Thread by @asymmetricinfo

All right, y'all. Let's talk the opioid crisis, and what we need to do to stop it from killing so many folks.

washingtonpost.com/opinions/the-i…

But first, let's do a little history on the opioid epidemic, which had a number of contributing factors.

First, there's doctors.

Doctors used to be insane opiophobes. Like, there were terminal cancer patients dying in agony, and doctors won't give them opiates because, you know, they might become addicts.

When regimes become illogically repressive, there tends to be a cultural correction. And often that correction goes a wee bit overboard in the other direction, which is what happened with the pain doctors in the 1990s. They were giving out too many opiates.

Second factor: addiction epidemics tend to rise and then burn themselves out, because younger people can see how destructive the drugs are over the long term, and they don't initiate use.

But over time, that effect wanes, because the people most likely to initiate haven't seen friends and loved ones wrecked by substance abuse. America had time to forget how dangerous opiates were, so we were probably due for some resurgence.

But the resurgence was bigger than it otherwise would have been because the medical establishment--encouraged by legitimate concerns about leaving pain untreated, but also irresponsible pharmaceutical marketing--was handing out so many pills.

Third factor: we noticed we were handing out too many pills, and regulators started to crack down. This probably stopped some initiations, but we already had all these addicts. Said addicts did not just say "Oh, welp, I'll just quit, then."

They turned to heroin, which is worse for you than prescription pills. Both because you're probably going to inject it, and because the doses are less reliable, raising the risk of an overdose.

They are aided in this by the fourth factor: a group of Mexicans from Nayarit who got really, really good at marketing cheap, potent "black tar" heroin. This is all chronicled in Sam Quinones' amazing book, "Dreamland"

If you're not going to read the book, you can listen to this fantastic podcast with @EconTalker. google.com/search?q=russ+…

But I highly recommend doing both. It's a terrific, if depressing, read.

In recent years, however, we've gotten a fifth factor. It isn't causing addiction. Instead, it's making addiction lethal. It's a drug called fentanyl, which is much more powerful than heroin, and therefore, easy to OD on if the dealer makes a mistake cutting it into smaller doses

The inability to dose correctly is killing huge numbers of addicts--enough that US life expectancy is actually falling for the first time in decades.

Before we go any further, let me be clear: I hate opiates. I didn't enjoy taking them the one time they were prescribed. I hope to never do so again. I wish no one needed them, and I certainly don't advocate recreational use. They're life-wreckers for too many people.

(I mention this because the general knock on libertarians is that we want to legalize drugs so we can get high. I hate getting high on anything more potent than a second glass of wine, and I really dislike opiates.)

But this is where we're at with opioids: American drug markets are awash with cheap fentanyl sourced from China. It's incredibly difficult to interdict, and because even small mistakes in cutting it are deadly, it's measurably pushing up our death rate.

Eventually, the opioid epidemic will burn itself out, as others have before. But fentanyl is now showing up in cocaine and meth, which means that our fentanyl problem isn't going away.

The only way to keep it from killing people is to get people out of the illicit market.

And while quitting opiates is obviously what we want for addicts, the reality is that they have to want to quit. If they aren't ready, the only way to save them is to help them access legal opioids. Methadone. Buprenorphine.

But those don't work for everyone. Which means we need to talk about making it possible for doctors to prescribe opiates to maintain addictions. Oxycontin. Maybe heroin.

@RANDCorporation has a paper out today on piloting prescription heroin, which has worked for recalcitrant addiction in Europe. We need to look at it here.

Is there moral hazard in this approach? Yes. If you make it easier for people to stay addicts, more people will stay addicts.

But death is not a good cure for drug addiction.

A friend asked me if this wasn't in tension with my recent column on naloxone, which pointed out that there may be moral hazard in making the drug--which reverses opioid overdoses--available; people may be less careful about how much they take.

washingtonpost.com/opinions/the-m…

In fact, they aren't in tension, because my position on both is the same: there is moral hazard, and that's bad. But the solution to moral hazard is not letting addicts die. There's moral hazard in buying insurance, too, but I still believe it's a net social good.

I know this is going to be hard for a lot of folks to swallow. But one final thing to consider: it's kind of shocking how much of the social dysfunction surrounding opioid addiction comes from the fact that addicts don't know when they're going to get their next fix.

Opioid addicts become monomaniacal about the drug; according to Quinones, the doctor who pioneered methadone therapy decided on that approach because he'd noticed that methadone addicts were the only ones able to carry on a conversation about something other than their next fix

This may be because methadone stays in the system longer, so you don't start withdrawing so quick. At any rate, the point is that when you resolve the uncertainty about when and where addicts can obtain the drug, they're more functional.

I'm not arguing heroin addiction is therefore just fine, splendid really. I still think you shouldn't take opioids unless you're in intractable, unbearable physical pain. But much of what we think of as the hallmarks of addiction are in fact the hallmarks of *illegal* addiction.

Which is why alcoholics are generally functional members of society for long timespans and not so tightly associated with petty crime waves. (DUIs and various sorts of violence are another story).

So to close: I understand the arguments against anything that might encourage any amount of addiction. But fentanyl has changed that calculus. It's simply too dangerous to leave addicts in illicit markets. We need to offer some kind of legal access to reliable doses.

And we also need to think about what we're going to do about fentanyl-laced stimulants, because cocaine & meth are starting to make a comeback, and aren't really amenable to a methadone-type solution, for a number of reasons.

Most notably: long-term opioid use is bad in all sorts of ways, but it doesn't damage your body like long-term stimulant abuse. So while it's reasonable, if unpalatable, to support opioid addicts, it's hard to see doctors writing maintenance prescriptions for crystal meth.

On that happy note, I'll ask you to read the column, which is here, and contains different material from this tweetstorm: washingtonpost.com/opinions/the-m…