commenting on the reason for appointing Branstad, stated:

Governor Branstad’s decades of experience in public service and long- time relationship with President Xi Jinping and other Chinese leaders make him the ideal choice to serve as America’s ambassador to China.

During US President’s China visit in November 2017, Branstad, who shares a good rapport with Trump, did the groundwork for the visit. While in recent weeks tensions between both countries have escalated, with Trump imposing tariffs on Chinese goods worth $60 billion, the American president was delighted with the welcome he had received during his trip and had even told the Chinese President: “My feeling towards you is incredibly warm.”

It would be pertinent to point out that Trump’s decision to appoint Branstad as Ambassador to China (December 2016) came as a relief to the Chinese, given the fact that the US President took Taiwanese President Tsai-Ing Wen’s phone call, much to the chagrin of Beijing (since this went against established US policy).

If one were to look beyond the role of personal relationships in the very complex but important Beijing-Washington relationship, China lays a lot of emphasis on experience (educational, professional) in the US. If one were to examine the credentials of some of the top officials in Xi Jinping’s administration, US education as well as experience in dealing with economic issues pertaining to the US, has played a key role in some of the Chinese President’s appointments.

For instance, Liu He, whom Xi Jinping has appointed as a Vice Premier for overseeing the economy and financial sector, is US educated. Liu, who speaks fluent English, obtained a master’s degree in public administration from the Kennedy School of Government (Harvard University) in 1995. Apart from his in-depth understanding of the Chinese economy, Liu has also been involved in important discussions with US leaders.

Another significant appointment by Xi Jinping is that of Yi Gang, who has been named as Governor of the People’s Bank of China (PBOC). Yi obtained a business degree from the Hamline University in St. Paul, Minnesota, and a Ph.D. in economics at the University of Illinois, before moving to Indiana University at Indianapolis as a professor in 1986. He taught later at the Peking University in Beijing, before moving to the PBOC in 1997.

While economic and strategic issues are too complex to be driven by personal relationships or chemistry (though Trump seems to be a keen believer in personal chemistry given the emphasis he lays on individual ties) alone, an in-depth  understanding of the culture, politics, and economics of one’s interloctutors is especially handy. Given the current tensions between both countries over tariffs, this dynamic may prove to be especially useful.

3 key problems with Trump’s style of functioning

The removal of Rex Tillerson as Secretary of State (who was replaced by Mike Pompeo, Director of the CIA) reiterates three key problems in US President Donald Trump’s style of functioning: First, his inability to get along with members of his team; second, impulsive decisions driven excessively by ‘optics’ and personal chemistry between leaders; and, finally, his inability to work in a system even where it is necessary.

Tillerson, who had differences with Trump on issues ranging from the Iran Nuclear Deal (which Trump has been wanting to scrap, though his stance was moderated by Tillerson) to the handling of North Korea, is not the first member (earlier senior individuals to be sacked are, amongst others, Michael Flynn, who was National Security Adviser, and Chief Strategist Steve Bannon) to exit hurriedly. Gary Cohn, Director of the National Economic Council, quit recently after opposing the US President’s tariffs on imports of steel and aluminium.

The US President tweeted this decision:

Mike Pompeo, Director of the CIA, will become our new Secretary of State. He will do a fantastic job! Thank you to Rex Tillerson for his service! Gina Haspel will become the new Director of the CIA, and the first woman so chosen. Congratulations to all!

The US President admitted that Tillerson’s style of functioning was very different from his own (alluding to the latter’s more nuanced approach on complex issues).

Interestingly, the US President did not even consult any of his staff members, including Tillerson, before agreeing to engage with North Korean Dictator Kim Jong Un. The South Korean National Security Advisor, Chung Eui Yong, had met with Trump and put forward the North Korean dictator’s proposal of a Summit.

The US President agreed to this proposal. Commenting on his decision to engage with Kim Jong Un, Trump tweeted:

Kim Jong Un talked about denuclearization with the South Korean Representatives, not just a freeze. Also, no missile testing by North Korea during this period of time. Great progress being made but sanctions will remain until an agreement is reached. Meeting being planned!

While Chung stated that the Summit would take place before May 2018, White House has not provided any specific dates.

There is absolutely no doubt that, at times, bold steps need to be taken to resolve complex issues like North Korea. Trump’s impulsive nature, however – refusing to go into the depth of things or seeking expert opinion – does not make for good diplomacy.

In fact, a number of politicians and journalist have expressed their skepticism with regard to where North Korean negotiations may ultimately lead. Ed Markey a Democratic Senator from Massachusetts, stated that Trump “must abandon his penchant for unscripted remarks and bombastic rhetoric to avoid derailing this significant opportunity for progress.”

In a column for the Washington Post, Jeffrey Lewis makes the point that there is a danger of Trump getting carried away by the attention he receives. Says Lewis in his column:

Some conservatives are worried that Trump will recognize North Korea as a nuclear-weapons state. They believe that an authoritarian North Korea will beguile Trump just as it did his erstwhile apprentice, American basketball player Dennis Rodman. They fear that Trump will be so overjoyed by the site of tens of thousands of North Koreans in a stadium holding placards that make up a picture of his face that he will, on the spot, simply recognize North Korea as a nuclear power with every right to its half of the Korean peninsula.

All Trump’s interlocutors have realized that while he is unpredictable, one thing which is consistent is the fact that he is prone to flattery. During his China visit, for instance, Trump was so taken aback by the welcome he received and the MOU’s signed with Chinese companies that he started criticizing his predecessors.

Finally, while Trump, like many global leaders, has risen as a consequence of being an outsider to the establishment, with people being disillusioned with the embedded establishment, the US President has still not realized that one of Washington’s biggest assets has been strategic alliances like NATO and multilateral trade agreements like NAFTA. The United States has also gained from globalization and strategic partnerships; it has not been one way traffic.

It remains to be seen how Tillerson’s removal will affect relations with key US allies. If Trump actually goes ahead with scrapping the Iran nuclear deal (2015), it will send a negative message not just to other members of the P5 grouping, but also India. In the last three years, India has sought to strengthen economic ties with Iran and has invested in the Chabahar Port Project. New Delhi is looking at Iran as a gateway to Afghanistan and Central Asia. If Tillerson’s successor just plays ball, and does not temper the US President’s style of conducting foreign policy, there is likely to be no stability and consistency and even allies would be skeptical.

Japan on its part would want its concerns regarding the abduction of Japanese citizens by Pyongyang’s agents, decades ago, to not get sidelined in negotiations with North Korea. (13 Japanese individuals were abducted in 2002, 5 have returned but the fate of the others remains unknown.) Prime Minister Shinzo Abe has made the return of the abductees a cornerstone of his foreign policy, and his low approval ratings due to a domestic scandal could use the boost that is usually associated with the plight of those abductees.

The removal of Tillerson underscores problems with Trump’s style of functioning as discussed earlier. The outside world has gotten used to the US President’s style of functioning and will closely be watching what Tillerson’s successor brings to the table.