On opiate deaths, I've done some research and have a little bit of flavor I can add to the picture. I'll probably do a post on this eventually.
Everyone remembers the "opiate crisis," right? Doctors being told oxies were non-addictive, passing them out like candy, etc. This was actually mostly fine. Overdose deaths at this point were ~20k a year, and those overdoses were mostly heroin rather than oxies. Having legal opiates of known strength may have led to addiction, but it led to many fewer deaths.
Then around 2014 / 2015, we started cracking down on doctors in the US, and told them to prescribe 10x fewer legal and safe opiates or lose their license. Then you see a significant 1.5x peak in heroin interdiction around 2015 (lower left), as the demand from people suddenly cut off from legal opiates transitions to heroin:
And then since demand is still there and there's less supply, and because fentanyl is vastly denser and more smuggleable and less interdicted than heroin, fentanyl takes off in 2015. You see a jump in the total overdose deaths graph then, but you *really* see it when you cut overdose deaths by substance, in which case fentanyl is on an exponential takeoff starting in 2015:
Opiate deaths, now at ~100k a year, have 5x-d thanks to our solution to the "opiate crisis." It's the single biggest cause of death for people under 40, above car accidents.
The primary reason overdoses happen is that the difference between 3mg of fentanyl and 5mg of fentanyl is the difference between "feeling good" and "overdose."
When fentanyl contaminates other drugs like cocaine and mdma, or when fentanyl is pressed into pills, there can be a "chocolate chip cookie" effect, where it's not evenly mixed, and a local surplus forms a "chocolate chip" of fentanyl in the other drug / pill. Oops, that chip was 5mg instead of 3mg and you're dead now.
The reason fentanyl kills people is because it's added in imprecise amounts with slapdash mixing to either masquerade as heroin or opiate pills, or to add more addictiveness and oomph to other drugs, and the imprecision and slapdashery is killing people because of the 3mg / 5 mg thing.
In my own opinion, the only thing that might save these incremental ~80k lives a year is being willing to pass out legal opiates of known strength and purity again. Wholesale legal opiates are dirt cheap in reality - even very heavy addicts can be high out of their mind on ~$5 a day.
Addicts don't even LIKE fentanyl more, for the most part, it's purely driven on the supply side by concentration and smuggleability:
Heroin is preferred by between 1.7-6.7x, with older folk preferring it more:
*Ferguson et al, Investigating opioid preference to inform safe supply services: A cross sectional study (2022)
And although giving people safe, legal opiates is a pipe dream in the US, they've done it in Canada with some decent preliminary results:
Safe supply reduced nonlethal OD's 5.5x, ER visits by 14 annually, and by 5 hospital admissions annually (and there were zero lethal OD's in the study period):
*Lew et al The impact of an integrated safer use space and safer supply program on non-fatal overdose among emergency shelter residents during a COVID-19 outbreak: a case study (2022)
*Gomes et al Clinical outcomes and health care costs among people entering a safer opioid supply program in Ontario (2022)
It's been hard to measure safe supply's impact on lethal OD's in the couple of years it's been around, because the base rate is still fairly low, but there should be enough data for papers to come out in early 2025 that have a read on it.
I have been talking to a health care worker in Canada who tells me that Safe Supply has been vastly expanded and it's been a bad thing, because now it's big enough that organized crime has gotten involved, and trades money or fentanyl for the safe supply homeless people's pharmaceutical opiates. If that's true, we'll have to see how it comes out in the data - obviously if they're still using illegal fentanyl rather than the safe ones, deaths probably won't drop much.
Completely agree with you, if the sole measure of success is saving lives. Programs like Safe Supply have downstream benefits too if they fold in support for folks with other needs, like mental health support or career counseling. (Check out Carl Hart's work if you haven't seen it yet.) Safe supply/use space is such a political nonstarter though – moral repugnance, NIMBY resistance, plus all the cherry-pickable data that would accumulate: Negative impacts on the economy (extrapolated from models in which unemployed users remain addicted vs. recovering and finding jobs). A purported increase in addicts who wouldn't otherwise start using without the free supply. And, like you mentioned, criminal incursions. All easily translated into political talking points. I look forward to anything you post on this, because we still have a major problem with fentanyl and all the rest, but no easy solutions.
> Completely agree with you, if the sole measure of success is saving lives.
Yeah, that's my primary measure, because addiction is temporary, and death is permanent.
100k young people dead annually is an immense loss. Around 600k incremental people have died since we decided to "crack down" on legal, safe opiates. At the common ~$9M per life valuations, that's ~$5.5 TRILLION in losses.
And sure, those are drug addicts! Who needs em?? Buncha deviants and ne'er do wells. And have you heard the music they like??
But a good chunk of that 600k people would have straightened up and gotten jobs and had kids. Actually, at the Sackler stage, a lot of those people *already* had jobs and kids and were doing fine. It was the crackdown that pushed them to illegal heroin, and then the interdiction crackdown that pushed them to fentanyl, and now we kill 100k young people a year, many of whom would eventually come out of it and be productive adults if they could get pharmaceutical and cheap doses of opiates, just so we can say we're tough and take crime seriously.
But legal, safe opiates are really mild, physically. The worst side effect they usually have is constipation - compare against alcohol, which is a literal poison, and which drives drunk driving, spousal abuse, etc.
I don't care if more people get high legally or addicted to something that costs <$5 a day, with much fewer negative health or social externality effects than alcohol. It's not going to drive crime or homelessness, because the cost is so low. During the Sackler part of the story, those people were fine! Opiate deaths were *tiny.* They had jobs, they raised their kids.
And yeah, I'm a fan of Carl Hart, I have his book, and appreciate the pointer to him.
> A purported increase in addicts who wouldn't otherwise start using without the free supply. And, like you mentioned, criminal incursions. All easily translated into political talking points.
Yep, it's basically a non-starter in America politically, we're just going to keep killing 80k incremental young people a year. And we're not going to stop fentanyl, when 1kg can service a major city's demand for several weeks. Which I personally think is a real shame.
What's funny, and on a related note to your "increase in addicts" point, if you do a cost benefit analysis, it would be vastly, overwhelmingly worth it to pass out free drugs to "problem homeless" in an out-of-the-way physical location with a lot of transportation friction, and free up our downtowns in major cities.
As in, much cheaper than any other option, with attendant massive decreases in crime, and increases in value from usable downtowns, and that's assuming you 10x the "problem homeless" population by passing out free drugs, driving more people to opt-in. I wrote about that in this post:
Again, almost certainly a political nonstarter. But with such a huge degree of benefit relative to cost, I feel like if even one major city could trial it, the evidence would be pretty compelling.
I found your Wirehead City post compelling in part because I think you were fair and inclusive about projected costs. (Plus you included "contingencies", which could be real-world events and/or stuff that didn't get modeled.)
Here you mentioned that alcohol is worse than opiates/opioids. I may circle back to the comparison soon now that the Surgeon General has declared even small amounts of alcohol to be carcinogenic (though I will definitely reiterate that when "small" is small enough, there's no convincing evidence of increased risk of any problem).
"The true rates probably are declining now, owing to the impact of Ozempic and other semaglutides, a trend that should become increasingly visible as data from 2024 and 2025 are explored. Although I find some hope in this, I also have mixed feelings, because I suspect that for some people, what's needed most is a change in lifestyle rather than the drugs."
You "suspect" this? Seriously? You're a doctor! This is something elementary-school children, from a glance at themselves and their parents, KNOW. The ONLY long-term success is a coordinated assault on diet, consumption habits, and corporate drug-dealing in sugar and carbs. Ozempic isn't a solution; it's not even a Band-Aid. It's an illusory fix for the wealthy. It's *not* "hope"! Even if Musk got his way, and these drugs became cheap, the intravenous-drip dependency on these drugs for continued results is no different than crack to get high (skinny).
I hear you, and I tend to agree, but look: (a) I'm not that kind of doctor. I have a PhD in Experimental Psych from Cornell, followed by many years of teaching research methods and occasionally stats. I think people like me should be careful when making pronouncements about health, even if we think we understand the data better than clinicians do (and, to be frank, we often do). (b) "Suspect" wasn't an ideal choice of words. What I meant to allude to is that some people who struggle with obesity and related conditions do lead healthy lifestyles but aren't able to overcome their genetics. I think your point makes total sense as a generalization about public health, but it doesn't apply to literally every individual. This is roughly analogous to what can be said about the misuse of prescription opioids that started to emerge in the 1990s. Opioids were wildly overprescribed, owing in part to corporate malfeasance, and yet, for specific individuals (e.g., folks suffering the most severe chronic pain), we can't say those drugs weren't needed.
On opiate deaths, I've done some research and have a little bit of flavor I can add to the picture. I'll probably do a post on this eventually.
Everyone remembers the "opiate crisis," right? Doctors being told oxies were non-addictive, passing them out like candy, etc. This was actually mostly fine. Overdose deaths at this point were ~20k a year, and those overdoses were mostly heroin rather than oxies. Having legal opiates of known strength may have led to addiction, but it led to many fewer deaths.
Then around 2014 / 2015, we started cracking down on doctors in the US, and told them to prescribe 10x fewer legal and safe opiates or lose their license. Then you see a significant 1.5x peak in heroin interdiction around 2015 (lower left), as the demand from people suddenly cut off from legal opiates transitions to heroin:
https://imgur.com/a/JhIhAZu
And then since demand is still there and there's less supply, and because fentanyl is vastly denser and more smuggleable and less interdicted than heroin, fentanyl takes off in 2015. You see a jump in the total overdose deaths graph then, but you *really* see it when you cut overdose deaths by substance, in which case fentanyl is on an exponential takeoff starting in 2015:
https://imgur.com/a/ykdRmA2
Opiate deaths, now at ~100k a year, have 5x-d thanks to our solution to the "opiate crisis." It's the single biggest cause of death for people under 40, above car accidents.
The primary reason overdoses happen is that the difference between 3mg of fentanyl and 5mg of fentanyl is the difference between "feeling good" and "overdose."
When fentanyl contaminates other drugs like cocaine and mdma, or when fentanyl is pressed into pills, there can be a "chocolate chip cookie" effect, where it's not evenly mixed, and a local surplus forms a "chocolate chip" of fentanyl in the other drug / pill. Oops, that chip was 5mg instead of 3mg and you're dead now.
The reason fentanyl kills people is because it's added in imprecise amounts with slapdash mixing to either masquerade as heroin or opiate pills, or to add more addictiveness and oomph to other drugs, and the imprecision and slapdashery is killing people because of the 3mg / 5 mg thing.
In my own opinion, the only thing that might save these incremental ~80k lives a year is being willing to pass out legal opiates of known strength and purity again. Wholesale legal opiates are dirt cheap in reality - even very heavy addicts can be high out of their mind on ~$5 a day.
Addicts don't even LIKE fentanyl more, for the most part, it's purely driven on the supply side by concentration and smuggleability:
Heroin is preferred by between 1.7-6.7x, with older folk preferring it more:
*Ferguson et al, Investigating opioid preference to inform safe supply services: A cross sectional study (2022)
And although giving people safe, legal opiates is a pipe dream in the US, they've done it in Canada with some decent preliminary results:
Safe supply reduced nonlethal OD's 5.5x, ER visits by 14 annually, and by 5 hospital admissions annually (and there were zero lethal OD's in the study period):
*Lew et al The impact of an integrated safer use space and safer supply program on non-fatal overdose among emergency shelter residents during a COVID-19 outbreak: a case study (2022)
*Gomes et al Clinical outcomes and health care costs among people entering a safer opioid supply program in Ontario (2022)
It's been hard to measure safe supply's impact on lethal OD's in the couple of years it's been around, because the base rate is still fairly low, but there should be enough data for papers to come out in early 2025 that have a read on it.
I have been talking to a health care worker in Canada who tells me that Safe Supply has been vastly expanded and it's been a bad thing, because now it's big enough that organized crime has gotten involved, and trades money or fentanyl for the safe supply homeless people's pharmaceutical opiates. If that's true, we'll have to see how it comes out in the data - obviously if they're still using illegal fentanyl rather than the safe ones, deaths probably won't drop much.
Completely agree with you, if the sole measure of success is saving lives. Programs like Safe Supply have downstream benefits too if they fold in support for folks with other needs, like mental health support or career counseling. (Check out Carl Hart's work if you haven't seen it yet.) Safe supply/use space is such a political nonstarter though – moral repugnance, NIMBY resistance, plus all the cherry-pickable data that would accumulate: Negative impacts on the economy (extrapolated from models in which unemployed users remain addicted vs. recovering and finding jobs). A purported increase in addicts who wouldn't otherwise start using without the free supply. And, like you mentioned, criminal incursions. All easily translated into political talking points. I look forward to anything you post on this, because we still have a major problem with fentanyl and all the rest, but no easy solutions.
> Completely agree with you, if the sole measure of success is saving lives.
Yeah, that's my primary measure, because addiction is temporary, and death is permanent.
100k young people dead annually is an immense loss. Around 600k incremental people have died since we decided to "crack down" on legal, safe opiates. At the common ~$9M per life valuations, that's ~$5.5 TRILLION in losses.
And sure, those are drug addicts! Who needs em?? Buncha deviants and ne'er do wells. And have you heard the music they like??
But a good chunk of that 600k people would have straightened up and gotten jobs and had kids. Actually, at the Sackler stage, a lot of those people *already* had jobs and kids and were doing fine. It was the crackdown that pushed them to illegal heroin, and then the interdiction crackdown that pushed them to fentanyl, and now we kill 100k young people a year, many of whom would eventually come out of it and be productive adults if they could get pharmaceutical and cheap doses of opiates, just so we can say we're tough and take crime seriously.
But legal, safe opiates are really mild, physically. The worst side effect they usually have is constipation - compare against alcohol, which is a literal poison, and which drives drunk driving, spousal abuse, etc.
I don't care if more people get high legally or addicted to something that costs <$5 a day, with much fewer negative health or social externality effects than alcohol. It's not going to drive crime or homelessness, because the cost is so low. During the Sackler part of the story, those people were fine! Opiate deaths were *tiny.* They had jobs, they raised their kids.
And yeah, I'm a fan of Carl Hart, I have his book, and appreciate the pointer to him.
> A purported increase in addicts who wouldn't otherwise start using without the free supply. And, like you mentioned, criminal incursions. All easily translated into political talking points.
Yep, it's basically a non-starter in America politically, we're just going to keep killing 80k incremental young people a year. And we're not going to stop fentanyl, when 1kg can service a major city's demand for several weeks. Which I personally think is a real shame.
What's funny, and on a related note to your "increase in addicts" point, if you do a cost benefit analysis, it would be vastly, overwhelmingly worth it to pass out free drugs to "problem homeless" in an out-of-the-way physical location with a lot of transportation friction, and free up our downtowns in major cities.
As in, much cheaper than any other option, with attendant massive decreases in crime, and increases in value from usable downtowns, and that's assuming you 10x the "problem homeless" population by passing out free drugs, driving more people to opt-in. I wrote about that in this post:
https://performativebafflement.substack.com/p/an-incentives-based-problem-homeless?r=17hw9h
Again, almost certainly a political nonstarter. But with such a huge degree of benefit relative to cost, I feel like if even one major city could trial it, the evidence would be pretty compelling.
I found your Wirehead City post compelling in part because I think you were fair and inclusive about projected costs. (Plus you included "contingencies", which could be real-world events and/or stuff that didn't get modeled.)
Here you mentioned that alcohol is worse than opiates/opioids. I may circle back to the comparison soon now that the Surgeon General has declared even small amounts of alcohol to be carcinogenic (though I will definitely reiterate that when "small" is small enough, there's no convincing evidence of increased risk of any problem).
"The true rates probably are declining now, owing to the impact of Ozempic and other semaglutides, a trend that should become increasingly visible as data from 2024 and 2025 are explored. Although I find some hope in this, I also have mixed feelings, because I suspect that for some people, what's needed most is a change in lifestyle rather than the drugs."
You "suspect" this? Seriously? You're a doctor! This is something elementary-school children, from a glance at themselves and their parents, KNOW. The ONLY long-term success is a coordinated assault on diet, consumption habits, and corporate drug-dealing in sugar and carbs. Ozempic isn't a solution; it's not even a Band-Aid. It's an illusory fix for the wealthy. It's *not* "hope"! Even if Musk got his way, and these drugs became cheap, the intravenous-drip dependency on these drugs for continued results is no different than crack to get high (skinny).
I hear you, and I tend to agree, but look: (a) I'm not that kind of doctor. I have a PhD in Experimental Psych from Cornell, followed by many years of teaching research methods and occasionally stats. I think people like me should be careful when making pronouncements about health, even if we think we understand the data better than clinicians do (and, to be frank, we often do). (b) "Suspect" wasn't an ideal choice of words. What I meant to allude to is that some people who struggle with obesity and related conditions do lead healthy lifestyles but aren't able to overcome their genetics. I think your point makes total sense as a generalization about public health, but it doesn't apply to literally every individual. This is roughly analogous to what can be said about the misuse of prescription opioids that started to emerge in the 1990s. Opioids were wildly overprescribed, owing in part to corporate malfeasance, and yet, for specific individuals (e.g., folks suffering the most severe chronic pain), we can't say those drugs weren't needed.