Thursday, January 31, 2013

Opiate Users get Lobotomized

Here is some sad but completely unsurprising news regarding the "treatment" for opiate addiction in China. This procedure, surgical destruction of the "pleasure center" in the brain (ablation of the nucleus accumbens), is not new and has been used on cocaine users in South America. I'm sure the "patients" were all fully informed and not at all coerced, just like when a judge "suggests" a defendant undergo drug treatment in the US. I have reproduced some paragraphs from two articles, though I highly recommend reading them both in full.

Controversial Surgery for Addiction Burns Away Brain’s Pleasure Center by Maia Szalavitz
How far should doctors go in attempting to cure addiction? In China, some physicians are taking the most extreme measures. By destroying parts of the brain’s “pleasure centers” in heroin addicts and alcoholics, these neurosurgeons hope to stop drug cravings. But damaging the brain region involved in addictive desires risks permanently ending the entire spectrum of natural longings and emotions, including the ability to feel joy.
David Linden, professor of neuroscience at Johns Hopkins and author of a recent book about the brain’s pleasure systems calls the surgery “horribly misguided.”  He says “This treatment will almost certainly render the subjects unable to feel pleasure from a wide range of experiences, not just drugs of abuse.”

Given the available evidence, in fact, it’s hard to find a scientific justification for even studying the technique in people at all. Carl Hart, associate professor of psychology at Columbia University and author of the leading college textbook on psychoactive drugs, says animal studies suggest the approach may ultimately fail as an effective treatment for addiction; a 1984 experiment, for example, showed that destroying the nucleus accumbens in rats does not permanently stop them from taking opioids like heroin and later research found that it similarly doesn’t work for curbing cocaine cravings. Those results alone should discourage further work in humans. “These data are clear,” he says, “If you are going to take this drastic step, you damn well better know all of the animal literature.” [Disclosure:  Hart and I have worked on a book project together]. 
Moreover, in China, where addiction is so demonized that execution has been seen as an appropriate punishment, it’s highly unlikely that addicted people could give genuinely informed consent for any brain surgery, let alone one that risks losing the ability to feel pleasure. And even if all of the relevant research suggested that ablating the nucleus accumbens prevented animals from seeking drugs, it would be hard to tell from rats or even primates whether the change was due to an overall reduction in motivation and pleasure or to a beneficial reduction in desiring just the drug itself. 
There is no question that addiction can be difficult to treat, and in the most severe cases, where patients have suffered decades of relapses and failed all available treatments multiple times, it may make sense to consider treatments that carry significant risks, just as such dangers are accepted in fighting suicidal depression or cancer.  But in the ablation surgery studies, some of the participants were reportedly as young as 19 years old and had only been addicted for three years.  Addiction research strongly suggests that such patients are likely to recover even without treatment, making the risk-benefit ratio clearly unacceptable.

Pleasure Center Lobotomy: The Logical Extreme of The Brain Disease Model of Addiction by Steven Slate

You must understand that the idea of addiction, as currently conceived, holds that people use drugs because of the structure and functioning of their brain. In this view, addiction has nothing to do with thoughts, beliefs, or values. It has nothing to do with personal awareness and judgment of various life options and the pursuit of happiness – it has everything to do with the makeup of one’s brain – nothing more, nothing less. And if that is true – that you use drugs because your nucleus accumbens “wants” the dopamine triggering powers of drugs, and will push you to do anything to get more drugs, then removing it must be the simplest and most surefire solution to ending addiction. 
So all of you counselors and addiction theorists who have a history with addiction and identify as lifelong recovering addicts and alcoholics, and spread this tragic view to vulnerable troubled people, here’s your solution: put your brain and life where your mouth is, and move to China to get this procedure done. You will be cured of your disease. This is the end product of all your propaganda. Just beware of the full implications of this, as Maia lays out in her article:

Alcohol Poisonings During Prohibition

The Chemist's War The little-told story of how the U.S. government poisoned alcohol during Prohibition with deadly consequences.
Frustrated that people continued to consume so much alcohol even after it was banned, federal officials had decided to try a different kind of enforcement. They ordered the poisoning of industrial alcohols manufactured in the United States, products regularly stolen by bootleggers and resold as drinkable spirits. The idea was to scare people into giving up illicit drinking. Instead, by the time Prohibition ended in 1933, the federal poisoning program, by some estimates, had killed at least 10,000 people.
I did, however, remember the U.S. government's controversial decision in the 1970s to spray Mexican marijuana fields with Paraquat, an herbicide. Its use was primarily intended to destroy crops, but government officials also insisted that awareness of the toxin would deter marijuana smokers. They echoed the official position of the 1920s—if some citizens ended up poisoned, well, they'd brought it upon themselves. Although Paraquat wasn't really all that toxic, the outcry forced the government to drop the plan. Still, the incident created an unsurprising lack of trust in government motives, which reveals itself in the occasional rumors circulating today that federal agencies, such as the CIA, mix poison into the illegal drug supply. 
During Prohibition, however, an official sense of higher purpose kept the poisoning program in place. As the Chicago Tribune editorialized in 1927: "Normally, no American government would engage in such business. … It is only in the curious fanaticism of Prohibition that any means, however barbarous, are considered justified." Others, however, accused lawmakers opposed to the poisoning plan of being in cahoots with criminals and argued that bootleggers and their law-breaking alcoholic customers deserved no sympathy. "Must Uncle Sam guarantee safety first for souses?" asked Nebraska's Omaha Bee.

This is an interesting article about how the federal government poisoned industrial alcohol during alcohol prohibition.  To this day there are calls for the government to infiltrate drug trafficking organizations to poison supplies, thereby murdering thousands of users. It is only when these proposals are put into the proper historical context that the motivations of the authors become clear. These people want to kill drug users. They don't care who you are, if you are a good person, have children or others depending on you or whatever. If you use the "wrong" drugs you deserve to die, that's it. The following quotes were taken from a debate over alcohol prohibition in 1926. I wonder how many people would defend Wheeler today. In 100 years, how many people will still advocate poisoning the supply of opiates?

"The government is under no obligation to furnish the people with alcohol that is drinkable, when the constitution prohibits it. The person who drinks this alcohol is a deliberate suicide." Wayne Wheeler.

"Any man who takes a drink of alcohol today may be poisoned without a trial by jury, without anything, just be poisoned because he dared take it!" Clarence Darrow responding to Wheeler.

Friday, January 25, 2013

The Economic Case for Decriminalizing Heroin

The Economic Case for Decriminalizing Heroin by Dylan Matthews
From the Washington Post Wonk Blog

The University of Chicago’s Gary Becker and Kevin Murphy, who generally lean right on matters of public finance, made some waves by calling for the full decriminalization of drugs in the Wall Street Journal. They don’t want to just, say, decriminalize the use of marijuana while still banning its sale, as Massachusetts does. They want to decriminalize the sale and use of heroin, and meth, and crack, and other hard drugs. 
Becker and Murphy have been making this argument for a while. Indeed, they first broached the subject back in the 1980s when they argued that many drug addicts are perfectly rational consumers. They, like the savviest grocery shopper, use the resources they have to get what they want in a cost-effective manner. It’s just that what they want happens to be drugs.
But the most relevant paper for understanding the Becker/Murphy critique is one they coauthored with CUNY’s Michael Grossman, who was last seen in these parts arguing for a tax on junk food. The paper attempts to describe the economics of the drug market in the broadest sense. In particular, the authors want to combat the idea that legalizing drugs would lead to more addictions. 
Becker, Murphy and Grossman think this view is dramatically mistaken and they build a model to show why. They put together an equation that outputs the benefits to society of a drug prohibition regime, taking into account the social cost of drugs but also the cost of enforcement, and the enjoyment that drugs provide to their consumers. They then used that equation to determine the regime that maximizes social welfare and determined what the cost of drugs would be under that regime. 
Here’s the kicker: if drugs sold for that price after taxes in an environment where drugs are legalized, they’d still be cheaper than drugs sold on the black market. So the legal market would drive illegal producers out of business, there wouldn’t be any of the enforcement costs — including huge social costs like mass incarceration — that come with drug prohibition, the government would gain considerable new tax revenue, and because the price is the same, consumption of drugs wouldn’t be any different than under prohibition. In short, the best form of prohibition is still worse than legalize-and-tax.

"In short, the best form of prohibition is still worse than legalize-and-tax"

The idea behind Becker, Murphy and Grossman's proposal to legalize and regulate (despite the headline they mean the L and R words) the sale of heroin is to keep the price similar to that of the current black market.  They hypothesize that the high price will keep use down.

Let's start with the positives with such a regime:
There would be enormous savings from police time spent enforcing prohibition, incarceration costs (including the opportunity cost of locking up citizens who would otherwise be working and paying taxes), court costs and all the expenditures of fighting the drug war.
The loss of a customer base would decimate the black market.  Drug cartels may not disappear, but their major source of revenue would dry up. Prostitution, human smuggling and other areas organized crime traditionally deals in require far more work and are not nearly as profitable.  Without drug trafficking these cartels would be significantly weakened.  The term "Narco-state" would become obsolete.
Users would presumably be getting pure drugs with labeled dosages. Sterile ampules of heroin suitable for injection could be made available along with clean syringes. Heroin could also be formulated in smokable or
insufflatable (snortable) formulations. Naloxone and naltrexone could also be made available or given along with every purchase. Blood-born disease transmission among IV users and overdoses would both decrease. Funds currently directed toward ineffective (indeed some say counter-productive) public information campaigns demonizing heroin could instead be used to educate users about using opiates safely.

Unfortunately for users who have a habit, this regime will not significantly improve their lives. It is the high cost alone which prevents those dependent on black market opiates from having normal lives. Furthermore heroin is not a particularly expensive drug, at least at first until tolerance develops.

According to Brian Bennett's excellent site, the per gram cost of heroin has been decreasing quite a bit since the 1980's. The last entry in his data set is the year 2003, in which the cost of a gram of heroin at the retail level (sales of less than a gram) was $372, or 37 cents per milligram. For the regime discussed in the Washington Post article to work, the cost would have to be below the black market prices. For the purposes of discussion, let's say the government set the price at 25 cents per milligram. It is also entirely possible that the black market could take a significant price reduction and still be profitable, but I will leave out that factor for the purposes of this discussion.

For the occasional user, or chipper, heroin is not particularly expensive. A dose of 10-20 mg of pure heroin, for an individual with no opiate tolerance, would get them feeling quite nice. For these individuals the cost of a dose would probably cost $5-10, and not exceed $20. Heavy users often reminisce over the days when they could get a buzz off a couple bags or a few percocets.  

For individuals who are physically dependent the benefits of the proposed regime are far more modest. Contrary to the popular mythology surrounding opiate (opioid), tolerance does not continue to develop indefinitely, every individual eventually reaches a plateau beyond which the returns rapidly diminish. We know from authors like de Quincey and Burroughs that extraordinarily high doses of opiates are not pleasurable, but rather cause some adverse symptoms. From reviewing the results of the Swiss heroin prescription trials, and other trials done in Vancouver, we know that the average daily dose (the plateau or therapeutic dose) is about 500mg. Therefore dependent users are still going to have to come up with over $100 a day to support their habit. As I said before it is the high cost alone which prevents even heavy heroin users from having otherwise normal, functional lives. The purposed regime will do nothing to end drug dependent prostitution or the acquisitive property crime that has become characteristic of heroin dependence in the 20th century.

Sunday, January 6, 2013

Best Comment Ever left on WSJ Article on Drug War

Have We Lost the War on Drugs?

Even God could not enforce prohibition and He only had two people to watch. We will always eat the apple.
Norman Gooding