In the last half of 2016, fentanyl, a synthetic opioid 50 to 100 times more potent than morphine, was detected in 56.3 percent of the opioid overdose deaths in the ten states that make up the CDC’s Enhanced State Opioid Overdose Surveillance program…
How do you solve this? You make available for purchase legal, reasonably priced, pure drugs. You make help getting off drugs available to anyone who wants it, free. (Tapering works in almost all cases.)
This is not a hard problem to solve. It is an easy problem to solve. It is also true that demonizing opiates, in particular, means that a lot of people don’t get the pain relief they need, especially chronic pain sufferers, whose nervous systems change over time so that they are more susceptible to pain.
We do not solve this problem because we are a bunch of moral hysterics who want to force our morals on other people, when their actions are less harmful than our prohibition is.
We also refuse to look at the actual cause of the opiate epidemic, which is fairly clearly economic despair and hopeless lives. Indeed, most drugs aren’t particularly addictive to people who have happy lives and things they want to do.
If you want to end at least half the deaths caused by opiate addiction, make it legally available (it will be more than half, because its illegality drives much of the behaviour that leads to death, beyond just adulteration.)
If you want people to get off opiates, create a society and economy which values them and treats them well. The policies to do this are fairly simple: Updated to deal with racism, sexism and environmental concerns, they are approximately the policies which ran the developed world in the post-war period until the ’70s. Tax the rich brutally, support high wages, have near-free tertiary education, make sure that jobs (or money) are so available that employers have to treat employees well, because employees who walk can always find another job.
This stuff can be complicated in the details, but it’s easy conceptually and hard only in the sense that you have to have the political will and to stay on top of it.
As for opiates and other drugs, just make them legal, regulate them, and make addiction treatment available.
The dead frustrating issue about most of our social problems is that the solutions are more or less known, we just don’t, actually, want to solve them. We prefer the problems to the solutions, or enough of us, combined with enough oligarchs, do.
We can fix our economy, our society, and our drug problem any time we want. Sadly, that is no longer true for the environment, but we can mitigate that damage.
Perhaps one day we’ll decide to do so. Much of this suffering is by choice, and as a society, we’re choosing it.
The results of the work I do, like this article, are free, but food isn’t, so if you value my work, please DONATE or SUBSCRIBE.
(PLEASE CHECK THE BYLINE ABOVE. YES, IT’S MANDOS AGAIN.)
Single-payer is proposed by many as the most ideal way to reform the payment/insurance process for health care in the US, for reasons with which I mostly agree, based on personal experience. The Canadian experience is drawn up, again mostly appropriately, as part of the evidence-base for this view. But if one is going to use Canada as an example, it is important to understand, in some detail, how single-payer was accomplished and what lessons this has for the US.
Canada has single-payer health care, but it did not come out of nowhere. It came from a left-wing government in the province of Saskatchewan, and it came after quite a dramatic fight, including a strike by medical doctors, who were its fiercest opponents.
The history of opposition to Saskatchewan was documented in a very detailed and high-quality MA thesis from 1963 by Ahmed Mohiddin Mohamed at the University of Saskatchewan, which, as far as I can tell, is the authoritative original history on opposition via media to the Saskatchewan single payer plan. Mr. Mohamed (I am unable to locate his present-day particulars or even if he is still alive) managed to get his hands on a treasure-trove of documents from various “players” not that long after the original events.
That opposition involved a great deal of media and propaganda, including astroturf organizations called “Keep Our Doctors” (KOD) committees. It is important to note that even if a lobby group is “astroturf” in the sense of being supported by vested interests, it is not the case that the people who run it, work for it, support it, etc., don’t have genuine beliefs in line with activities of the group. The KOD committees actually and genuinely originated with mothers, particularly rural mothers, who had the vaunted “personal relationship” with their local doctors and the ideological belief that their doctors would be justified in leaving Saskatchewan and abandoning their patients if they were forced into a monopsony. The song should be familiar to Americans — professional liberty and all that. Their local doctors convinced them that the Saskatchewan government would be responsible for denying them access to health care.
Of course, not only were they egged on by their own doctors, eventually medical organizations and ideological businessmen got into the game via their wives and organized province-wide KOD committees, radio propaganda, etc. The public focus and concern of all the protest and propaganda were very simple, as above: Professionals should have the right to choose their working conditions, and the pricing power that single-payer insurance gave government effectively made the government the dictator of doctors’ working conditions, and the ordinary Saskatchewan patient would suffer from this in various ways.
There is one important feature, however, of the anti-single-payer campaign: All the Saskatchewan government’s antagonists went out of their way to agree that people who could not afford access to medical care themselves, should still receive it. Their counterproposal was instead that there be voluntary regulated insurance, and the government would instead use its funds to pay the premiums of those who could not afford it. Doctors would charge patients directly — remember, we’re talking about a health care system that involved direct cash payments — and patients would submit the bills to the insurance agency, if they didn’t just want to pay the cost themselves. The medical associations agreed then only to charge poor patients what the insurer would pay out, so that poor patients would not have to swallow the costs.
The problems with this are obvious, of course. The Tommy Douglas government didn’t buy it, and proceeded to institute single-payer and break that doctors’ strike. The rest is Canadian history. But what is remarkable, and what I would like to emphasize, is that at no time did anyone make the public argument that the indigent should simply go without care.
In point of fact, the Canadian health care system still has ideological opponents in Canada, both among doctors and rich patients who think their wealth should allow them to skip the queues that do indeed sometimes result from the monopsony more easily than they do now (by going to the US). The difference is that it is still not possible in Canada to admit in public that you don’t think that those who can’t afford it shouldn’t have access to quality care. Almost all domestic Canadian attacks on single payer acknowledge the need for universal coverage, even if their proposed solutions won’t work as well as single payer.
That is a deep and fundamental difference with the United States of America and its health care debate. Admitting to a belief that someone should suffer medically for lack of funds does not put you beyond the pale of politics. I lived in the US during the Obamacare debate and had many acquaintances who expressed envy of the Canadian system under which I had lived my life previously; but I also had acquaintances who were willing to at least entertain the right-libertarian argument that property is an essential characteristic of being, and that to dilute my property for someone else‘s life — is a theft of my life. And they could make that argument in polite company and not be shunned.
To me, that is the most fundamental barrier preventing humane health insurance reform in the US. I find it difficult to believe that the US will achieve a single-payer health insurance system until nearly all opponents of single-payer, down to the college libertarian level, still feel obliged to make a halfway sincere-sounding argument that their preferred reform idea will pay for universal access to affordable care. From what I see in the health care debate in the US, that day is not here yet, although the discomfort that the Republicans have in trying to find a way to delete Obamacare suggests that some progess has been made; people are uncomfortable with taking away what has been given, and what has been given is at least some insurance for some of the uninsurable. But if arguing to leave some uninsured is socially acceptable, then that will usually be the path of least resistance.
That less death is better than more death and less suffering is better than more suffering is something that Ian has emphasized a number of times throughout the years, just to clear up the odd ethical confusion that people sometimes have. It sounds obvious, but it’s easy to get lost in the weeds, and there are moral orders that view the suffering of other people as socially purgative, spiritually redeeming, as well as other ideas of non-scalable ethics, and so on.
But I’m always still a little taken aback when I read arguments to the contrary or that trivialize that distinction. Such as in this article at Naked Capitalism:
4) Liberal Democrats have yet to answer the question why it’s terrifying that 540,000 people will die in the next decade under the AHCA/BCRA, but not terrifying that 320,000 will die under the ACA. They have no moral standing at all.
Don’t get me wrong. Trumpcare is undoubtedly worse. The estimates are that by 2026 as many as 51 MILLION Americans would be uninsured. As of 2016 there were still 27 million Americans without health insurance. But saying Trumpcare is worse and Obamacare is better is like saying, “It’s better to catch crabs from sleeping with a hot young lady, than to get it from a used gym towel.” Sure. I guess. But shouldn’t we just be focusing on the fact you have crabs? Who gives a shit about the towel? And shouldn’t you also switch gyms?
If you’re in the, uh, 220 kilopeople additionally likely to die under the Trumpcare regime or the 24 megapeople additionally likely to be uninsured, then surely the difference between Trumpcare and Obamacare is worth more than the difference between getting an STD from a sexual encounter or without one. (And what if you’re one of the 24 million additionally uninsured, and you’re the one who got the STD…?)
Certainly, it cuts both ways. Single payer will dramatically cut the death rate from lack of health care access (although I am skeptical that it will cut it to 0, there is still complexity and austerity in the Canadian system that means that some necessary care is not perfectly accessible, even though I would never recommend trading the Canadian system for any other existing system…) So, Obamacare is certainly worse than single payer.
Thus, by all means, advocate for why single payer is better than Obamacare (it is). Absolutely, make the argument that a Republican Congress dominated by people who really like the ritual of tax cutting for visible increased suffering (remember what I said above: there is a widely held moral position that increased suffering is a moral good) should consider something that reduces the suffering for which they openly wish. Certainly, make the argument that a neoliberally-dominated Democratic party should yield up control to people who reject the market-fascination of neoliberalism. Or whatever strategy takes your fancy.
But don’t pretend that Obamacare vs. Trumpcare is not a real choice and that the distinction between the two doesn’t mean something, that the fact that the immediate political choice is between the two and not between Obamacare and single payer doesn’t say something very important about US society.
The Republicans are working hard to pass an amendment to the ACA called the AHCA. Assuming it succeeds, which I wouldn’t take for granted, it would take Obamacare, with all the latter’s deficiencies and faults, and make it even worse. Meaning: It will probably kill a lot of people through health care denial due to pre-existing condition denials and the reinstatement of lifetime coverage limits. If they fail to pass it, it would be because Obamacare is designed to make itself hard to retract; as Obamacare contains the bare minimum required to improve the status quo ante, anything significant they take away from it renders it unworkable. If it passes, it would be because they had decided that it was the closest to the status quo ante that they could achieve.
The status quo ante was terrible, but contrary to the beliefs of many, it wasn’t “unsustainable” in some sort of fundamental way. It could be contained by gradually excluding more and more people from insurance coverage, and therefore, down the line, care. This is not a debate about health care, but about how to pay for health care. It is about austerity, and the status quo ante was ultimately just a slow ratcheting-up of austerity. (Yes, I know, Obamacare is a ratcheting-up of austerity, but it is a slower one.)
One of the talking points against the AHCA is that it appears to be designed to give the rich a tax cut. However, the tax cut is, in proportion to many of its beneficiaries, quite small, even as it dwarfs the incomes of many. It’s not a giveaway that in itself should raise the political passions of its beneficiaries. Many of them won’t spend it or won’t notice the effect on their lives or wealth planning. Even the insurance industry is skeptical of key portions of the bill, and they’re not prone, as they say, to altruism.
The Republicans have invested a lot of political capital in the idea of undoing Obamacare. Instead of that small a tax cut, if they were rational political actors, they could easily have come up with a bill that targeted large swathes of their constituencies for a substantial improvement in their (bad) standard of coverage, even if they wanted to target Democratic constituencies for tribal reasons. They could have done this without even instituting single payer (aka public monopsony) and ruining their constituents among the insurance and corporate medical sector. It doesn’t appear that this is on order.
The picture only makes full political sense if you see the cutting of health insurance coverage as a political goal in itself, if not some kind of fundamental ideological “end.” Or for the symbolic appearance of trading coverage for a token tax cut, in a way that is likely to create further damage to the US economy. And that successful Republican politicians think that they can expel millions of people from the ability to pay for health care, including their own constituents, is a sign both of the significance of that symbolic appearance and the cultural limits of the US health insurance debate.
And well-deserved it will be. (Mylan makes the Epi-pen, which went from $90 to $600, and which schools are required to buy by law to stop fatal allergic reactions.)
Chair of Mylan literally held out middle fingers to regulators, Congressional critics, his own executives over profiteering concerns. pic.twitter.com/vezvKcDW3f
While I actually find this pretty funny, it’s also the sort of thing that makes me think, “up against the wall,” because a lot of people are dying so that Coury can get rich.
Now, I, of course, would never condone political violence. I believe that poor people and, lately, middle class people should just die, or just do non-violent things and never, ever, ever do violent things when their lords and masters are getting rich off of their own backs and the backs and lives of their children.
But it might be, it just might be, that others might not be as committed to pacifism as I, and that when things go sideways, they might remember the people who engaged in this sort of profit gouging.
Might?
Might not.
But perhaps our lords and masters have become overly insulated from the results of their actions.
THERE were two “Reigns of Terror,” if we would but remember it and consider it; the one wrought murder in hot passion, the other in heartless cold blood; the one lasted mere months, the other had lasted a thousand years; the one inflicted death upon ten thousand persons, the other upon a hundred millions; but our shudders are all for the “horrors” of the minor Terror, the momentary Terror, so to speak; whereas, what is the horror of swift death by the axe, compared with lifelong death from hunger, cold, insult, cruelty, and heart-break? What is swift death by lightning compared with death by slow fire at the stake? A city cemetery could contain the coffins filled by that brief Terror which we have all been so diligently taught to shiver at and mourn over; but all France could hardly contain the coffins filled by that older and real Terror—that unspeakably bitter and awful Terror which none of us has been taught to see in its vastness or pity as it deserves.
‘Nough said.
Oh, and Coury? He deserves a round of anatomically challenging self-fulfillment.
The results of the work I do, like this article, are free, but food isn’t, so if you value my work, please DONATE or SUBSCRIBE.
Let us introduce you to Rat Park. You’ve heard the story about how addictive drugs are. Put a rat in a cage with a lever for water and a lever for water with drugs (heroin/cocaine) and without drugs, and the rat will soon be hitting the lever for drugs as fast as it can.
Professor Alexander built Rat Park. It is a lush cage where the rats would have colored balls and the best rat food and tunnels to scamper down and plenty of friends: Everything a rat about town could want. What, Alexander wanted to know, will happen then?
In Rat Park, all the rats obviously tried both water bottles, because they didn’t know what was in them. But what happened next was startling.
The rats with good lives didn’t like the drugged water. They mostly shunned it, consuming less than a quarter of the drugs the isolated rats used. None of them died. While all the rats who were alone and unhappy became heavy users, none of the rats who had a happy environment did.
Sigh.
Somehow the story of Rat Park doesn’t get told often. I’ve read a lot on pain policy and addiction, and I hadn’t heard of it until recently.
Why is that, I wonder?
What has changed in the US to cause the “sudden” opiate epidemic, do you think?
…
Well, we all know the answer. The US isn’t “Human Park” any more, it’s a dystopian nightmare, full of poverty, despair, and people isolated from friends and family. The social welfare stats for large parts of the country are in free fall.
When life is shit, people turn to chemical joy–or chemical anaesthesia, at least.
What the US is doing is cracking down on opiate use, as if it’s a criminal problem. OR they are pretending it’s a medical problem.
It’s neither. It’s a social and economic problem, and its to do with a society which offers shitty lives for people.
In the 1800s, Emile Durkheim, the pioneering sociologist, did a study on suicide. He did it specifically because suicide seemed like the most individual of decisions.
And he found that it wasn’t; the likelihood and number of suicides tracked social engagement almost exactly. Roman Catholics committed suicide the least and had the strongest social ties. After the Catholics were the Protestants, then then non-religious, and those categories tracked how much social contact people had.
Most of who we are is other people and our relations to them. Most of the rest is our environment. Decisions that seem like they are made by individuals are really only partially so; they are informed by the environment in which we live. They are influenced by people, economic opportunities, and beauty, or the availability of love, friendship, security, and hope.
The opiate epidemic won’t be “fixed” through criminilization or medicalization: Even if opiate overdoses go down, people will turn to other forms of self-destructive behavior. This is because the problem isn’t opiate availability, it is that their lives are objectively shit.
Want to fix the opiate epidemic? Start with a 90 percent marginal tax rate on the richest people in America and spend the money on making everyone else’s lives better. Oh, and do simple stuff like universal health care, which, well, costs less and produces better results and doesn’t lead to despair, because people know that if they get sick they’ll get the care they need and it won’t cost them everything.
The results of the work I do, like this article, are free, but food isn’t, so if you value my work, please DONATE or SUBSCRIBE.
I’m seeing some Dem wonks–establishment ones–who think that the Democrats will wind up embracing single payer, possibly in the next election.
I want to state something simple about this: Do not try to be clever about this.
Offer Medicare for all, with a bill that is no longer than 20 pages. Do not try to “fix” things, because this generation of approved wonks is incapable of doing that, or of writing a bill that is shorter than War and Peace.
That’s unnecessary. The great bills under FDR were all short, the bill creating Canada’s single payer system was short, etc.
Writing too many finicky implementation details into bills is lunacy. You write principles and outcomes and let bureaucrats, regulators, and appointees figure out how to deliver.
And, in the case of Medicare, it basically works, and it works better than anything the current generation could possibly come up with. This is incontestable in practice, because the bills they have written over the last 30 years are all awful messes.
Medicare for all. Just extend who gets it.
That’s all.
The results of the work I do, like this article, are free, but food isn’t, so if you value my work, please DONATE or SUBSCRIBE.
The Ohio governor unveiled a plan Thursday that targets the place where experts say many opioid addictions begin — the doctor’s office.
Gov. John Kasich’s order limits the amount of opiates primary care physicians and dentists can prescribe to no more than seven days for adults and five days for minors…
…The new limits, which have gotten the blessing of the Ohio Board of Pharmacy, the State Medical Board, and the state’s dental and nursing boards, do not apply to patients who take prescription painkillers for cancer treatment or to dying patients who are already receiving hospice care, Kasich said.
There are plenty of reasons other than cancer and hospice care. It’s a little unclear how strict this will be,
“Health care providers can prescribe opiates in excess of the new limits only if they provide a specific reason in the patient’s medical record,” the state said in a statement.
Nonetheless, I find this crazy and punitive to people who actually need pain medication. Many doctors are already reluctant to prescribe painkillers due to crackdowns, and this will drive people even further towards buying illegal drugs. You certainly want people on codeine or morphine in preference to various synthetic opioids, which can be far more dangerous.
Ohio doesn’t have an opioid addiction problem because of availability; it has one because of deep socioeconomic problems which manifest as personal despair and breakdown. Some people will always use drugs, but “epidemics” of drug use happen when people don’t have better options.
The results of the work I do, like this article, are free, but food isn’t, so if you value my work, please DONATE or SUBSCRIBE.
