Chris [Christopher DeMuth] seems to believe that nationalism is sort of a “natural” loyalty of people, which is being jeopardized by international institutions. But is it? Historically nationalism has competed, sometimes ferociously, with other loyalties, beginning with religion and the family (the two main targets of one of the favorite policies of nationalism: a national education system). I won’t argue against the idea that human beings are gregarious and need to belong to something. But that something is more often than not a club, an association, a football team, or a municipality. The nation is quite a remote object: in some countries, it represents a very strong element of identity; in some, it doesn’t. It is more often than not a (political) manufacture, not a spontaneous offspring. In this case, it typically grows by crowding out other loyalties: most notably, indeed, religion.
I have watched several videos from the National Conservatism Conference that was held in DC last month. For me, the most provocative talks were:
Paulina Neuding on how immigration is affecting Sweden.
Mary Eberstadt on social conservatism.
J.D. Vance on libertarianism
Both Eberstadt and Vance scapegoat libertarianism for the opioid crisis. MY thoughts:
1. I would like to see this case made more carefully. Specifically, which libertarian-influenced policies can be shown to have caused the crisis?
2. This reminds me of the way that the left blames the financial crisis of 2008 on “an atmosphere of deregulation” or “neoliberalism,” a narrative that I find unpersuasive. In fact, in the decades prior to 2008, regulations were promulgated with the intention of tightening the safety and soundness of banks. Risk-based capital regulations were a particular tool. The fact that these regulations did not work, and in fact had perverse effects, is an indictment of regulation, not of de-regulation.
And of course, there is also a counter-narrative on the opioid crisis. Jeffrey Miron and others write,
We instead suggest that the opioid epidemic has resulted from too many restrictions on prescribing, not too few. Rather than decreasing opioid overdose deaths, restrictions push users from prescription opioids toward diverted or illicit opioids, which increases the risk of overdose because consumers cannot easily assess drug potency or quality in underground markets. The implication of this “more restrictions, more deaths” explanation is that the United States should scale back restrictions on opioid prescribing, perhaps to the point of legalization.
I am not here to argue for this view. That is not the point of this post.
3. I am surprised to hear that libertarianism has been such a powerful force in American politics and society. I think our record is one of few victories, many defeats. The biggest win was that when the country was fed up with the Vietnam War, we got the draft abolished (but even now there are mumblings about “national service”). We teamed with progressives to legalize marijuana and gay marriage, in the latter case with help from the courts. But when it comes to government spending, unfunded liabilities, the expansion of the Administrative State, and the perversion of the principle of federalism, we have lost big time.
4. Libertarians already were thrown under the bus in the George W. Bush administration. No Child Left Behind. Expansion of Medicare to include prescription drugs. Nation-building. The whole “compassionate conservatism” motif.
5. I don’t think that what the Republican Party needs right now is a circular firing squad. Let the Democrats march under the banner of social justice, and Republicans could counter that with the principle of equality under the law. Let the Democrats champion socialism, and Republicans could counter by championing capitalism. Let the Democrats focus on America’s guilt as an oppressor, and Republicans could counter with a focus on the moral progress of America. Let the Democrats attempt to raise the status of non-traditional sexual identity, and let Republicans attempt to raise the status of grandparents.
I know I’m not supposed to comment, but this opioid thing is right in my professional wheelhouse.
In the 90s Purdue started pushing opioids big time. From aggressive marketing to outright bribes. Their first target were unionized workers in industries where they did the kind of physical work that would naturally lead to aches and pains. They convinced doctors/hospitals to prescribe these drugs aggressively (saying that pain was a kind of disease that needed to be treated, rather than you know a natural outcome of welding for eight hours a day that you just have to live with). They also paid health insurers a lot of rebates to make sure these drugs got prime formulary placement. If you look at a map of opioids you can see how wherever Purdue was pumping marketing dollars at this time are the areas worst hit by the opioid crisis.
This was particularly insidious because lots of people that would never take “illegal drugs” would take something that their doctor prescribed (it’s safe, right…). Once they got addicted, they sometimes substituted illegal drugs or used legal drugs in an unsafe manner (chewing rather than swallowing Oxy). But the real problem is that a whole class of otherwise responsible rule followers got hooked into this through active deception.
Medicare/Medicaid subsidizing these drugs was a problem, but it came after Purdue’s initial marketing (Part D wasn’t even around in the 90s, Medicaid expansion was Obama).
I think for a lot of people “libertarian/capitalism” means “make money any way you can, no matter who it hurts”. Purdue never used violence against anyone. It never shoved opioids down anyones throat. Especially in the early going, you can’t really claim there was a government subsidy aiding them (these group health plans were mostly self insured free market plans). So everything they did was perfectly in line with the non-aggression principle, which in libertarian philosophy basically means it was all A-OK. If it ended up hurting lots of people…caveat emptor losers!
Since you seem to be something of a expert with insider knowledge of the subject, I’d like your opinion on the following story.
One theory I’ve come across is that opioids filled a gap left by the elimination of rofecoxib and valdecoxib. Merck pulled non-narcotic Vioxx from the market in September 2004 because of the increased frequency of serious cardiological side effects for those already at higher risk. Though, as I understand it, there are still some open controversies on the matter.
In 2005, the FDA and its Canadian counterpart voter to let it back on the market because the benefits outweighed the costs, but Merck declined to do so. It may be coming back for a niche purpose to treat severe pain in joints degraded by the consequences of hemophilia.
But millions upon millions of people were using it to treat all kinds of bad pain, apparently with great success and very little abuse or pathologies associated with addition to opioid-based painkillers.
Again, as I understand it, the “oxy” and “codone” companies like Purdue stepped into the breach, and deaths from overdose / abuse of typical prescription opioids continued a slow-but-steady rise of the pre-2004 trend.
But then everything went to hell in 2010 when the FDA started to crack down on prescriptions. That left a lot of people who had developed addictive dependencies on these narcotic-painkillers to turn to heroin (grown in or sent through Southern Mexico as in Dreamland), or synthetics like fentanyl and tramadol, with lot coming from China.
And, after it had thankfully petered out a generation before, it unfortunately launched the renaissance a new junkie-wave and established an economic network of smuggling and distribution of those drugs that is now deeply entrenched in many poorer communities especially in the burnt-out rust belt, with the predictable consequence of a lot of extra “deaths of despair” from those much more dangerous substances, especially from non-college-graduates, and increasing by age-cohort (see: https://www.brookings.edu/wp-content/uploads/2017/03/6_casedeaton.pdf)
What’s your take on all that?
I can’t speak too much to rofecoxib and valdecoxib. It never came up in my work. And 2004, I wouldn’t be working in this industry till much later. I know some history of opioids because they are still such a big deal, but I can’t tell you about every drug over the last couple of decades.
I can say that what gets pushed by doctors and placed favorably on formularies is hugely influenced by financials. The FDA banning something certainly helps remove the competition, but there are other ways to push your stuff if you’re willing to spend the money.
Even the perception of health claims is mostly a function of money spent. Oxycontin was supposed to be the “new, safe, non-addicting” pain med. Whether or not it’s true, Purdue spent enough money to convince people it was true.
My take is that treatment for serious pain was never controversial. That’s not the part of the market that is the main cause of the problem, and quite frankly those people were going to need something no matter what.
The main issue is that “I have some aches and pains” went from “you’ve just got to live with it pal, here’s a heating blanket” to “here are some pills”. “Pain is a disease like any other, this is the cure” or something like that was the marketing point drilled into people. Not prescribing opioids for pain was compared to not prescribing an anti-biotic for a serious infection.
This was especially prevalent in the context of men that did physical work and had some kind of insurance plan. Anyone that does physical work for a living is going to have some aches and pains. Is that worth medicating? Before Purdue, the answer was no. After Purdue, the answer was yes. They pushed doctors and hospital to prescribe it and health plans to cover it.
This dramatically expanded the market, and drew in lots of otherwise normal boring middle class people that would never have tried out an illegal drug. The primary issue here was “this high status authority figure is telling me this is good.” One reason I don’t go whole hog for “deaths of despair” is that mapping where Purdue poured its money into this strategy is a better correlation to opioid dependency than poverty or some other metric. It just happens that where Purdue poured its money is where people work with their hands and economic circumstances have generally not been great for such people lately.
Not that far from me there is a town where they have a counter on the town hall for how many people have died from opioids YTD. This is not a depressed WV town. The average household income is $80k, and you wouldn’t find signs of decline that would explain it. But it is an area in the exurbs where there are a lot of men who work with their hands and have health plans and where Purdue spent money.
Once people are hooked you get this dilemma of whether to keep them hooked on legal stuff (which isn’t a good equilibrium) or try to get them to go cold turkey or what if they turn to the illegal stuff etc etc. That’s one of those pragmatic technical questions that we aren’t going to solve in the comments section.
My main point is that we wouldn’t be debating this at all if authority figures hadn’t pushed this stuff on people. They are supposed to be safeguarding their health, but instead they were lining their pockets.
This isn’t a case of trying to outlaw something that is already popular. Purdue CREATED a market for this stuff that wouldn’t have been there without them. If they didn’t do what they did then people wouldn’t have gotten hooked in the first place and would have an interest in Chinese Fentanyl.
I think you’ve already seen it, but I highly recommend SSC’s write up of his trip to a conference pushing brain meds. Brain meds are to women what painkillers were to men.
https://slatestarcodex.com/2019/05/22/the-apa-meeting-a-photo-essay/
The opiod crisis always seems like trends
1) The US society is doing very poorly dealing with the transition from High School graduate to defined career, especially Blue Collar career. I am not sure how to fix as local government, church and community played a bigger role but these have declined for generations.
2) My guess Purdue ‘knew’ of the addiction issues much like alcohol companies, McDonalds, Coca-Cola, etc. It appears they who would be their prime would be. However, they would not be prepared that black markets could provide similar products so cheaply. (Is the price for Chinese Fentanyl dose is close to a candy bar?)
3) Because some of this was legally purchased and cheap black market sales controlled the crime impact. Back in the 1980s it felt like the number of deaths caused by the crime of buying and selling drugs versus drug themselves was true. (It was exaggerated but not by much.)
Perhaps – just perhaps,
That 3 categories way of observing “our” social order obscures what has always been the crux in the development (and westward movement) of what has become Western Civilization; to-wit; the relationship issues of cooperation, competition, and conflict between individuality and collectivism. *Individuality* being here understood to stand for the distinguishing characteristics (and motivations) of separate humans and *individualISM* standing for the expression of those characteristics and motivations in a social context.
In both “nationalism” and “conservatism” we are observing the social context in its “collectivist” nature. Not all statements of “libertarian” viewpoints avoid those considerations, though they are mostly framed by the priority “values” of individuality in those relationships that form any collective.
Reason has an article about a research paper on the opioid crisis comparing Germany (no crisis) with Canada and Australia (crisis). Scapegoating libertarianism for the opioid crisis seems like an exercise in extreme caricature.
The one constant with all of these conservative speakers is faith. It almost feels like religious conservatives are trying to redefine themselves in terms of nationalism.
She complains about frequent bomb blasts and hand grenades and crime…
Her ulterior motive and objection is that the recent Swedish identity, the ethnic+cultural+national and maybe linguistic identity is being destroyed. Her real concern is repressed, she would be tarred as a racist and a bigot if she expressed that openly, so she’s sublimated her concern to that of crime and grenades. The crime and grenades issue is a valid concern, but that is not her real concern, nor any of the people here. I believe that is just the best socially acceptable argument she can find to object to the traditional Swedish identities being destroyed.
Niko, don’t project your views onto other people. Neuding made her case against “mass immigration without integration”. Her talk doesn’t need clarification nor a search for suppressed ideology. You also don’t speak for me, if I’m included in “any of the people here”.
Let Republicans go for Grandparents. They did with Donald Trump who was the Grandparent R candidate in the post-WW2 era. Sounds like a long term poor strategy:
1) Grandparents are more likely to protect housing regulation (keep the neighborhood the same) and Social Security. Older people are more conservative but not necessarily more libertarian.
2) Um there is life cycle issue as grandparents vote more often but also decrease your pool each election. Some of the Demographic Destiny is beyond exaggeration but did you know Texas has ~40% of Hispanic-Americans which exactly the same as California ~40%? (Texas does not go Blue due to D energy policy but Texas Redness is melting.)
3) The best way to convert young people into conservative Republicans (or a Clinton Democrat) is get young people married, have children, a mortgage, a good career and an employer based health coverage. And that is happening later in life (30+) and the palo-conservatives are more focused on this concern than libertarians.
3a) I still think low birth rates is the main driver of the Japanification of all major developed nations. Thriving capitalism needs good cheap labor.
4) The palo-cons see the large corporations moving away from social conservatism. And the Palo-cons also see the WWC not minorities having the worst economic prospects. Economic prospects for WV residents is not good. (Note I know Baltimore & Chicago have not had urban renewals like NY and LA so there is lots of variation here.)
5) ‘When the Federal Government does not control behavior’ then other actors fill in. So Free Speech battles are about Tech companies. (I always believe the Founding Fathers believed local governments were going to control the population behavior not Federal.)
Why are you surprised by the political libertarians influence?
The palo-con see the Koch Brother wing of the Republican Party as ‘Libertarian’ and to quote asfd “libertarian/capitalism” means “make money any way you can, no matter who it hurts”
This might an exaggeration but the palo-conservative, Pat Buchanan or Rod Dreher, did not trust Mitt Romney and see large corporations make no pretense about treating an American worker any better than a Chinese worker. (Of course they tend to forget that most large global corporations also have global customers as well. Any debate on the values of Hollywood to middle America forgets large budget movies are expected to earn lots in China.)
Collin says:
“2) Um there is life cycle issue as grandparents vote more often but also decrease your pool each election.”
Grandchildren are still arriving, keeping the pool pretty much in balance, so far.
Um, what if the next generation of grandparents (which would be Gen Xish here!) is not as conservative as Kling Boomers?
And they voted heavy Obama in 2008.
“The seventeenth century was the age of revolution in western Europe. It was also the age of national unification. The facts are not entirely unrelated. The rulers of the new centralized monarchies, threatened by internal opposition in their different States, sought naturally to deepen their power by bringing all those different States under their control; and the classes which resisted those rulers sought, no less naturally, to strengthen their resistance by finding allies among their fellow-subjects in other States. In the Iberian Peninsula Olivares sought to unite the separate kingdoms and States of the Peninsula into a unitary kingdom of Spain. In England both Crown and Parliament sought to create a unitary kingdom or commonwealth of Great Britain. Like the Spaniards, the English failed in the seventeenth century, but succeeded in the eighteenth, though with an important difference: in Spain it was the monarchy which united the kingdoms, in England the Parliament.”
That’s from The Crisis of the 17th Century by Hugh Trevor-Roper, which I figure is worth re-reading.
It has to do with the point Chris makes, “that social customs and national traditions are a firmer foundation for political order than the ideology of atomized, free-floating individual autonomy.”
A little history can be a big help. Otherwise you’re like the economist in the old joke: “Assume a can opener.”
Political order needs foundations. And in fact those foundations exist. A good economist works like a geologist or an archaeologist, trying to work out what actually happened in history to get society to this point. A bad economist just makes it all up on a blackboard. And worse than that would be the economists who try to justify the permanent rule of an unaccountable and authoritarian class of officials, whatever their failures and regardless of their results. But of course then other people, like the Levellers, always turn up to challenge them.
So it was that these protestors, Hugh Trevor-Roper says, “roused their followers against the new ‘juggling junto’ of Cromwell and Ireton.”
John Lilburne, the most quoted of the Levellers, was the one who says, “unnatural, irrational, sinful, wicked, unjust, devilish, and tyrannical it is, for any man whatsoever, spiritual or temporal, clergyman or layman, to appropriate and assume unto himself a power, authority and jurisdiction to rule, govern or reign over any sort of men in the world without their free consent.”
Trevor-Roper: “The preachers, we are told, declared ‘that after the oppressor was taken away, the oppression ought not to be continued’ and that true patriots would prefer ‘to be poor in a rich Commonwealth than rich in a distracted, poor and almost ruined nation.’ At the time of the last Leveller mutiny these radical sentiments were not relished and the preachers, though thanked, were not invited to print their sermons. Next day Parliament ordered that the Act prohibiting the clergy from meddling in politics be reported. The Levellers believed that this Act was directed against them; but in fact, when it was passed, on 9 July, the threat from that side was over; the last Leveller mutiny had been crushed, and the text was openly directed only against royalist propaganda and, more generally, against those who directly or indirectly preached or prayed against the power, authority or proceedings of the Parliament.”
This post has a very broad scope. Hopefully you will have time to follow up with a series of narrower posts on this important topic.
1. Mingardi’s analysis is off in several ways.
First, sure, one can say that broader loyalties compete with the narrower ones he seems to prefer, but it goes both ways, and one can be “loyal to oneself” in which case individualism competes with those good loyalties too. If we worry about this side-effect of nationalism because those intermediate-scope loyalties are apparently so important (indeed they are), then why shouldn’t we worry about this side effects of individualism too?
But wait, why put a halo on intermediate loyalties? Those can be either positive or negative, especially when there is rivalry with other intermediate associates. One can be loyal to a prison gang, or have solidarity with co-ethnics in jury trials (why Singapore had to abolish them), or to one’s class with contempt for those lower down the ladder.
And of course one can be more loyal to the political movement associated with a particular ideology than to the rest on one’s compatriots, and, well, isn’t everyone complaining about that these days, hoping that we can all “come together”? Come together about what? Necessarily, “higher loyalties competing with lower ones”.
You want your flotilla of sailboats to stick together for the marina party? You’re going to need to lower sails, drop anchors next to each other, and ties that bind the raft-up. Otherwise there is no possibility of sticking together as soon as the first stormwind blows.
Also, “coming together” is one way to keep peace and establish harmony. Another way is for the Big Boss to terrorize potentially contentious subgroups into submission by credibly threatening to crush anybody who gets out of line. At least so long as Big Boss is able and willing to do so, and the minute he’s not, watch out. (It’s actually indeterminate which approach is more compatible with “Libertarianism” (cf. “14th Amendment Libertarianism”), but the former seems to be more stable and pleasant than the latter.)
There is actually no principled way to distinguish between “team spirit” / “Esprit de Corps” (which we’re supposed to like) and “tribalism” (which we’re supposed to not like) in any potentially competitive context, except that currently, people assign positive valence to the former and negative valence to the latter, mostly on the double-standard basis of “Who Over Whom?”, good guys vs. bad guys considerations.
But for whatever intermediate loyalties one considers to be bad – i.e. ‘tribal’ – having higher loyalties compete with and suppress / crowd-out those lower ones and encouraging a larger, “we’re all in the same boat” group consciousness is the point, that is, not a bug, but a feature.
And second, loyalties are not necessarily maximally rivalrous at all. There is a whole spectrum of how competitive loyalties can be, and the “concentric circles” model in which the strength of loyalty depends mainly on closeness of relations tends to answer the “distant, semi-artificial national entity” issue in a satisfactory manner. There are also mechanisms of “stay in your lane” establishments of exclusive jurisdictions that tend to minimize the occurrence of disputes, and indeed, many societies developed a variety of traditional institutions to accomplish just this objective to the point where many people don’t perceive any salient incompatibilities (cf: “God, Country, and Corps”). Furthermore, loyalties can form into what people perceive to be hierarchies, of principles of values and reciprocity logically extended with each increase in scale, and which are mutually reinforcing on net (which is part of what Filmer was trying to say in Patriarcha).
2. I don’t think it’s fair to ask for ‘policies’ because he’s talking about influence on the party, but I’m open to being convinced otherwise. It’s a different vice, but Libertarians certainly seem to favor the policy of minimal control on obscenity, and depending on your view of the consequences, that was probably a mistake.
I haven’t hopped on the Vance bandwagon – I guess I don’t get what the ‘big deal’ about the guy is supposed to be except for having an admirable bootstrapping story and having lived on both sides of the divide which Charles Murray already described in depth – but I think his argument basically boils down to a kind of Douthat-Salam-style “Reform Conservatism” (i.e., “How I learned to stop worrying and love State Power to achieve my preferred social ends.”) and traditional advocacy for socially conservative state paternalism, especially with regards to those struggling with (a) self-destructive vices, and (b) economic disruptions too rapid to adapt to, and severe enough to cause a hard-to-reverse entropic breakdown in social capital (very much “civilization vs barbarism” language, I know).
Now, in Douthat’s case, he was fond of blaming some phantasm of “Zombie Reaganism” for why the GOP was reluctant to take his advice and wouldn’t agree with Boromir and wear the ring of power in order to redistribute tax money in the form of child credits to the grateful masses, and to stop opposing (often incoherently) a substantial role for the state in ensuring health care was affordable and accessible. So, what’s this zombie Douthat’s talking about? Mostly the same thing Vance is talking about.
Which is that libertarian intellectuals punch far above their weight and the libertarian ethos and ideas (most especially when they are aligned with progressive goals and/or big donor interest) have an out-sized influence on certain GOP positions, and that influence which favors individualism over “political familialism” (and enables a kind of “market fundamentalism” when rhetorically convenient) makes the party reluctant to intervene in certain ways – such as using the power of the state to deal with emergent social pathologies – and prevents the party from exploiting it’s natural political niche and settling on the organizational principle of turning the ordinary decent family into its base constituency by means of paternalistic and clientalist policies designed to keep people out of trouble and subsidize the formation and welfare of traditional nuclear family units. To the extent globalization and free trade undermine that priority, then they must yield, but libertarian ideas counsel the opposite case.
This gets into a much bigger topic, which is that there are really two rival kinds of “socialism” depending on who’s ox gets gored and who gets to dine on delicious ox steaks. There is a socially conservative socialism, which employs subsidies and manipulates the overall macroeconomic equilibrium to help families, especially marginal ones, and which is skeptical of rapid economic disruption and commercialized vice, and there is progressive socialism, which is more anti-market and family-indifferent and obsessed with leveling inequalities.
What Douthat and Vance seem to be saying is that the GOP must embrace socially-conservative socialism, but that the ‘libertarian’ instincts, impulses, and intellectual influence over the party is preventing that from happening, especially insofar as they provide convenient rationalizations to justify giving the big donors what they want, and avoiding losing battles on progressive trigger topics.
3. Yes, the GOP should try to avoid becoming a circular firing squad if it can. But it probably can’t be avoided. Because of divide-and-conquer tendencies in which a sizable chunk will defect on any particular issue, having a common enemy is no longer enough to hold the coalition together of all those opposed to some facet of the progressive agenda. The progressives have easily expressible ideologically organizing principles.
The GOP has little choice but to be for something in particular in order to survive as a party with any chance of decelerating social degeneration and the current progressive ideological singularity, which requires a single alternative magnetic pole of compelling attraction and makes the most important social choice clear.
And, I think it seems clear to most of us who have been paying close attention to this matter for a long time, that the only obvious candidate is a political ideology based on family units instead of atomized individuals.
“But when it comes to government spending, unfunded liabilities, the expansion of the Administrative State, and the perversion of the principle of federalism, we have lost big time… No Child Left Behind. Expansion of Medicare to include prescription drugs. Nation-building. The whole ‘compassionate conservatism’ motif.”
“raise the status of grandparents.”
Which generation exactly do you think favored these policies? The boomers are the rent-seeking generation, and they cannot stop congratulating themselves.
Co-author of the Cato piece here. There is little evidence that opioid addiction rates or abuse rates increased over the period that opioid prescription rates were rising. And while *prescription* opioid deaths were rising in the 1999-2010 period, *illicit* opioid deaths really began skyrocketing around 2010, when restrictions on prescriptions started hitting hard and people started switching to heroin and fentanyl. The “opioid epidemic” is really two very different (quite plausibly unrelated) phenomenon: a slow rise in prescription opioid deaths (which is really a very small risk applied across a very large population of total users), followed by an explosive rise in heroin/fentanyl deaths (which is really a very high risk behavior in a relatively small population). There is also good reason to believe that the official numbers aren’t real, particularly for the prescription opioid deaths (I wouldn’t make the same argument for heroin deaths). Pathologists will say “You can’t make a cause-of-death determination by toxicology alone” and “There’s no tissue concentration threshold that reliably identifies an overdose”, but this appears to be exactly what the medical examiners are doing. Remember that death certificates reflect a human being assigning a cause to something, and that we’re generally not very good at determining the causes of stuff. (Stephen Karch, who wrote a textbook called Pathology of Drug Abuse, has said this is a serious problem with the official numbers.)
Blaming the Sacklers, as some have tried to do, is kind of absurd because they only ever supplied a small fraction of the opioids prescribed. A large majority were generics or other manufacturers. If they *were* responsible for changing attitudes about prescription opioids, they deserve praise, not scorn. Chronic pain patients had a *very* hard time getting the medicine they needed until fairly recently, and the recent misguided, ham-handed efforts to restrict opioids have gotten legitimate pain patients thrown off the only medicine that works for it. See a Medium story about chronic pain patients who have committed suicide. Or see Jacob Sullum’s “No Relief in Sight” from all the way back in 1997. Or go on Twitter and find some comment threads by chronic pain sufferers. There is no perfect sorting mechanism. Any system that restricts opioid prescriptions is going to cut off legitimate patients, because there are inherently false positives and false negatives. As the Cato paper points out, rates of abuse among prescription opioid users are quite low, in the ~1% range.
Blaming libertarians is just utterly implausible. Doctors who were trying to treat chronic pain patients were getting harassed and even prosecuted all throughout this period (despite the undeniable rise in total prescriptions, there was this underlying crack-down throughout the period). Did we legalize any *alternatives* to opioids? Did we legalize marijuana or psychedelics or other recreational drugs (many things in the psychedelic and “dissociative anesthetic” categories are extremely safe and non-habit forming), which might have caused some users to substitute away from opioids? The past 20 or so years are a fairly pure example of libertarian warnings about the dangers of black market drug supplies.
I think we often lose sight of the fact that dose is the key factor in overdose deaths. Most of the coverage I’ve read glosses over the dose aspect and I’m frustrated that I don’t see anyone presenting relevant information. Are the overdoses mostly caused dose variability due to Fentanyl content? Is the Fentanyl all from prescription patches? How do high risk users determine and monitor dosage amounts?
Most of the fentanyl deaths are not from legitimate prescriptions, like the patch. It’s mostly illicit fentanyl being sold as “heroin.” Blaming these deaths on loose prescribing practices is a stretch. It’s wild speculation, really.
Another detail that is under-reported: most drug poisoning deaths are multi-drug poisonings. The CDC keeps a record of every single death that happens every year in the United States, including all contributing causes of death, and this is publicly available on the CDC’s website. Most so-called “opioid overdoses” are actually combinations of multiple substances: benzodiazepines, alcohol, anti-depressants, and various illicit substances. Only ~1/4 o 1/3 of opioid deaths involve a single substance. The rest involve multiple substances, which can combine to exacerbate the respiratory depression caused by opioids alone. Certainly, it’s a problem that illicit drug users don’t know the dose they’re taking. But it’s also true that they’re often taking other substances that “potentiate” the effects of opioids. There is this false narrative of the legitimate opioid patient becoming an addict and popping pill after pill until they overdose. I think this is not supported by a closer look at the data.
I’m speaking mostly to the dosage angle. The anecdotal evidence I’ve read in various news articles is that prescription fentanyl patches are bought/stolen and repackaged as an illicit heroin alternative/additive.
How many of the “multiple substance” overdoses are multiple opioid substances packaged as a single dose vs. other combinations?
How many of the opioid overdoses are oral vs injected?
If the illicit fentanyl comes from inexpensive synthetic sources, why hasn’t the illicit market moved completely to pure fentanyl?
Rather than “false narratives” I’m frustrated by the number of narratives that are plausible but premature. From my perspective, most narratives are jumping to conclusions without laying out the basic facts first.
I look at a post like this and my first thought is all those doctors that used to shill for the cigarette companies. “It profits a man not to sell his soul for the whole world, but for Wales?” The wonderful thing about ideology is you get people to sell their soul and you don’t even have to give them Wales in return.
We have the usual useless statistics. Like that when oxy/apap went generic most people took the generic. People buy things that cost $10-$20 more often then they buy stuff that costs hundreds of dollars, news at 11! This statistic is true of any drug class with generic alternative for obvious reasons. It’s not really relevant to the matter at hand. Being hooked in hydro/oxy -apap isn’t a good thing.
Your propaganda about pain is equally irrelevant. Purdue’s line on pain was that it was some vast untreated plague, but you don’t get the kind of prescription numbers we’ve seen, and the extreme practices amongst doctors and pharmacies, when you are just trying to provide pain relief to people with back surgery. Anyone whose seen those numbers would consider this claim comic.
The addiction stats which you slavishly copy here are straight out of Purdue propaganda.
Purdue trained its sales representatives to carry the message that the risk of addiction was “less than one percent.”50(p99) The company cited studies by Porter and Jick,51 who found iatrogenic addiction in only 4 of 11 882 patients using opioids and by Perry and Heidrich,52 who found no addiction among 10 000 burn patients treated with opioids. Both of these studies, although shedding some light on the risk of addiction for acute pain, do not help establish the risk of iatrogenic addiction when opioids are used daily for a prolonged time in treating chronic pain. There are a number of studies, however, that demonstrate that in the treatment of chronic non–cancer-related pain with opioids, there is a high incidence of prescription drug abuse. Prescription drug abuse in a substantial minority of chronic-pain patients has been demonstrated in studies by Fishbain et al. (3%–18% of patients),53 Hoffman et al. (23%),54 Kouyanou et al. (12%),55 Chabal et al. (34%),56 Katz et al. (43%),57 Reid et al. (24%–31%),58 and Michna et al. (45%).59 A recent literature review showed that the prevalence of addiction in patients with long-term opioid treatment for chronic non–cancer-related pain varied from 0% to 50%, depending on the criteria used and the subpopulation studied.60
Which just gets back to the original point. People who use this stuff because they have cancer or are burn victims NEED the drug, and stop using it once they don’t need it anymore. But you start shoving these pills down the throats of people who don’t need it over a prolonged period of time and you have problems.
Moreover, any review of the sales tactics and promotional strategy used by Purdue would clearly indicate (often in shocking and reprehensible ways), that getting doctors to hand out a few more pills to people with back surgery wasn’t the goal. The goal was to juice sales by any means necessary, and the best way to juice sales was to create a market for it by getting new patients of questionable medical necessity on the drug. Purdue even purposely targeted providers that it knew were probably abusing the medication in order to get them to prescribe even more. They aggressively tried to buy their way into favorable formulary placement and utilized copay coupons to “give the first one away for free”. Anyone who has actually seen data on this knows legitimate medical use can’t possibly explain pill mills.
There is perhaps a deeper problem though. At the end you rail about why we don’t have vast swaths of the population on pot, LSD, etc. Let’s say the overdose rate on all this stuff was 0.0000%. Would an entire country of strung out junkies be a good thing, even if none of them dropped dead? Is your pothead cousin someone you admire?
You know I have my problem with Ayn Rand and her philosophy, but at least there is an undercurrent of romantic human striving and accomplishment. Be all you can be! To the extent libertarianism promotes that idea, it’s at its best. But there is a kind of dirtbag loser libertarianism which is often very into marijuana that elicits no positive emotions out of me. It focuses almost entirely on the license to be a self indulgent loser. It’s like someone who has just turned 18 and wants to do something really irresponsible and stupid who as a defense screams “I am an adult!” Like their “adulthood” is a license to act like a child. No, we choose 18 because its the closest arbitrary point at which your supposed to have the judgement and self control to make adult decisions…unfortunately the fact that you want to do X just shows you aren’t there yet. People don’t say “I am an adult!” when they want a loan to start a business.
The pain patients who are getting kicked off their prescriptions are very real, and so is their suffering. It can be very hard to distinguish between a real chronic pain sufferer and a “drug seeker”, given that their behaviors can look very similar. Any attempt to crack down on “illegitimate” opioid use will necessarily mean kicking genuine pain sufferers off their opioids, which is often the only medicine that’s ever worked for them.
I invite anyone to look at the SAMHSA numbers on pain reliever abuse and addiction rates. Read their Behavioral Health Trends in the United States report; the 2014 report shows a time series going back to 2002. “Past month abuse” and “past year use disorder” rates are flat over the period when prescriptions tripled. The notion that Purdue created a new class of addicts that didn’t exist before is hard to believe, given that it’s not showing up in the numbers. The Monitoring the Future survey shows a similar trend: flat over the relevant period when opioid prescriptions were rising. I understand why someone telling the “corporate villain” or “libertarian experiment” narrative of the opioid phenomenon wouldn’t have a use for these statistics, but that hardly makes them “useless.”
If you look at the opioid poisoning deaths, most of them involve other substances: alcohol, benzodiazepines, anti-depressants, etc. It might make sense to say someone on a long term opioid prescription acquires a chemical dependence, that the pharmacology of the drug *causes* them to keep needing that drug. It makes less sense to claim that the pharmacology of the drug *causes* these other risk behaviors that lead to drug poisonings. That often requires deliberately engaging in other risky behaviors. A lot of the commentary on this story does not adequately distinguish between a chemical dependence (tolerance and withdrawal) and *addiction* (harmful behavioral patterns associated with a substance). The latter does not necessarily flow from the former. Conflating the two is a mistake.
The overall tone of your comment is way out of line and intentionally insulting. It’s not in the spirit of this page, “taking the most charitable view of those who disagree.”
I think it is unworthy of you to say that J D Vance scapegoats libertarians. He thinks libertarian policy prescriptions are inadequate, but how is that scapegoating?