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Practically-A-Book Review: Dying To Be Free

I am the last person with a right to complain about Internet articles being too long. But if I did have that right, I think I would exercise it on Dying To Be Free, the Huffington Post’s 20,000-word article on the current state of heroin addiction treatment. I feel like it could have been about a quarter the size without losing much.

It’s too bad that most people will probably shy away from reading it, because it gets a lot of stuff really right.

The article’s thesis is also its subtitle: “There’s a treatment for heroin addiction that actually works; why aren’t we using it?” To save you the obligatory introductory human interest story: that treatment is suboxone. Its active ingredient is the drug buprenorphine, which is kind of like a safer version of methadone. Suboxone is slow-acting, gentle, doesn’t really get people high, and is pretty safe as long as you don’t go mixing it with weird stuff. People on suboxone don’t experience opiate withdrawal and have greatly decreased cravings for heroin. I work at a hospital that’s an area leader in suboxone prescription, I’ve gotten to see it in action, and it’s literally a life-saver.

Conventional heroin treatment is abysmal. Rehab centers aren’t licensed or regulated and most have little interest in being evidence-based. Many are associated with churches or weird quasi-religious groups like Alcoholics Anonymous. They don’t necessarily have doctors or psychologists, and some actively mistrust them. All of this I knew. What I didn’t know until reading the article was that – well, it’s not just that some of them try to brainwash addicts. It’s more that some of them try to cargo cult brainwashing, do the sorts of things that sound like brainwashing to them, without really knowing how brainwashing works assuming it’s even a coherent goal to aspire to. Their concept of brainwashing is mostly just creating a really unpleasant environment, yelling at people a lot, enforcing intentionally over-strict rules, and in some cases even having struggle-session-type-things where everyone in the group sits in a circle, scream at the other patients, and tell them they’re terrible and disgusting. There’s a strong culture of accusing anyone who questions or balks at any of it of just being an addict, or “not really wanting to quit”.

I have no problem with “tough love” when it works, but in this case it doesn’t. Rehab programs make every effort to obfuscate their effectiveness statistics – I blogged about this before in Part II here – but the best guesses by outside observers is that for a lot of them about 80% to 90% of their graduates relapse within a couple of years. Even this paints too rosy a picture, because it excludes the people who gave up halfway through.

Suboxone treatment isn’t perfect, and relapse is still a big problem, but it’s a heck of a lot better than most rehabs. Suboxone gives people their dose of opiate and mostly removes the biological half of addiction. There’s still the psychological half of addiction – whatever it was that made people want to get high in the first place – but people have a much easier time dealing with that after the biological imperative to get a new dose is gone. Almost all clinical trials have found treatment with methadone or suboxone to be more effective than traditional rehab. Even Cochrane Review, which is notorious for never giving a straight answer to anything besides “more evidence is needed”, agrees that methadone and suboxone are effective treatments.

Some people stay on suboxone forever and do just fine – it has few side effects and doesn’t interfere with functioning. Other people stay on it until they reach a point in their lives when they feel ready to come off, then taper down slowly under medical supervision, often with good success. It’s a good medication, and the growing suspicion it might help treat depression is just icing on the cake.

There are two big roadblocks to wider use of suboxone, and both are enraging.

The first roadblock is the #@$%ing government. They are worried that suboxone, being an opiate, might be addictive, and so doctors might turn into drug pushers. So suboxone is possibly the most highly regulated drug in the United States. If I want to give out OxyContin like candy, I have no limits but the number of pages on my prescription pad. If I want to prescribe you Walter-White-level quantities of methamphetamine for weight loss, nothing is stopping me but common sense. But if I want to give even a single suboxone prescription to a single patient, I have to take a special course on suboxone prescribing, and even then I am limited to only being able to give it to thirty patients a year (eventually rising to one hundred patients when I get more experience with it). The (generally safe) treatment for addiction is more highly regulated than the (very dangerous) addictive drugs it is supposed to replace. Only 3% of doctors bother to jump through all the regulatory hoops, and their hundred-patient limits get saturated almost immediately. As per the laws of suppy and demand, this makes suboxone prescriptions very expensive, and guess what social class most heroin addicts come from? Also, heroin addicts often don’t have access to good transportation, which means that if the nearest suboxone provider is thirty miles from their house they’re out of luck. The List Of Reasons To End The Patient Limits On Buprenorphine expands upon and clarifies some of these points.

(in case you think maybe the government just honestly believes the drug is dangerous – nope. You’re allowed to prescribe without restriction for any reason except opiate addiction)

The second roadblock is the @#$%ing rehab industry. They hear that suboxone is an opiate, and their religious or quasi-religious fanaticism goes into high gear. “What these people need is Jesus and/or their Nondenominational Higher Power, not more drugs! You’re just pushing a new addiction on them! Once an addict, always an addict until they complete their spiritual struggle and come clean!” And so a lot of programs bar suboxone users from participating.

This doesn’t sound so bad given the quality of a lot of the programs. Problem is, a lot of these are closely integrated with the social services and legal system. So suppose somebody’s doing well on suboxone treatment, and gets in trouble for a drug offense. Could be that they relapsed on heroin one time, could be that they’re using something entirely different like cocaine. Judge says go to a treatment program or go to jail. Treatment program says they can’t use suboxone. So maybe they go in to deal with their cocaine problem, and by the time they come out they have a cocaine problem and a heroin problem.

And…okay, time for a personal story. One of my patients is a homeless man who used to have a heroin problem. He was put on suboxone and it went pretty well. He came back with an alcohol problem, and we wanted to deal with that and his homelessness at the same time. There are these organizations called three-quarters houses – think “halfway houses” after inflation – that take people with drug problems and give them an insurance-sponsored place to live. But the catch is you can’t be using drugs. And they consider suboxone to be a drug. So of about half a dozen three-quarters houses in the local area, none of them would accept this guy. I called up the one he wanted to go to, said that he really needed a place to stay, said that without this care he was in danger of relapsing into his alcoholism, begged them to accept. They said no drugs. I said I was a doctor, and he had my permission to be on suboxone. They said no drugs. I said that seriously, they were telling me that my DRUG ADDICTED patient who was ADDICTED TO DRUGS couldn’t go to their DRUG ADDICTION center because he was on a medication for treating DRUG ADDICTION? They said that was correct. I hung up in disgust.

So I agree with the pessimistic picture painted by the article. I think we’re ignoring our best treatment option for heroin addiction and I don’t see much sign that this is going to change in the future.

But the health care system not being very good at using medications effectively isn’t news. I also thought this article was interesting because it touches on some of the issues we discuss here a lot:

The value of ritual and community. A lot of the most intelligent conservatives I know base their conservativism on the idea that we can only get good outcomes in “tight communities” that are allowed to violate modern liberal social atomization to build stronger bonds. The Army, which essentially hazes people with boot camp, ritualizes every aspect of their life, then demands strict obedience and ideological conformity, is a good example. I do sometimes have a lot of respect for this position. But modern rehab programs seem like a really damning counterexample. If you read the article, you will see that this rehabs are trying their best to create a tightly-integrated religiously-inspired community of exactly that sort, and they have abilities to control their members and force their conformity – sometimes in ways that approach outright abuse – that most institutions can’t even dream of. But their effectiveness is abysmal. The entire thing is for nothing. I’m not sure whether this represents a basic failure in the idea of tight communities, or whether it just means that you can’t force them to exist ex nihilo over a couple of months. But I find it interesting.

My love-hate relationship with libertarianism. Also about the rehabs. They’re minimally regulated. There’s no credentialing process or anything. There are many different kinds, each privately led, and low entry costs to creating a new one. They can be very profitable – pretty much any rehab will cost thousands of dollars, and the big-name ones cost much more. This should be a perfect setup for a hundred different models blooming, experimenting, and then selecting for excellence as consumers drift towards the most effective centers. Instead, we get rampant abuse, charlatanry, and uselessness.

On the other hand, when the government rode in on a white horse to try to fix things, all they did was take the one effective treatment, regulate it practically out of existence, then ride right back out again. So I would be ashamed to be taking either the market’s or the state’s side here. At this point I think our best option is to ask the paraconsistent logic people to figure out something that’s neither government nor not-government, then put that in charge of everything.

Society is fixed, biology is mutable. People have tried everything to fix drug abuse. Being harsh and sending drug users to jail. Being nice and sending them to nice treatment centers that focus on rehabilitation. Old timey religion where fire-and-brimstone preachers talk about how Jesus wants them to stay off drugs. Flaky New Age religion where counselors tell you about how drug abuse is keeping you from your true self. Government programs. University programs. Private programs. Giving people money. Fining people money. Being unusually nice. Being unusually mean. More social support. Less social support. This school of therapy. That school of therapy. What works is just giving people a chemical to saturate the brain receptor directly. We know it works. The studies show it works. And we’re still collectively beating our heads against the wall of finding a social solution.

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317 Responses to Practically-A-Book Review: Dying To Be Free

  1. Princess Stargirl says:

    I do not get why there aren’t more people who are i favor of just trashing some but not all parts of the government. Like I think we would be alot better off with no FDA. Really just needs laws about labeling, false advertising and purity (it has to be as pure as you say it is). Just trash the FDA imo. The incentive structure is just too horrible. The FDA is screwed if they approve a dangerous drug, but no one (except SSC readers) gets made if they delay a needed drug or treatment.

    However I think environmental regulations work pretty well. And I think while welfare and re-distribution could be done better the re-distribution programs in the USA function well enough to be worth it. In fact we should probably increase re-distribution if we can afford it. Another example is that many nations seem to get good results with single payer healthcare. So I think the USA should, if possible, adopt single payer. (the government would not pay for drugs it considers unsafe but wouldn’t prohibit them).

    What I have always wondered is why basically the only people who want to get rid of any important government functions want to get rid of almost all the government functions. Seems natural that the government functions well at some tasks but poorly at other?

    edit: Many people do seem to accept the government is bad at policing speech. And its a bad idea to let the government police speech at all. I am not really anti-government. But I think the government is terrible at managing safety of chemicals and it should stop trying. Even if in theory it could do good.

    • Anonymous says:

      Like I think we would be alot better off with no FDA. Really just needs laws about labeling, false advertising and purity (it has to be as pure as you say it is).

      Someone would have to enforce compliance. If not the FDA, then who? I agree that the FDA could focus its mission on these sorts of things and stop drawing pyramids showing people how to eat.

      • DanielLC says:

        Just have them be enforced by whoever enforces false advertising laws when food and drugs are not involved.

        • caryatis says:

          This would be the FTC/CPSC. But I don’t see why those agencies would be better than FDA, especially since determining whether something has been falsely advertised can be *really* complicated when it comes to drugs. If someone has to enforce it, better the agency with a bunch of doctors and chemists on staff.

          • Godzillarissa says:

            I think the point is that the FTC (or CPSC) is already there. So instead of having an _additional_ agency (with a huge organisational overhead), why not let the FTC handle that by hiring a few additional doctors and chemists?

            Of course, if the FTC decides to have a ‘food and drugs’ branch, it’s effectively another FDA, and we’ve won nothing…

      • Izaak Weiss says:

        The FDA doesn’t draw food pyramids; that’s why the food pyramid is so out of whack with most dietary suggestions. It’s run by the Department of Agriculture – that’s why it’s so grain heavy. They just want people to buy from american farmers, so they emphasize the grains they grow.

        • William O. B'Livion says:

          It’s not that they want people to buy from American Farmers as we get grains from lots of places. If that was the case then Beef would be up a lot higher than fruits and vegetables on that list.

          It’s that most of htem believe that grains are good for you.

        • Harald K says:

          I don’t see the US food pyramid recommend a lot of corn, and they do recommend rice on the bottom rung, which is hardly grown in the US. Soy, which is second only to corn in the US, isn’t even mentioned.

          OK, so they put breakfast cereals in the base. That may be a bit self-serving of the USDA. But all the national food pyramid things I know make some allowance for traditional diet, and breakfast cereal is a thing Americans do.

        • Jiro says:

          http://www.latimes.com/nation/la-na-climate-food-20150118-story.html

          Government scientists try to get food pyramid changed because meat contributes to climate change.

      • William O. B'Livion says:

        Go pick up a piece of electronics in your house.

        Almost any one.

        if you’re in the US there is a 99.5% (made that number up, but it is that high) that here is a U/L label, sticker or emboss on it some where.

        Underwriters Laboratories–they are not a government agency, they are for-profit safety consulting and blah blah firm. You pay to get your shiznit tested and then you get the stamp.

        Don’t see why chemicals can’t be treated the same way.

        Oh, and I know This Dude who does process/safety inspections/consulting in the Pharmaceutical field. It’s not *nearly* as clean as you’d like to think.

        • Protagoras says:

          I do check for the “USP” myself when buying vitamins, but while I haven’t heard anything bad about them, I don’t know enough to know it’s fully trustworthy. But it seems that many people who buy supplements have even less idea what to look for than I do, and the presence of lots of people who will buy any old thing regardless of whether there are any stamps or not means lots of supplements don’t see any advantage to going to the effort of being verified (or being genuine). I suppose it’s more obvious if an electronic device doesn’t work, so companies wouldn’t last long selling complete junk, and as long as they’re going to the effort to make a product that works, they might as well get the official endorsement for it (I imagine many retailers require it, to reduce returns and such).

          • Noumenon72 says:

            UL will tell you if your device will short out and catch on fire. I also extruded plastic for truck beds in a factory and we couldn’t begin production till UL approved the flame retardant. So I think companies maybe also want to be sure their own warehouses and delivery trucks aren’t going to catch fire.

    • Nornagest says:

      Really just needs laws about labeling, false advertising and purity (it has to be as pure as you say it is).

      98% pure and the rest is dioxin is very different from 98% pure and the rest is sucrose.

      But that’s an edge case that could probably be dealt with without a sprawling virtually unaccountable bureaucracy.

      • Princess Stargirl says:

        Yes. I really mean they should not be deciding heat substances people can take. Or what treatments are legal. They have failed at this task imo.

        I agree its non-trivial how to enforce purity laws. But that is a far cry from the FDA.

        • Brett says:

          This is what pisses me off about the supplement/vitamin industry – the FDA is effectively barred from enforcing purity/false advertising laws on them. So that you get supplement manufacturers selling “St. John’s Wort” and “Echinachea” that are effectively just the contents of some compost heap in China, with absolutely no trace of the named herb. I may despair of trying to get folks to actually sell stuff that works, but getting people to sell stuff that is what it says it is is a solved problem.

    • Wrong Species says:

      That’s why we need a neoliberal party. I’ll hand out the copies of The Road To Serfdom.

      • Shenpen says:

        Are you serious? The Road To Serfdom is very, very outdated, it is a product of the post-WW2 time where the Soviets were powerful and Leftism in the West had this macho, quasi-tyrannical, gung-ho spirit. When politicians talked about a War On Poverty and similar tough-ass terminology, and the NHS in the UK was sold as “disease is an enemy and it is the governments job to fight enemies”. Leftism was very, very ultra-masculine. Hayek lived in the UK and warned people which way that is going.

        We live in totally different times now! Leftism became feminine. It is not about get yo guns buddies and wage war on the ass of disease and poverty and crush it stomping into the curb and all that, not the masculine stuff anymore. Today it is the feminine stuff, it is all about being bleeding-heart, a niiiiiice, and compassionate and will someone please think of the children, and go volunteer in a soup kitchen (if you want to get in a good university) and never hurt anyones feelings and similar feminine / pacifist stuff.

        The MOOD AFFILIATION of Leftism changed and that is the most important aspect of political discourse!

        The Road To Serfdom carreis the masculine mood affiliation of the post-WW2 era and is useless – because it comes accross as outdated and downright weird – in the feminine mood affiliation of Leftism today.

        • Wrong Species says:

          I don’t understand the relevance of what you said. Have you actually read The Road to Serfdom?

        • Eli says:

          Your comment comes across as uninformed about Leftism, uninformed about neoliberalism, and, I’m afraid to say, sexist to boot. Could you back off the stuff about femininity being “weak” and masculinity being assertive/”strong”? It’s really rather dumb.

          (I’m cis-het-male and not from Tumblr, but come on dude.)

    • “What I have always wondered is why basically the only people who want to get rid of any important government functions want to get rid of almost all the government functions.”

      In my case, you could drop the “almost.”

      The short answer is that we don’t have a mechanism to get governments to do good things. That includes getting governments to limit themselves to those activities that produce net benefits. A government with institutions to redistribute wealth may sometimes use them in the ways you approve of, but it will also use them to subsidize farmers via high crop prices which means more expensive food which is a regressive tax. The same factors, broadly described, that make the FDA work badly also prevent it, or the War on Drugs, from being abolished.

      One way to put the point is to start with the central argument, at least from the standpoint of economists, in favor of government, which is market failure—reasons why individual rationality doesn’t always add up to group rationality, such as the public good problem. If you think about the source of market failure, it’s the fact that people make decisions much of whose cost or much of whose benefit goes to other people.

      That sometimes happens in the private market, but it is the exception not the rule. On the political market it is the rule. Almost nobody making decisions that affect that market, whether voter, regulator, special interest group lobbying, elected official, or judge, both bears a significant fraction of the costs and receives a significant fraction of the benefits produced by his decisions. There is no mechanism to make it in the interest of decision makers to make the decision that is in the general interest. The market does have such a mechanism, although an imperfect one.

      Of course, to take the argument all the way to anarchy requires some thought on how private institutions could replace what are traditionally seen as the minimal functions of government. My attempt can be found in the second edition of The Machinery of Freedom as a free pdf on my web page or the third as an inexpensive kindle on Amazon.

      To put my point differently, the right question to ask is not what outcomes we want but what institutions. Judge the institutions not by what they say they will do but by your best estimate of what they will do, based in part on what similar institutions have done in the past.

      Hope this helps. You did ask.

      • Bugmaster says:

        You probably answered this in your PDF, but still: without the government, how would we solve coordination problems such as the Tragedy of the Commons or national security or national transportation; or extremely long-term investment problems like building supercolliders (or inventing transistors, really) ?

        One solution that libertarians often come up with is, “we’ll form a corporate entity that does that stuff”, but a). it’s not clear to me where that entity’s funding will come from, and b). it’s also unclear why that entity would be better than our current government at doing its job.

        • Squirrel of Doom says:

          The standard libertarian/ancap solution to the Tragedy of the Commons is to not have any commons. Tragedy averted! OK, it’s not always trivial what should be owned how, but there are always reasonable ways.

          National security is an ancap problem area. Libertarians see it as the very reason to have a state.

          National transportation is seen as a non issue.

          Super colliders and other expensive science. I don’t have a great answer for that, but I’d expect Bill Gates type billionaires to pick up part of the tab.

          Note how this is completely different from setting up a corporate entity and give that the monopoly rather than a government agency. Make rules, not organizations!

          • Bugmaster says:

            > The standard libertarian/ancap solution to the Tragedy of the Commons is to not have any commons.

            Ok, so what about the classic situation where I set up a factory that produces some amount of airborne pollution; or where I have a fishing boat that I use to extract fish from a giant lake ? I own the land the factory stands on, and possibly I own some portion of the lake. You are my neighbour, and for some reason you enjoy breathing and fishing. What’s the next step ?

            > National transportation is seen as a non issue.

            How do I get from LA to SF ? What about SF to NY ?

            > Note how this is completely different from setting up a corporate entity and give that the monopoly rather than a government agency.

            How is it different ? In both cases, you are ceding all control over some resource, good, or service to a single entity, are you not ? A government is managed differently from the corporation, this is true, so are you implying that a corporate monopoly is more accountable to its consumers than a government is ?

          • Tracy W says:

            Ok, so what about the classic situation where I set up a factory that produces some amount of airborne pollution; or where I have a fishing boat that I use to extract fish from a giant lake ? I own the land the factory stands on, and possibly I own some portion of the lake. You are my neighbour, and for some reason you enjoy breathing and fishing. What’s the next step ?

            Okay: factory, with clearly-defined property rights, either you have the right to pollute your neighbour’s air, or your neighbour has the right to enjoy fresh air. If you have the right to pollute, your neighbour can pay you to not pollute said air. If the neighbour has the right to enjoy fresh air you can pay the neighbour to forego that right.

            The result is efficient either way on the first order, although some allocations of rights may cause particular problems. Most obviously equity. Also, less obviously, if you have the right to pollute and can cheaply pollute your neighbour you might set up some pollution just to extract payments from your neighbour (eg growing a tree that produces particularly sticky leaves and seeds on your shared boundary that is upwind from your neighbour, imposing massive cleaning costs on said neighbour).

            Fishery: the classic solution is individual transferrable quotas (ITQ). Someone sets a total fishing quota per year. If you want to fish, you buy or rent a right to take X% of the safe number of fish per year. If you want to wish a lot, you buy or rent the right to take NX% fish per year. Ditto your neighbour if your neighbour wants to fish. (Note there are other ways of allocating fishing rights to limit overfishing which I’m not going to go into here.)

            The trouble with the libertarian viewpoint is that (a) generally air pollution flows over more than just the land right nearby, so transaction costs prevent this sort of trading, and with fisheries, working out what the x should be and policing that you only take X% fish per year can get expensive, albeit not as expensive as having the entire fishery collapse from overfishing.

          • Bugmaster says:

            @Tracy W:

            > generally air pollution flows over more than just the land right nearby, so transaction costs prevent this sort of trading

            Yes, exactly. In addition, if I did set up such a factory, then in practice, I could very easily say, “According to projections, this factory will make me $1e9 over the next 10 years. If you want me to move, pay me $1e9”. In essence, this means that my power to violate your rights (to breathe, in this case) is almost completely unchecked, since very few people have $1e9 to spare. You could try and get all your neighbours together and collect the money, but a). that still may not be enough, and b). most people won’t pay, because they don’t feel like subsidizing solutions to your personal problems.

            > Fishery: the classic solution is individual transferrable quotas (ITQ). Someone sets a total fishing quota per year.

            Who is this “someone” ? Why does he have the power ?

        • shemtealeaf says:

          I don’t think the point is that market entities will do everything better than the government. In my opinion, they can do some stuff better than government, and most of the stuff about the same.

          The key point is that market entities are a lot less likely to do some of the really objectionable stuff that government does.

          • onyomi says:

            “About the same”? Is that really your experience of government agencies? When you go to the DMV or city hall, do you think, “this is about the same level of service I expect when I go to a private store”?

          • @onyomi

            That’s going to vary a lot, and there are some places where there is considerable overlap between the level of service that local bureaucracy provides and that of local shops. I’m ancap, but I think government *can* be very efficient at providing some services; it depends a lot on culture.

          • onyomi says:

            Could you cite an example of something government does efficiently?

          • Bugmaster says:

            @onyomi:

            > Could you cite an example of something government does efficiently?

            I personally can’t answer this question in absolute terms, but I can list several cases where the government has, historically, performed more efficiently than the free market (though obviously not with optimal efficiency):
            * Roads, and transportation in general
            * Eradicating diseases, especially via vaccination
            * Supplying potable water to residents, and pollution control in general
            * National security, i.e. defence against external threats
            * Mass literacy
            * Pure scientific research (as opposed to applied R&D)
            * Distribution of the broadcast spectrum

          • JB says:

            To the people reacting with surprise to this comment — do consider the possibility that some people may live in countries where governments function more efficiently than yours does, or where markets function less efficiently than yours does.

          • onyomi: “Could you cite an example of something government does efficiently?”

            I was using your example of DMV vs private store. I have been to some private stores where I got worse service than some DMV visits. Additionally, I read from time to time people’s accounts of American govt offices vs various European govt offices, and the European ones sometimes sound considerably more friendly and efficient than the standard American ones, which I’m used to.

          • onyomi says:

            I’m not talking about things that the government does which the private sector theoretically cannot do, or, more realistically, which the private sector will tend to underproduce relative to the standards of some, I’m talking about the efficiency of production/delivery of goods and services.

            In the case of roads, for example, sure the government builds more roads in most countries than does the private sector, but when a private individual or company does choose to build a road do you expect he’ll do it more slowly, poorly, and at greater expense than the government? Or would you expect the opposite? I would certainly expect the opposite.

            If you are comparing apples to apples (how efficiently can the private sector do x compared to how efficiently can the government do x), then I can’t think of any area in which I’d give the advantage to government.

            The only real advantage government has is the perception of authority on the part of the populace, which allows them to make demands, such as taxation, which no ordinary firm could. With this, of course, comes tremendous power to do things a private company could not (whether any of those things, such as wealth “redistribution” are desirable is another question), and the ability to command huge chunks of society’s resources, but not efficiency. That is, of all the things people would tolerate a private firm doing, I cannot think of any the government would do more efficiently.

            In the case of vaccines, promoting literacy, etc., for example, it is certainly true that the government, with its ability to tax, could, in absolute terms, produce more vaccines, more books, etc. than any individual private firm could. But would they do it cheaper, better, and faster than a private firm hired to do the same thing? Unlikely.

          • onyomi says:

            “I have been to some private stores where I got worse service than some DMV visits.”

            I also had a surprisingly pleasant interaction with a police officer the other day. The key word here is “surprisingly.” I left thinking, “wow, that police officer seemed genuinely concerned with my safety and did not talk down to me or keep me waiting an unreasonable amount of time or anything! what a great guy!” Then I realized that he had basically just acted the way I expect any employee at any private business I patronize to act, which, coming from a police officer, felt surprisingly good.

            It’s not that there aren’t kind, hard-working, polite people in government offices and grumpy, lazy, mean people in private businesses, it’s that government has almost no incentive to treat its “customers” (subjects who get to vote for their rulers whom they call their (public) “servants”) well or use their money efficiently. If you have a bad experience at the DMV, what are you going to do, go to an alternative licensing organization? If you have a bad experience with the local police, what are you going to do? Organize a recall election for the mayor?

          • Bugmaster says:

            @onyomi:

            > If you are comparing apples to apples… then I can’t think of any area in which I’d give the advantage to government.

            I thought I was comparing apples to apples. For example, healthcare in the US is more expensive, and more wasteful (i.e., you get less of it per dollar) than in countries where it is effectively nationalized.

            Roads as we know them today did not exist at all until the government took charge of them.

            Before the government took care of basic education (reading/writing/arithmetic), literacy was pretty much a privilege reserved for the aristocracy (I will gladly grant you that our current government could be doing a much better job on this front, but it’s still better than nothing).

            As far as I can tell, few if any people were performing vaccinations at all, unless governments took charge of the process.

            I agree that, whenever vigorous competition takes place, there exists incentive for the competitors to offer superior customer service. However, there’s an even stronger incentive to out-compete one’s rivals by growing bigger, at which point customer service goes out the window. For example, note that telecom giants such as Comcast have a lower customer approval rating than even our Congress.

            In addition, sometimes there’s simply no room for competition. For example, if I want to get from Point A to Point B, there’s usually only one optimal way to build a road between these two places; there’s no room for 100 road companies to build 100 competing roads.

            And sometimes, the Tragedy of the Commons rears its ugly head. For example, some people would willingly purchase a vaccination package from a commercial vaccination company — but many would not. Some would refuse for religious reasons, some for ideological ones, but most would do so because it’s simply not a rational way to spend one’s money. The probability of your child getting measles is relatively small, especially if there are plenty of suckers around who spend money on vaccinating their kids — right ?

          • onyomi says:

            Bugmaster, you seem to be missing my point. I’m not talking about whether or not government can compensate in areas where the private sector tends to underproduce, I’m talking about how much money is spent per unit of vaccines, per mile of road, etc., how quickly and well the thing is produced, etc. in other words, efficiency of production, not wisdom in choice of what to produce.

            Cases like “education was not widely available” or “there weren’t enough roads” may be evidence that the private sector tends to underproduce some things, but not that it produces them inefficiently.

            The only true apples to apples efficiency comparison I’m seeing here is healthcare, since I saw a claim that nationalized healthcare spends less per patient with better or equal outcomes. But there we are comparing two different forms of government healthcare, not free market healthcare versus single payer. Arguably a quasi-nationalized system of private providers applying for reimbursement may be even less efficient than a fully nationalized single payer system, but that’s again a government to government comparison, since the US govmt, all told, and including state-level medicaid, etc. devotes as much or more of its budget to healthcare as most developed nations with nationalized healthcare.

            Although I don’t support it, it at least makes sense to me to say, “historically, the free market does not produce enough [education, vaccines, roads…] and justice demands we have more […], therefore we must tax the populace and use that money to ensure we get more […].” It doesn’t make sense to me to argue that not only will we get more […], but that the government will do it better, faster, cheaper than the private sector could have.

          • James Picone says:

            But the private sector doesn’t build interstate highways, vaccinate people, educate the entire population, or provide healthcare to the entire population. There’s no good way to compare the efficiency of the government doing a thing to the private market doing a thing when the private market can’t do that thing.

            I suspect Bugmaster is of the opinion that the efficiency of not providing a service is less than the efficiency of providing that service at any cost, and you aren’t Onyomi.

      • Princess Stargirl says:

        As it turns out I have read “The Machinery of Freedom.” I have also read much of Bryan Caplan’s work. “Mises, Bastiat, Public Opinion and Public Choice” was so wonderful to read. After I read that paper so many things made sense to me that had previously been very confusing.

        In general I think I am reasonably familiar with alot of the ancap literature and I find it very interesting. I definitely agree that “market failure” is a terrible argument for government. I am am always surprised people use “public goods problems” to argue for democracy. Since an “informed electorate” is a public good. And its in no individuals voters rational altruistic interest to inform themselves to vote well (I use altruistic interest not self interest because even if a voter cares about all citizens equally voting is a waste of time).

        So as it turns out I am fairly familiar with your views on this and I didn’t mean to criticize them. But I think your views are fairly uncommon. The majority of libertarians are not ancaps. And a large chunk of ancap argue quite differently from you.

        Also even if I understood the reasoning of libertarians/ancaps I still would not understand the bulk of people. Most people do not think any major part of the government should just be disbanded. Though as other commentators have pointed out the NSA may be a popular target for dismantling.

        Freedom of speech has gone pretty well in most people opinions. Why then don’t most generally pro-government people want to add at least a couple more “Hard limits” on governments.

        Also I agree with you that most of the reduction in world poverty has come from economic growth not re-distribution. But I still feel the central goal of the government should be re-distribution. Though it can do some other things tolerably well. I think the killer app for government is re-distribution. Its a complicated philosophical question if re-distribution is a good thing or is justified. But I think it is and this more or less requires me to support alot of government.

        Thanks for taking the time to write that comment. And especially thanks for writing “The Machinery of Freedom.”

        • Jon Gunnarsson says:

          Though I am a libertarian and even an ancap, I agree with you that redistribution would be desirable if it were done well. However, doing redistribution well is an extremely difficult problem since it’s so easy to create perverse incentives.

          As evidence of this, notice how most First World countries have managed to build up a sizeable underclass over the last few decades. On top of that, notice how much is being distributed from relatively poor people to relatively rich people, such as the farm subsidies mentioned above or coporate welfare.

          I just don’t think it is realistic to expect governments to do a good enough job at this. The incentives for politicians and voters aren’t there to create a good system for redistribution since voters have no reason to be well-informed or rational about which programmes will work well; what voters voting for redistribution want is warm fuzzy feelings, not cold hard cost-benefit evaluations.

      • Shenpen says:

        I think it would be useful to drop the tired old government vs. market debate and reframe it as roughly like you did, principal-agent problems, moral hazard, or to borrow Taleb’s expression: decision should be made by people with skin in the game.

        The issue is, that not all market setups have decisions made by people with skin in the game, and not all government setups have decisions made by people who have no skin in the game.

        Taleb actually documents nicely the issue of investment bank managers having not enough skin in the game wrt the 2008 crisis.

        On the government side, the issue is with discussing government as such in English online, government usually means the Federal government of the USA. State level governments have more skin in the game and you can notice how they get an order of magnitude of less flak from US libertarians. Sometimes it feels like, many Alabama libertarians / conservatives think if at least the yankees up north would leave them alone and they would be government by the good old boys in Alabama that would be kinda good enough.

        It gets even better if you adopt an international picture. It seems the canton level governments of Switzerland have plenty of skin in the game. Denmark finances socially services centrally, but decides on the spending locally, town mayor level. That is plenty of skin in the game. Government seems to work leaps and bounds better if decentralized. A few years ago there was a bit of a scandal in Hungary of the local water utility facilities of a town which is operated by a French company. Who do you think had more skin in the game, the owners in Paris or the mayor and his voters who live local?

        So a picture emerges:

        A market of huge corporations: little personal skin in the game as far as managers are concerned

        A market of small businesses: a lot of skin in the game

        Federal US or EU level of government: little skin in the game

        Town level government: lot of skin in the game?

        See? It seems the issue is not really government or market, but big and monstrous vs. small and local. Small and local governments, small and local businesses have the most skin in the game.

        And that was my sales pitch for neo-Chestertonian Distributism.

        You may want to review John Medaille’s Towards A Truly Free Market, which summarizes this position rather beautifully.

        • Nornagest says:

          I think I’d be in favor of devolving implementation to the local level wherever possible. But the problem with devolving policy decisions is that the smaller a scale you operate on, the more vulnerable they are to interest-group politics and petty tribalism.

          I’ve got lots of bad things to say about my state government, but I’m Californian and my state behaves more like a nation in a lot of ways. Local politics are still shitty, though, just in different ways: I’d point to the San Francisco sit/lie dispute of a few years ago as showcasing some of the worst on all sides. (I once contemplated going up to Haight, finding the guy with a pit bull, and interviewing him about how it feels to be responsible for a social media war, but I never got around to it.)

      • DanielLC says:

        Without government, how would we prevent someone from starting a government?

    • social justice warlock says:

      I do not get why there aren’t more people who are i favor of just trashing some but not all parts of the government.

      This is already pretty much everyone but libertarians and anarchists, who are unusual in caring about the size of government as such.

      • Nornagest says:

        I can’t remember the last time I heard a call for the dismantlement of some well-defined part of government from the liberal side of the fence. You occasionally hear it from conservatives, but usually only the more libertarian-leaning ones.

        You hear calls for the repeal of individual laws from all political corners, but usually not ones that would meaningfully change the structure of government.

        • Anonymous says:

          As a liberal, I’m in favor of abolishing school districts. (You heard it here first.)

          • taelor says:

            As a liberal, I’m in favor of abolishing school districts. (You heard it here first.)

            Assuming you are not also advocating for abolishing public education, how would you organize government-run schools in a school district less world? Centralized agency at the State or Federal level?

          • Anonymous says:

            @Taelor, I favor replacing “government run” schools with overlapping networks of independently run schools (basically, charters). Some administrative functions would be moved up to the state level, and standards would be national, but schools would have a lot of freedom as to how they want to do things, who to hire and fire, etc.

            Funding would be per child.

          • Jiro says:

            I’ve read stories about cases where a school district’s funding did depend on the number of students. The result was that homeschooling was deliberately obstructed by the district because every time someone homeschools, the district loses money.

            Beware perverse incentives.

          • Anonymous says:

            And I’ve been part of a case where the principal obstructed homeschooling because he was an asshole.

          • Jiro says:

            The fact that problems can arise anyway because someone is an asshole doesn’t mean that we should avoid worrying about those problems being caused by perverse incentives.

        • hylleddin says:

          Some of the more extreme liberals want the military disbanded. Slightly less (Though only slightly) extreme liberals want the NSA disbanded.

          • cbhacking says:

            Parts of the NSA have provided value to the world. I’m not sure anybody will ever trust them to improve crypto again in the future, but they did so in the past. I’d like to see them re-made, trashing all the parts that aren’t about producing beneficial services (anybody who thinks the market can or will solve things like strong crypto has seen little if any of the charlatanry widespread in the crypto market).

            The TSA, on the other hand, can be dropped in a five thousand foot pit, sealed by pouring molten lead over it, and then fired out of a cannon into the sun. Or just defunded, ideally with something lawfully unpleasant happening to the people who abused the power of the TSA to abuse other people.

            There are good reasons for the FDA to exist – seen any Thalidomide babies recently? – but I agree that it could use a lot of shaping up.

            The military is necessary in general, but at least 50% of it could go. We really don’t need to spend nearly so much of our national resources on it except in times of actual war (and no, the “war on terror” doesn’t count any more than the “war on drugs”).

            We seem to have entirely too many organizations devoted to regulating and policing various kinds of drug-like things. The DEA and ATF both seem at least redundant and possibly atrocious, though I don’t actually know that much about them and have never had anybody give me a serious attempt at justifying their existence.

            I’m sure I could come up with plenty more, were I looking at a list of agencies and portions of government. In fact, going back to the TSA thing, we got along fine (YES, including 9/11, which was a horrible tragedy but did not actually damage the country that badly except by our overreaction to it) before the DHS existed at all. Some of the pieces of it (like the Coast Guard) have legitimate reason to exist, but then, the CG existed before.

            Anyhow, while I do not associate with any political party, in terms of social and economic ideas I qualify as liberal.

          • Nornagest says:

            @cbhacking: I’d forgotten about the TSA; I have heard liberals (and conservatives!) call for its dismantlement.

            On the other hand, it’s a pretty obvious call. Fuck the TSA.

        • Protagoras says:

          I’m pretty liberal, and I tend to agree with anonymous about school districts. I’d also like to see the NSA disbanded, for that matter. And, relevant to the present topic, I certainly think the DEA should be abolished.

          • David Hart says:

            I certainly think the DEA should be abolished.

            I’d be very surprised if that wasn’t a majority view among USAian liberals.

            But given that the American public’s failure to think rationally about drugs is basically at the root of the whole problem the OP is about, I could well be mistaken.

          • Anonymous says:

            I’m definitely some stripe of “left” (my views are a kinda democratic socialist/civil libertarian fusion), and I’m openly in favor of revoking the CIA’s charter. It seems to me that they continually both A) commit immoral and illegal acts in order to advance American interests, and B) consistently fail to actually advance American interests.

            We’ve got seventeen intelligence agencies. I propose we could get by with sixteen.

        • grendelkhan says:

          Speaking as a liberal, I’d be in favor of a more evidence-based approach toward a lot of things. For example, this sort of report seems to imply that there’s a lot of terrible and expensive things we do to kids. We could stop doing those, for example. Or putting people in prison; we could do a lot less of that. Mass incarceration is a structural kind of thing, right?

          I think the issue may be that your standard-issue liberal doesn’t have a principled stance about the ideal size of government; if starting a program is a good idea, that makes the ideal size of government larger, and if shutting it down is a good idea, then the ideal size of government is smaller.

    • Illuminati Initiate says:

      I currently don’t have a very solid position on economics, but I think I am currently in favor of socialist-ish economic policies, but am often against many government “regulations” in the usual sense. I mean sure, I might want the excess profits of enterprises to go to the state to be redistributed. But ridiculous drug regulation? Zoning laws? Stupid stuff like banning large sodas? Pointless housing restrictions? What good ever comes out of any of that? (Employee safety stuff are examples of regulations of this type I support)

      Also, I have an attitude where I’m like “if you want to do free market capitalism at least do it right“.

      (In regards to the FDA, at the very least there should be an exception that terminally ill patients can try whatever experimental drug they want).

      • Wrong Species says:

        When you say socialist do you mean Sweden-socialist or Venezuela-socialist? It’s such an ambiguous word.

    • Blue says:

      What you probably want is a government that is *good at making decisions quickly*. We purposefully made a government that can only make decisions slowly and with effort, with the libertarian-friendly goal of limiting what the government would then do.

      But rather this led to the consequence that dismantling poorly-conceived or simply outgrown programs, is very hard. So you have this ponderous bus of a government that can neither go forward too fast, nor veer quickly enough to avoid an accident.

      More efficient governments would be unicameral, unitary parliaments, or even elected dictators. I don’t endorse those, but it would solve this particular problem of “get rid of the bad agencies, empower the good ones.”

      ***

      Also count me as “another leftist who would outright abolish certain parts of the government.” The military, compulsory education, most of our penal system, the Dept of Ag, etc. In fact if grants were large enough to accomplish redistribution, I’d prefer devolving most political authority to city governments.

    • gattsuru says:

      However I think environmental regulations work pretty well. And I think while welfare and re-distribution could be done better the re-distribution programs in the USA function well enough to be worth it. In fact we should probably increase re-distribution if we can afford it. Another example is that many nations seem to get good results with single payer healthcare.

      Do you believe that you have experienced the internal mechanics and costs of these structures more, or less, often than the structures you believe the government does not handle well? Do you think there may some interesting information there?

      The costs of environmental regulation in particular are very well-hidden from the average constituent, but I would bet a nontrivial amount that you’ll find that they are very poorly balanced.

      • Princess Stargirl says:

        My opinion on single payer is based purely on data. Many nations with single payer systems spend less that the USA (in terms of GDP) and get comparable health outcomes. There are some counter arguments that explain the disparity and oppose a switch to single-payer. But I was not convinced by these.

        Environmental policy is somewhat complicated. I think the costs in the USA of environmental regulation are not too bad (based on econ papers). In some countries however environmental regulations have proved very costly. The US situation could easily change imo and we may have just gotten lucky. For example had the US banned fracking I would not have a good opinion of the EPA. And I have no personal to fracking.

        Also problematic is that the world seems close to badly over-reacting about Global warming. I am aware that global warming has occurred and significant warming will probably resume soon (we seem to be in an pause of sorts). But the IPCC has consistently over-estimated warming. And moderate warming on the time scale of century does not seem catastrophic (and the IPCC estimates for the next 100 years are not extreme). People worrying about extreme warming by 2500 are really off base imo. So maybe environmental regulations will get out of hand soon, I don’t know. Also I bare almost none of the costs of environmental regulations but I am concerned about them in general.

        Really the only cost of the FDA I personally bare is they make LSD hard t find. But that is not my critical issue with the FDA. The burden of drug testing has made drugs very expensive and really harmed R&D. I don’t have serious medical problems and have never been a hospital for long. But the FDA unnecessarily delaying useful treatments (as they are) is why I really hate them.

        So I don’t my reasons are really based on my personal experience.

        • James Picone says:

          Depends what you mean by ‘moderate warming’. With any sensible climate sensitivity, burning fossil fuels from now to the indeterminate future and not doing anything to stop burning fossil fuels results in a lot of warming. Wikipedia’s article on RCPs is pretty good – the ‘do nothing about global warming right now’ option is at least RCP 4.5, depending on the actual trajectory of emissions. RCP4.5 has a mean of 2c above preindustrial somewhere in 2046-2065, and gets to ~2.4c above preindustrial by 2100 (again, mean of distribution, which corresponds to an ECS of ~3. Low-ball ECS estimates of 1.5-2 give 1.5c and 1.7c above preindustrial in those two time periods).

          RCP4.5 has CO2 emissions peak in 2040 and then decline. IIRC it’s currently very hard to pick what RCP we’re actually taking, because we’re only a couple of years into them and by definition they all start at the same point, but RCP4.5 honestly seems like a lowball estimate of emissions in a minimal-mitigation scenario like you seem to be endorsing. And it ends up with pretty significant temperature changes by mid-century, causing significant harms, and with a nontrivial risk of really, really bad changes. About 10% of the ECS probability mass is >4c, mostly in the range 4c-6c. If the ECS is 4c, you can add ~2 degrees to the RCP4.5 estimates above. If it’s 6c, you can add about 4 degrees.

          That’s why this thing is scary. Things that we are doing now are basically guaranteed to cause some pain in 50 years time, with maybe a 5 to 10% chance of being utterly catastrophic, but the effects are 50 years distant, so we can’t rely on the “Oh shit, there’s a giant concentration drop in ozone at the south pole” effect to force cooperation.

          • “You probably answered this in your PDF”

            I gave at least my answers to these questions in a book published a little over forty years ago. The pdf is of the second edition.

            The short answer is that some things won’t get done under anarcho-capitalism that should be done, but I at least argue that, under circumstances in which A-C is stable (not all environments meet that requirement), the result can be expected to be less bad than the result of the alternative.

          • “burning fossil fuels from now to the indeterminate future”

            I don’t know what you think of as the indeterminate future. In my view, any projection beyond the end of the century, and probably even a projection that far, is worth very little. A century is a long time and, with the current rate of technological change, the world is changing very fast. By 2100 we could have wiped ourselves out through some mechanism unrelated to climate change, we could have become so powerful and wealthy that climate change problems will be trivial to deal with, we could have changed things in one of many other ways that make the projections irrelevant to the reality. That’s why, in Future Imperfect, where I was exploring possible futures resulting from possible technological revolutions, I mostly limited myself to about three decades out, figuring that beyond that things got too uncertain.

          • James Picone says:

            I think we’ve already crossed the point where we’ve caused notable and significant harms (for example, I expect sea level rise to be a problem over the next several decades). I think we’ve reached the point where there’s a low-but-plausible risk of catastrophe. Continuing to emit until 2040 seems exceptionally risky to me, and is also close enough that projecting that far seems sensible.

            I don’t expect the Arctic icecap to exist in three decades time, for example. It’s possible that it’ll have an essentially ice-free Arctic summer in /one/ decade.

            It’s possible the singularity or nuclear war happens before the really serious outcomes kick in, but betting on it seems like poor risk management.

            What’s anarcho-capitalism’s solution to CFCs, incidentally? That seems like an example that isn’t readily resolved and also isn’t very controversial. I don’t see how the Montreal protocol happens without something strongly resembling government regulations happens.

        • Tracy W says:

          Many nations with single payer systems spend less that the USA (in terms of GDP) and get comparable health outcomes.

          As do many countries without single payer systems, such as Germany, France, Singapore, and the Netherlands.

          Basically US health care policy is uniquely stuffed.

    • Anonymous says:

      Like I think we would be alot better off with no FDA.

      I work for moderately big pharma, for a company that prides itself on its compliance record and QA process.

      I see things, not every day but probably every month, that makes me think “Thank God for auditors.”

    • I do not get why there aren’t more people who are in favor of just using the Ring of Power for good and not for evil.

      • grendelkhan says:

        Isn’t this just begging the question of “is government inherently evil?”. I can come to all kinds of fun conclusions if I assume that, for example, right-libertarians are all baby-eating monsters with a taste for toddler toes, but that just kinda communicates my ideology, rather than actually backing those conclusions.

        (Aside: I’m thrilled to have had an opportunity to use “to beg the question” properly.)

    • BearHeelCub says:

      “But I think the government is terrible at managing safety of chemicals and it should stop trying”

      Do you remember when the when the river in Pittsburgh caught on fire? That is what happens when you let industry regulate itself. The incentives are completely wrong to dissuade industry from taking advantage of/falling victim to the tragedy of the commons.

      Or, lets look at the existing market for herbal remedies, which operates under rules almost exactly like the ones you are advocating for the pharmaceutical industry. How confident are you that herbal remedies do what are claimed for them?

      • Princess Stargirl says:

        Regulation of polluting rivers is environmental regulation. I explicitly said I think the EPA in the USa does a pretty decent job.

        What is your point about herbal remedies? If the government wanted to issue seals of approval that wouldn’t bother me. The issue is the government can currently ban the use of substances/treatments. The government has badly mis-used this power. Their failure has resulted in millions of destroyed live, trillions of dollars wasted due to over the top regulatory burden and a serious retardation of medical progress. I don’t have a problem with the government releasing recommendations though.

        • Anonymous says:

          The basic function of the FDA is to ensure that drugs are proven efficacious and safe before they are given to the public. Drug development is a non-trial exercise with a great degree of complexity. If you want to see how well a private standards organization handles that type of task, I would suggest the credit rating agencies as a good model (when they were dealing with mortgage backed securities. ) The certified bonds as highest quality which were utter junk.

          Any good truly good.development process will be very expensive. A private ratings agency will be incentivized to reduce this cost by simply ignoring the complexity, especially in a competitive market.

          Yes, the FDA has some shitty sensitivities to “war on drugs” type political priorities, but you seem to be ignoring that drugs aren’t easily assessed for quality by the consumer. Much like the government needing to enforce that lead can’t be in consumer products, the government has to enforce that drugs are tested as efficacious and safe.

          • HeelBearCub says:

            Sorry this last comment was from me.

          • James Picone says:

            I think the change being suggested here is that instead of the FDA banning drugs that don’t pass their testing, the FDA issues a stamp-of-approval that only FDA tested and certified drugs can get, and then people who care about the FDA can pay attention to that certification.

          • Princess Stargirl says:

            You are ignoring the vast problems caused by the FDA/DEA. You have to argue that without them even worse problems would exist. Not just argue that without the FDa/DEa there would be some problems. If you argue for the FDA/DEA actually address the fundamental arguments against it.

            Also yes I have no issues with the FDA/DEA issues stamps of approval.

          • BearHeelCub says:

            “Also yes I have no issues with the FDA/DEA issues stamps of approval.”

            What are you claiming the FDA does? It certifies that a manufacturer has proven its claim about its drugs and that the manufacturer is monitoring those drugs to ensure they meet the safety claims. Scott is complaining about how the treatment of one single drug is out of whack, not that all drugs are prevented from being prescribed.

            You seemed to be arguing that the FDA should only certify that Nexium contains Esomeprazole and nothing else. I’m not even sure you think the manufacturer should be required to make a safety claim, let alone an efficacy claim, let alone prove them. And the logical end point of your what you are suggesting seems to be that all drugs be available over the counter.

            If that is not what you are saying, then I am not following you.

          • houseboatonstyx says:

            the government has to enforce that drugs are tested as efficacious and safe.

            Effacacious and safe are quite different problems. Imo new remedies (prescription drugs and recent combinations of herbal ingredients) should be tested for safety. But when a herb has been in use for centuries in different countries, its dangers if any, would already have been noticed, and footnoted in reputable herbal compendiums.

            As for effectiveness, the same applies somewhat. If separate cultures all over the world have been using X herb for Y problem, that’s evidence in its favor.

          • Nita says:

            If separate cultures all over the world have been using X herb for Y problem, that’s evidence in its favor.

            Most herbs don’t grow all over the world, so the evidence of this sort seems to be in favour of prayer and sacrifice.

          • HeelBearCub says:

            “But when a herb has been in use for centuries in different countries, its dangers if any, would already have been noticed, and footnoted in reputable herbal compendiums.”

            This statement has very little to do with what StarPrincess proposed. I brought up herbal remedies because, under the unregulated free market system that exists for dietary supplements, we have very little sense of the actual efficacy of herbal products. It’s a perfect counter-balance to the idea that the market will automatically fill the need to prove efficacy.

      • Jaskologist says:

        Ripped from yesterday’s headlines!

        The authorities said they had conducted tests on top-selling store brands of herbal supplements at four national retailers — GNC, Target, Walgreens and Walmart — and found that four out of five of the products did not contain any of the herbs on their labels. The tests showed that pills labeled medicinal herbs often contained little more than cheap fillers like powdered rice, asparagus and houseplants, and in some cases substances that could be dangerous to those with allergies.

    • Eli says:

      I do not get why people go on and on about “Chesterton’s Fence” this and “unintended consequences” that, and then say, “Government just kinda sucks so much we should get rid of it wholesale”, as if this claim didn’t have its inverse implied by the former two claims.

      • James Picone says:

        Aren’t those two different groups? I’d expect Chesterton’s fence from classical conservatives or neoreactionaries, and I’d expect “let’s get rid of the entire government” from libertarians.

  2. Anonymous says:

    At this point I think our best option is to ask the paraconsistent logic people to figure out something that’s neither government nor not-government, then put that in charge of everything.

    Privately-funded gated communities in the middle of nowhere, perhaps just large enough to gain control over local government, equipped with everything people might need for day to day living. (Of course, if a suboxone user wants to leave the community and live somewhere else, that might be a problem.)

    (Also, are paraconsistent logic people really a thing?)

    • Scott Alexander says:

      >> “Also, are paraconsistent logic people really a thing?”

      Well, yes and no.

      • Doug S. says:

        I see what you did there. 😛

        I think people who specialize in paraconsistent logic are called “judges” and “lawyers”… in the U.S., at least, you can construct a logically valid argument for damn near anything, but judges still tend to make consistent rulings in most cases.

    • William O. B'Livion says:

      http://www.ted.com/talks/paul_romer?language=en

      Although he’s talking about doing it in un and under developed nations.

    • Protagoras says:

      Graham Priest and the late Richard Sylvan were the big paraconsistent people I’m familiar with. Priest is very highly respected in philosophy circles; Sylvan was a bit of a nutter in some ways, but still had an overall decent reputation. I haven’t followed recent philosophy of logic enough to know who (if anyone) has followed their lead.

    • I did not know what paraconsistent logic was until Scott mentioned it in his piece. I’ve now read the Wiki article, which is enough to make me feel like I at least understand what it’s about, and I’m pleased tohave this knowledge. (Actually, I’m especially pleased that I’m not the only one who finds the theorem that anything follows from a contradiction to be absurd, and that others have considered this.)

      • Anonymous says:

        Let’s consider it in a different venue:

        Suppose 0 = 1. You can then show that any relation between reals is true.

      • Anonymous says:

        The principle of explosion is correct. The issue is that most humans are bad at logic. So they take things that look like contradictions, but aren’t, and assume that therefor contradictions exist in reality. A good example is equivocation, which will trivially generate contradictions because the different meanings of the term will have different logical implications (and thus can easily have contradictory implications). Another is the mistaken assumption that a converse is a negation: the converse of A->B is B->A, which can be true for both statements at the same time in deductive logic; the negation of A->B is A&!B, which can never be true for both statements at the same time in deductive logic.

      • Anonymous says:

        A story goes that the famous English mathematician G.H. Hardy made a remark at a dinner party that falsity implies anything. A guest asked him to prove that 2 + 2 = 5 implies that McTaggart – a Hegelian believer in true contradictions- is the Pope. Hardy replied, “We also know that 2 + 2 = 4, so 5 = 4. Subtracting 3 we get 2 = 1. McTaggart and the Pope are two, hence McTaggart and the Pope are one.”

    • Alex says:

      You mean Galt’s Gulch?

  3. Anonymous says:

    But modern rehab programs seem like a really damning counterexample. If you read the article, you will see that this rehabs are trying their best to create a tightly-integrated religiously-inspired community of exactly that sort, and they have abilities to control their members and force their conformity – sometimes in ways that approach outright abuse – that most institutions can’t even dream of. But they don’t work. At all. The entire thing is for nothing. I’m not sure whether this represents a basic failure in the idea of tight communities, or whether it just means that you can’t force them to exist ex nihilo over a couple of months. But I find it interesting.

    As you wrote:

    Problem is, a lot of these are closely integrated with the social services and legal system. So suppose somebody’s doing well on suboxone treatment, and gets in trouble for a drug offense. Could be that they relapsed on heroin one time, could be that they’re using something entirely different like cocaine. Judge says go to a treatment program or go to jail.

    You can’t force people to function well in a tight-knit authoritatian community.

    Military institutions work because they pre-select, select, and constantly re-select for people who function well in this kind of communities.
    People who go to drug rehab, on the other hand, are pre-selected for being the kind of people who make bad life decisions and can’t function well in the society at large (otherwise they wouldn’t be doing drugs in the first place) and court orders further selects for unwilling partecipants.
    Also, the mere strength of an improperly treated addiction to a drug like heroin might be strong enough to overcome any psychological benefits that a tight-knit might offer.

    • Scott Alexander says:

      I predict some rehabs have a very low percent of people there undergoing forced treatment, but don’t do much better.

      (also, the army used to have both conscripts and people who enlisted after a judge told them it was jail or the army)

      Also, the rich are already doing fine. When conservatives talk about community, the whole point is to help people with serious problems. If we’re saying community doesn’t work for them, that already seems like it sinks the theory.

      • drunkenrabbit says:

        The military has changed a lot since it became an all-volunteer force. It now requires a decent score on an intelligence test and no criminal record. I’m guessing the pre-Vietnam force was considerably more violent and dysfunctional, but I can’t find any good numbers. I do know that as late as the 90s it was pretty common for unit leaders to unofficially sanction the beating of chronic troublemakers.

        • Tarrou says:

          I must disagree. 11-B2O here, ~seven years active duty. The required score on the “IQ” proxy test is a 29 out of 100, and you can get a waiver (if the recruiter really needs to hit quota that month) for a score all the way down to a 23………on a multiple choice test. You can literally be dumber than chance and get in. If you can fill in bubbles without eating the pencil, you’re a go.

          As to no criminal record, I don’t know quite what you mean. If you mean the Army doesn’t take certain serious felonies, (murder, rape) then yes. If you mean they don’t take anyone with an arrest or conviction for something criminal, that would eliminate virtually every infantryman of my acquaintance. In my basic class was a guy whose personnel file I saw, he had three felony convictions, assault with intent to kill and attempted murder twice. And about forty misdemeanors ranging from possession with intent to fare jumping. I had two misdemeanors when I went in.

          There are plenty of reasons why the military works (in its own dysfunctional way), but selecting good, smart, cooperative types isn’t one of them.

          • drunkenrabbit says:

            For the ASVAB, a score of 23 means 23rd percentile, not a score of 23 percent. For comparison, 23rd percentile on an IQ test is a score of 89. Now, the IQ test is normalized for the general population and the ASVAB is normalized for people who take the ASVAB, so I’m not sure how commensurable they are.

            As for the criminal record thing, I hear it has varied a lot over time. When I joined, people with felony convictions still occasionally got waivers but had to jump through hoops. An acquaintance I went in with in 2009 (I was an 11B for three years) had done a year for felony possession/distribution, but needed a few hundred hours of voluntary community service and a letter from his congressman before they’d give him a waiver. It’s gotten stricter now, I heard of a guy who couldn’t get a waiver for the misdemeanor he’d gotten when he set his neighbor’s lawn on fire. But yeah, I was being way too broad when I said “no criminal record”.

            The main point I was trying to make is that the military generally draws from people in the smartest/least criminal 70% or so of the population. Which isn’t a super high bar to clear, but it does tend to keep out the people who cause the worst kinds of trouble.

          • William O. B'Livion says:

            I’ve got a long history with the military, I’ve either served in or worked for the Military in 4 decades.

            You’re both right. The military ended the “join the .* or go to jail” in the late 1970s or early 1980s.

            But you can get a waiver for *almost* anything if you’re willing to put in the effort, and in so doing the military narrows down your choice of job fields on entry.

            If you score a 24 on your ASVAB you’re going to be in the Combat Arms field, probably as a 11B, and a rifleman at that.

            The thing is you don’t need great *intelligence*[1] to be a rifleman, you need to be a hard worker, follow orders and more importantly NOT DISOBEY them. Like “keep your finger off the trigger” and “don’t pull the pin out of the grenade until it’s time”.

            I’ve worked with a lot of people of limited intelligence over the years, and those that knew and understood their limits were *awesome* to work with because they knew that it was unlikely they knew better, and if they thought they saw something wrong they’d ask–they wouldn’t assume they knew more than the guy who designed the system.

            OTOH, the bright sparks of limitless intelligence and limited experience…There are more things in heaven and earth Horatio.

            The military *NEEDS*, in certain positions at certain times a particular type of person, and we can tell that person by personality traits, or by their track record. If they have a track record of spontaneous violence, constantly testing authority and other examples of a sociopathic personality then they might, with a bit of a certain kind of discipline make a REALLY good Ranger. Not a general purpose leader, but frankly a killer.

            Which is what the military is there for after all.

            And the folks who set up the recruiting models know that sometimes the non-sociopath boys might be a little more boy than their community wants to deal with, but they aren’t really evil (like the sociopaths) and make good soldiers and good leaders when they have a challenge, so they’ll give them *a* chance.

            Had a lot of those in the Marines. Some were good, some should have had chains wrapped around their body and dropped in the sound.

            [1] In context of the last 3 posts by Dr. A, I’ve been trying to formulate a coherent response, but I’m not that smart and *I usually don’t mind*.

          • Anonymous says:

            drunkenrabbit, I believe AFQT is normed against the national population, not just the test-takers.

          • drunkenrabbit says:

            @anon

            Thanks, you’re right. I never knew that. It’s a little disturbing, I met a couple fairly dumb people in the military, and if they were all at least 89 I can’t imagine what 80 looks like.

          • zz says:

            >You can literally be dumber than chance and get in.

            So just doctors can’t join the army, then?

          • Anonymous says:

            @zz:

            Relevance???

        • Multiheaded says:

          I’m guessing the pre-Vietnam force was considerably more violent and dysfunctional, but I can’t find any good numbers.

          Read The Naked and the Dead by Norman Mailer.

          • drunkenrabbit says:

            I did. I wasn’t a huge fan. It seemed clunky and amateurish, and despite Mailer’s talk about “compassion” towards his characters, it seemed more like condescension. The flashbacks, especially, I thought were cringe-inducing, patronizing views of working-class lives through a college graduate’s eyes.

            Besides, he was a cook and didn’t really see combat. I’m guessing some of the compelling parts were inspired by stories he’d heard. But I wouldn’t take his work as a whole for a good representation of life in the WWII Pacific Army. Not that I know for a fact that he’s wrong, but I feel like there’s too many reasons to take his characterization with a couple grains of salt.

          • Multiheaded says:

            Yes, absolutely. It’s mostly that I’m kinda suspicious of the dominant American narrative of ultimately virtuous and wholesome decent young guys who are occasionally stained by the brutality and terror of their circumstances. Mailer’s one of the few counterexamples that I know of.

          • von Kalifornen says:

            I don’t know to what degree this is true, but I’ve heard that the US army in Vietnam was partly composed of the US’s worst troops, because Vietnam was considered an unimportant sideshow and the US’s best troops were in Germany preparing for a hugeass Soviet invasion.

      • William O. B'Livion says:

        You’re assuming (in that paragraph) that 100% (or nearly so) of people can be comfortably and soberly integrated into “community”.

        You’re also ascribing to all conservatives what only a certain kind would say.

        We don’t think that community “just works” for everyone, what we (generally) believe is that you have an obligation to at minimum not shit on your community.

        To quote from Russell Kirk:

        Sixth, conservatives are chastened by their principle of imperfectability. Human nature suffers irremediably from certain grave faults, the conservatives know. Man being imperfect, no perfect social order ever can be created. Because of human restlessness, mankind would grow rebellious under any utopian domination, and would break out once more in violent discontent—or else expire of boredom. …

        Now this doesn’t speak directly to addition, but to the imperfect and imperfectability of man[1][2], and the futility of creating *a* specific order that man will live in.

        Some people are just too broken to fit in, others need a little help, chemical, instructional, doctrinal or otherwise.

        [1] This is in some sense the “no true scotsman” arguement because if you were to “perfect” a human the argument would be that you’ve done something to make them not “man” anymore–taken away their free will, etc.

        [2] As a conservative I reserve the right to use the classical “man” to refer to the entire human race, and don’t get all culturally imperialist and tell me I shan’t. I can’t type as fast as Dr. Alexander, and trying to type out all the variations every time takes too long.

        • ozymandias says:

          “Person” is six characters. Your disclaimer is 270. This argues that for every piece where you aren’t going to use “person” more than ninety times, it would save you energy to type “person.”

          (This, of course, assumes that you do not copy-and-paste a standard disclaimer.)

          • Rowan says:

            It also assumes the energy cost is mostly that of physically typing the characters, when I expect cognitive effort is the more significant part – translating “man” when you say it in your head to “person” for the benefit of readers who have other preferences than you probably gets more draining than typing up a disclaimer straight from your stream of consciousness after only a few goes.

        • David Hart says:

          As a conservative I reserve the right to use the classical “man” to refer to the entire human race, and don’t get all culturally imperialist and tell me I shan’t.

          Others have already called you up on this, but I still have a question. The fact that you bothered to include a disclaimer means that you are already aware of the fact that a lot of people think it rude and insensitive to use a word to refer to the whole of humanity that implicitly excludes about half of it. And you could easily rephrase ‘imperfectability of man’ as ‘human imperfectability’ – that would actually save you a few characters, and even when you have to use a slightly longer word like ‘people’ or ‘humans’, that’s still at most a few more letters. You could have said ‘duty’ instead of ‘obligation’, ‘society’ instead of ‘communnity’, ‘debate’ instead of ‘argument’ – you are not obviously going out of your way to use the shortest possible words in other contexts, so I’m not persuaded that that is your true rejection.

          So my question is: why is it important to you to be seen to knowingly not care about using language that casually excludes about half of us? Or have I misunderstood your position?

          • nydwracu says:

            Signaling.

            Don’t expect people outside your faction to adopt your faction’s signals.

          • Anonymous says:

            But nydwracu, why would you merely expect, when you can demand?

          • Anonymous says:

            Using the word “man” to refer to the human race has a poetic quality. It is also historically legitimate, the word was used that way for a long time. Some people resent it when others try to control their language, taking away their choice to employ this poetic effect. It’s kind of like when the French decided that Americans were not allowed to call bubbly white wine champagne anymore, a common practice, and for some reason everybody seems to have just capitulated to this demand.

            Here’s a song released in 2010, co-written and sung by a woman which uses the word “man” in this sense. (https://www.youtube.com/watch?v=k-FW9uwQUNo) Then again she’s French/Israeli, so maybe she hasn’t gotten the memo that she should be offended by this usage.

          • David Hart says:

            nydwracu:

            Don’t expect people outside your faction to adopt your faction’s signals.

            You may well be correct. But there was something odd about the flauntingness – he wasn’t merely using a term that could easily be replaced by one that needn’t offend anyone, he was actively drawing attention to the fact that he was doing so – as if he is proud to deliberately choose the more hurtful of two language options. That’s not a very charitable way of putting it, I know, and I could be failing to think of a much more conciliatory motivation, but you can understand, I hope, why it would be surprising that that would be what someone seemed to want to signal?

            anonymous:

            Using the word “man” to refer to the human race has a poetic quality.

            If you mean it’s a more euphonous word than ‘human’; something you can sing with, or rhyme more easily, I agree. But other than that, I don’t understand what extra poetry it has compared to ‘human’.

            And I’m not trying to tell anyone that they should be offended by this usage, just pointing out that some people are, and for reasons that are perfectly understandable and valid, so when someone proudly announces that they intend to use the less polite, less inclusive option, one is entitled to inquire as to what their motivation is.

          • Nornagest says:

            But there was something odd about the flauntingness […] as if he is proud to deliberately choose the more hurtful of two language options.

            If someone clearly intends to tell you “fuck you, I’ll do what I want”, don’t act like you’re surprised when you glean a “fuck you” from their phrasing.

          • nydwracu says:

            If you always choose the least hurtful option, all people need to do to completely control you is self-modify to feel immense amounts of pain whenever you don’t do what they want — or merely credibly present themselves as feeling immense amounts of pain when you don’t do what they want.

            If you don’t want people you completely disagree with to control you, well, you can’t take them at their word for when they’re hurt.

            You can also, of course, create a general idea in the culture that other people will feel immense amounts of pain when anyone doesn’t do what you want, and speak on the behalf of this group — whether or not it exists and feels that pain. The actual facts don’t matter; all that matters is that enough other people will think it does that you can ‘call out’ the offender for doing things that those other people will perceive as causing pain, thus tarring the offender as a Bad Person. Once this possibility exists, it will be used until everyone, even the people who don’t believe in the claims that the outcaller implicitly appeals to, knows that there are certain things they can’t say on pain of being seen as a Bad Person.

          • Anonymous says:

            he was actively drawing attention to the fact that he was doing so – as if he is proud to deliberately choose the more hurtful of two language options. That’s not a very charitable way of putting it, I know

            A more charitable–and, more importantly, probably more accurate–explanation is that he doesn’t think it is hurtful. Or that, if it is hurtful, it is only so because people go banging on about how hurtful it is, on and on until we’re all trained to unthinkingly take offense.

            If you mean it’s a more euphonous word than ‘human’; something you can sing with, or rhyme more easily, I agree. But other than that, I don’t understand what extra poetry it has

            Euphony, memorability, and nostalgia (and to a lesser extent, facilitation of rhyme and singing) seem to me to be perfectly adequate qualifications for poetic use.

            And I’m not trying to tell anyone that they should be offended by this usage, just pointing out that some people are

            I’m not persuaded that that is your true rejection.

          • Nita says:

            Well, “man” used to mean “person”, before it was narrowed down to “male person” for, uh, some reason.

            So, I’m all for reclaiming “man” as “person”, but then guys have to be “weremen” again.

          • InferentialDistance says:

            Do “weremen” turn into beer-drinking, cat-calling, muscle-bound hooligans on the full moon?

          • Using “man” to refer to all people does have a poetic effect, but I think it’s to throw the writer and the reader into far mode. It’s a distraction from thinking about actual human beings.

          • Anonymous says:

            If someone clearly intends to tell you “fuck you, I’ll do what I want”, don’t act like you’re surprised when you glean a “fuck you” from their phrasing.

            “Fuck you” is very hurtful language. If you are called out on that, are you more likely to apologize and change your vocabulary, or to say “I’ll do what I want”?

            Or to say, “Well, it shouldn’t hurt you, so get over it”?

          • Nornagest says:

            “Fuck you” is very hurtful language. If you are called out on that, are you more likely to apologize and change your vocabulary, or to say “I’ll do what I want”?

            Or to say, “Well, it shouldn’t hurt you, so get over it”?

            I keep forgetting that implication doesn’t work too well in this crowd.

            To be more explicit: William O’Blivion’s initial comment was about persisting in the use of allegedly hurtful language (using “man” to mean “humanity”) after being called out for it. I interpret that as isomorphic to “fuck you, I’ll do what I want”, with the continued use of extensive “man” being the “fuck you”.

            In other words, though he’d probably disagree that it’s objectively offensive by some reasonable standard, he knows it’s subjectively offensive and he’s using that to convey meaning. It’s central to his message, in fact. Thus it shouldn’t be surprising in this context, and neither should what David Hart called “flauntingness”.

            It’s kind of like a more sophisticated version of this:

            Boy: Stop saying ‘booger’. It’s gross.

            Girl: Shut up, booger. Booger booger booger.

            Boy: Teacher!

            Am I making more sense to you now?

      • vV_Vv says:

        I predict some rehabs have a very low percent of people there undergoing forced treatment, but don’t do much better.

        You are probably thinking of rehabs for rich people. While it might be true that they have a lower fraction of convicts than rehabs for homeless people, I suppose that it is still a significant fraction, since rich drug addicts get convicted for offenses such as DUI, and are probably much more terrified of going to jail than poor people are.
        Anyway, convicts or not, drug addicts tend to be socially dysfunctional people.

        (also, the army used to have both conscripts and people who enlisted after a judge told them it was jail or the army)

        And I suppose there is a reason they don’t do it anymore.

        Also, the rich are already doing fine. When conservatives talk about community, the whole point is to help people with serious problems. If we’re saying community doesn’t work for them, that already seems like it sinks the theory.

        Is “community” something supposed to be in the conservative space of the political spectrum?

        It seems to me that attempts at social engineering to create tight-knit communities is mostly a leftist thing: the Soviet Union was, at least originally, intended to be based on a relatively decentralized system of local communities (soviets, kolkhozy, etc.). In the West, Hippie communes were left-leaning.
        In fact, one could argue that the whole point of Communism and Socialism, as their etymology suggests, is to shift the focus and purpose of the economy and politics from the satisfaction of usually competing individual interests towards the functioning of eusocial-like communities.

      • jaimeastorga2000 says:

        Also, the rich are already doing fine. When conservatives talk about community, the whole point is to help people with serious problems. If we’re saying community doesn’t work for them, that already seems like it sinks the theory.

        Do you remember your zombies post? I think an important part of the conservative mindset that you are missing is an acceptance that not everybody can be saved. Strong communities may help most poor people lead somewhat better lives, but there are always going to be a few wretches who will cause trouble and misery no matter what environment they are placed in. Maybe a few more of these can be helped with more extreme methods such as turning them into wards of decent and functional people, but even then there are a few people who are so messed up that nobody wants around even as legal wards. In these cases, the only thing you can do is commit them to a mental institution for life, lock them up in prison for life, or let the state to put them out of their misery the next time they commit a capital offense.

        This, of course, only holds for a constant level of technology. Maybe some chemical really can move people up a level of functionality and said chemical is sufficiently cheap and available that we can treat those people as functioning at their enhanced level for all practical purposes. And if you can simply send nanobots into someone’s brain to fix whatever is wrong with them, all bets are off.

    • Tarrou says:

      I don’t think it’s selection…….see my post above. It does have a lot to do with an overarching mission, inter-unit competition, and intense bonding over shared hardship. The military is a whole parallel culture, with its own language, social norms, and desirable characteristics, all of which are vastly different from civilian life. And it has the advantage of a minimum of four years to work on people. Most drug programs are shorter than Basic.

      • William O. B'Livion says:

        For a certain class of addiction Boot camp *IS* a drug program.

        I went in a pack a day smoker. Didn’t touch one for 3 months, and there was probably only 4 or 5 times in those 3 months when I really, really wanted one.

        Of course, as soon as I graduated boot camp and got in the taxi, back on them. Smoked another 16 years.

  4. Frog Do says:

    As far as “society is fixed, biology is mutable”, my off the cuff response is have we tried just straight up killing drug users? How are the drug problems in MENA countries? East Asian nations? How WEIRD is this problem?

    • ckp says:

      >As far as “society is fixed, biology is mutable”, my off the cuff response is have we tried just straight up killing drug users?

      Well yes that would “work” if your criterion for success is “number of drug users” but I think it misses the point …

      • Harald K says:

        It’s not so far off from some people’s suggestion. Yes, suboxone works. So does methadone and heroin on prescription. But for a lower and lower value of “work”.

        Giving people heroin on prescription reduces crime, so if that’s what society cares about, fine. But it’s also writing off the addict as a lost case. You give up helping them be functional members of society, responsible in their personal relationships etc. They’ll spend the rest of their lives – which may not be long, Norway had more prescription methadone deaths than heroin deaths for a while – safely sedated and zero expectations, for our sake.

        The problem is that an addict may want that. It isn’t just because they use drugs that they can’t cope with personal responsibilities and societal expectations – it goes the other way too. (When Norway had a policy of only offering methadone to “those who had tried everything”, lots of drug users were in a hurry to fail other treatments as fast as possible.) If you ask to be written off as a lost case as a human, am I really doing you a favour by doing so?

        By comparison, suboxone is certainly a lot better. But it only helps with physical addiction. For those who say that’s half of the problem, bear in mind that just about every drug addict go through withdrawals now and then, either voluntarily or not. What makes them addicts, is that they come back to the drug after beating the physical addiction.

        The drug treatment center that refused Scott’s patient may sound cruel, but they may have perfectly reasonable priorities. If you can’t even temporarily/willingly go through physical withdrawal (most addicts can), then maybe they aren’t equipped to help you.

        There is no magic pill. Yeah, Scott is a doctor, he likes biological solutions, but drug abuse remains a social problem. You’d better hope society is mutable (then again, the diversity of existing societies, and how much and rapidly they’ve changed the last 100 years, ought to give some hope here).

        • David Hart says:

          But it’s also writing off the addict as a lost case. You give up helping them be functional members of society, responsible in their personal relationships etc.

          I don’t understand why. It’s well recognised that people can be functional heroin addicts, requiring a daily dose in order to feel normal, but otherwise living an ordinary, productive and socially connected life.
          They may not be the sort of heroin addict that Scott Alexander regularly sees, but they exist, and if someone is able to live a normal life if and only if they have a regular dose of heroin, then how is giving them a reliable, clean dose ‘writing them off’? Heroin doesn’t even have the physically damaging qualities of alcohol; if you get too much, you overdose and possibly die, and if you get impurities then that can harm you too, but as far as I understood, the medical consensus is that heroin has basically zero chronic toxicity, and the irregular dose and impurity problems are solved by having medical-grade quality, accurately labeled quantity doses (which the medical profession can provide but the illegal market can’t) – so prescribing someone a long-term dose, even a lifetime dose, is not that different in principle from prescribing long term insulin to a diabetes patient.

          [Disclaimer – I’m not trying to claim that all heroin addicts can be fully functioning members of society; merely that some can, and that therefore I don’t understand why giving them a prescription is writing them off].

          • Harald K says:

            > It’s well recognised that people can be functional heroin addicts, requiring a daily dose in order to feel normal, but otherwise living an ordinary, productive and socially connected life.

            Is it? Especially a daily dose, that I have strong doubts about. The reason methadone is prefered over heroin for treatment (and burprenorphine is preferred over that again) is that it’s slower and lasts longer, as opposed to the quick spike of injected heroin. Even in countries with heroin disbursement, they typically use methadone instead overnight.

            The kind of user you describe – who basically only has a physical addiction, but one that he absolutely can’t break, or even switch over to opiates more compatible with a normal life – if they exist at all, they’re definitively not typical. But yeah, I’ll grant, giving those a heroin prescription would not be writing them off.

          • Heroin maintenance therapy

            The British have had system of heroin maintenance since the 1920s. For decades it supplied a few hundred addicts nationwide, most of whom were doctors themselves.

            It’s a small but definitely non-zero portion of all addicts.

          • Harald K says:

            I know about the modern heroin disbursement programs. It’s from looking critically at these programs that I think giving people free heroin is mostly writing them off as lost cases.

            This is the kind of topic they fight over at wikipedia, so I warn against using it uncritically. “40% of all patients and 68% of those able to work had found employment after four years of treatment. Some even started a family, after years of homelessness and delinquency” is a study in positive spin!

            I didn’t know about the historical British one, but it sounds pretty crazy to give heroin to practicing doctors, especially as opioid replacement is a thing.

    • Scott Alexander says:

      I believe the rule around here is we keep proposals of genocide to Ozy’s Open Threads.

      • Vulture says:

        I thought that was just race-and-gender-in-open-threads? I’m not sure how I feel about general topics (especially in cases like this, where they are relevant) being deported there.

        • Anonymous says:

          Well, that’s why Scott’s the Blog Czar and not you 😛

          There are certain things that are simply too horrible to suggest in polite company. I think most people would agree that genocide is one of those things.

          • Harald K says:

            Yeah, blech. Give the neoreactionaries a finger, and they take the whole hand.

          • Vulture says:

            There are certain things that are simply too horrible to suggest in polite company. I think most people would agree that genocide is one of those things.

            Oh, I know. *Sigh*. It’s just a little bit depressing that this blog is now polite company. I do like the aggressive contrarianism.

      • Frog Do says:

        Should I assume for the future that the death penalty as equivalent to genocide as a general rule for this blog? I am not attempting sarcasm.

        • Generally when you’re using the death penalty for a crime you’re doing it to dissuade other people from committing the same crime or to provide vengeance for the victim or the victim’s family and friends.

          Neither of these seem to make sense in terms of drug abuse since the damage caused by drug abuse is generally much less than the damage inflicted by the proposed punishment. Which makes me and apparently many other commentators think that your motivation is just to get rid of all the drug users per se because you think they’re not really people and might cause problems.

          But maybe you really do think that drug use is as bad a thing as someone dying, in which case the death penalty might make sense here in a non-genocidal way (though I think your values are screwy in that case). Or maybe you have some other reasoning that escapes me.

          • Jiro says:

            Another reason to use the death penalty against a crime is the belief that if you kill the criminal, the criminal is incapable of committing any more crimes.

            Sure, you could argue for life imprisonment (I have my own response to that but don’t want to turn this into a death penalty thread), but I think it’s unfair to refer to killing criminals to prevent them from committing crimes as “genocide”.

        • Scott Alexander says:

          I’m sorry. For some reason I didn’t interpret you as talking about the death penalty. I just pictured, like, people with machine guns busting into crack houses and opening fire.

          My mistake. Your idea is still terrible, but in a totally different way than I thought.

          • Frog Do says:

            Edited: Deleted because it was poorly written and more than a little (pointlessly) angry.

            I will try and phrase my questions better in the future, to get more of the “here’s what the effects of these foreign countries currently-existing drug policy is” and less of the “HOW DARE YOU, ADVOCATING GENOCIDE! WHAT ARE YOU, A FOREIGNER!” responses.

            Though, on a lighter note, I suppose both answer “Is this a WEIRD thing?”.

      • Lays says:

        Surely this is mere mass murder, not actually genocide? (according to most but not all definitions)

        • suntzuanime says:

          Depending on how you want to define genocide, we may not even be allowed to advocate for mandatory public schooling.

          There is definitely a culture of drug use that would be extinguished by killing all the drug users. But then, it would be extinguished by finding really good treatment for drug addiction too, so I guess there’s really no way around genocide (there usually isn’t).

      • roystgnr says:

        I thought he was referencing Theodore Dalrymple’s “greatest drug worker in history” bit.

    • Tarrou says:

      Singapore does this, I believe. They have very low rates of drug usage. Of course, this is seen as quite barbaric, but you can get lashes for defacement of public property, so they seem to believe in the hard road. It does have a reputation as one of the cleanest and best-ordered places around. But I’d personally rather live somewhere a little more lax.

      • Anonymous says:

        Singapore has more executions than murders, but how do we really know it has low rates of drug use? Of the ~5 people I’ve known who have lived in Singapore, one was a drug dealer.

      • haishan says:

        Singapore certainly kills drug traffickers quite readily, but not “just” users. I’m not actually sure what happens if you’re a Singaporean heroin addict and you get caught — do you just get thrown in jail and detox there?

    • Tom West says:

      ave we tried just straight up killing drug users?

      Why not the opposite? Minimal accommodation + food + as many free drugs as you want. Probably knock down the crime rate by 50% right there.

      My only question is what percent of the population would you lose?

      • Yes plus you can’t vote or have children and we give you free high quality video entertainment to keep you off the streets.

      • William O. B'Livion says:

        To (once again) quote Depeche Mode https://www.youtube.com/watch?v=ErnMC7xokQ8 (which has the odd military tie-in)

        So we’re different colours
        And we’re different creeds
        And different people have different needs

        For over half of my life the only drug I really needed to function within spitting distance of “normal” was nicotine and the ritual of smoking.

        These days it’s 5mg of melationin and a whiskey or three at night. Oh, and Ibuprofen, my lovely lovely ibuprofen.

        Frankly I think it should be drugs at reasonable markup over cost and you can damn well take care of the rest of it yourself.

        But then I’m an evil anti-government hard case libertarian.

        In the Carboniferous Epoch we were promised abundance for all,
        By robbing selected Peter to pay for collective Paul;
        But, though we had plenty of money, there was nothing our money could buy,
        And the Gods of the Copybook Headings said: “If you don’t work you die.”

        If you reduce regulations to sane and rational you can greatly reduce the cost of housing and food so that even a pretty hard core junkie could work enough to get his drugs, and of course under this regime one could *easily* afford their daily doses of Suboxone while working as say Customer Service Representative for Comcast, or some other morally degrading job that would almost require drugs to get through.

        As much as people whine about the cost of living these days, if you live in a sane city (Say, Denver or Portland compared to NYC/SF/Chicago) you can work pretty menial jobs and still make enough for a SRO or a sharing a room.

        The problem, of course, is that many drug users are drug users for a reason, and that reason makes it hard to develop stable, er, habits.

        • Multiheaded says:

          Look, I might be a commie, but here I happily refer you to Tyler Cowen’s “Zero Marginal Productivity” argument. The “marginal” bit is important: if an employer sees that 9/10 employees who fit a certain profile are likely to generate $15k of added value a year while being paid $10k, but the remaining 1/10th are likely to cause $50k of damage… that adds up to ZMP. Which means that not even menial employment would make economic sense, not even with wage subsidies, which are icky in any case.

          All that is perfectly fine by me: just give all people a liveable basic income and let them sort the rest out themselves. The popular idea that people “need” to “earn” a living is confused, incoherent and immoral.

          • Princess Stargirl says:

            I agree strongly with the last part.

          • gattsuru says:

            The popular idea that people “need” to “earn” a living is confused, incoherent and immoral.

            I don’t think it’s true for literally everyone, but I’ve seen and myself experienced serious and significant negative effects from long term “being between jobs” (not strictly unemployment but close enough for government work). For a lot of people, a lack of meaningful and necessary schedule with external validation hurts, and the less social an animal you are, the easier it is to ball into yourself further. Even in countries with very generous social services (Canada, pre-2006 Germany), there’s a very strong tie between unemployment and depression. There’s also a multitude of studies show post-retirement effects from prolonged unemployment, even in societies that portray a comfortable retirement as paradise!

            You can argue that this is cultural and we should change the culture, or that there are other solutions (/some/ people can take MMO-like structures as a fix, but this doesn’t seem to work for most), but even if there is such a solution we need to test its implementation well before rolling it out on a larger scale.

            ((This is also before we get to the merely social issues, like employment’s tie to high status in most modern societies, or inevitable gray- and black-market environments inevitably produced by social services.))

      • Jon Gunnarsson says:

        The problem with this solution is that it might well induce more people into becoming drug addicts in order to get free stuff.

    • William O. B'Livion says:

      They do that in a lot of eastern nations (look at the penalties in Singapore for drug possession), and all it really does is raise the cost.

    • Anonymous says:

      I hate when communities of smart (and therefore contrarian) folk attract people who like saying ridiculous human decency violating things that they’d never actually do in real life just to sound edgy.

      So I guess I’ll say the obvious, true, stupid, necessary thing: No, we haven’t tried that because it is evil.

      • William O. B'Livion says:

        But the problem is that *some people* have tried it, and it doesn’t f*king work.

        Most of us feel the need once and a while to get off, some do it with their friend Jim or Jack, some with a spliff, some go run 11 miles through the mountains or strap a board to their feet and throw themselves off the side of a cliff. Some shoot heroin.

        This is one thing that just pisses me the F*K off about my many of my soc-con brethern, they’re absolutely heads in the f*king sand about human nature. Oh, the left is too–in many ways far worse (and many so-called “social conservatives” are just religious progressives).

        We want sex and drugs, we want candy, not homework. But that way lies rack and ruin, or to quote Kipling again:

        On the first Feminian Sandstones we were promised the Fuller Life
        (Which started by loving our neighbour and ended by loving his wife)
        Till our women had no more children and the men lost reason and faith,
        And the Gods of the Copybook Headings said: “The Wages of Sin is Death.”

        Many of them will tell you–cigar and scotch in the same hand– that drugs are bad and you shouldn’t do them.

        And they’re right. The CDC claims “Excessive alcohol use led to approximately 88,000 deaths”, (I’ll leave out my editorial about the CDC) and the “CDC calculated annual heroin and OPR death rates per 100,000 using bridged-race population estimates†”

        But it’s your life. YOUR LIFE. If you want to spend it in a drug induced haze, as long as you don’t expect me to fund it, have at it.

      • I emphatically (and phatically) agree

      • drunkenrabbit says:

        I mean, given the example of Singapore, which has draconian anti-drug policies but is still considered a member in good standing of the international community, I wouldn’t say that the suggestion is totally beyond the pale.

    • Doug S. says:

      have we tried just straight up killing drug users

      It worked in Maoist China. Some ridiculous percentage of people in pre-Communist China had become opium addicts, thanks to the British Empire…

      • David Hart says:

        To be fair, Maoist China did a lot of straight-up killing anyway. I kind of feel that
        a) your baseline rate of opiate dependency should not be calculated on the assumption that you have a powerful external empire actively trying to get your citizens hooked (since that doesn’t hold), and
        b) your post-intervention rate of opiate dependency ought to have counted against it the number of people directly murdered by the government, or starved as a result of government negligence.

        The question is: are there any good examples of countries that manage to use the death penalty to minimise opiate use without either being under a regime so tyrannical and chaotic that no one could honestly wish to implement it, or being a small, very rich, densely populated and relatively easy-to-police island.

        I’m not well-placed to go on a deep google quest right now, but if contemporary China still has enough of a drug ‘problem’* to be executing hundreds of people for drug offences every year, then we are entitled to be skeptical.

        *Of course, the sort of people who advocate killing people who use drugs tend to be very bad at, or actively opposed to, distinguishing between problematic use and non-problematic use, often denying that non-problematic use is even possible. I would propose that any policy that reduces harms to would-be problematic drug users ought to have deducted from its calculus any harms imposed on non-problematic drug users.

      • That reminds me… I have seen a claim that “…the British-induced Opium Wars in China and the scourge of the drug, a tragedy created in the name of ‘free trade,’ caused far more deaths over time than Mao’s revolution and his regime ever did.”

        Out of what bodily orifice did that claim come from?

        • thirqual says:

          It does depend on how far you are willing to stretch “the consequences of the Opium Wars’, I suppose. Some scholars say they caused the destabilization of the Qing regime, and are the cause for the rebellions. The lowball estimate for the biggest one, the Taiping Rebellion is 20 milions casualties IIRC (Wiki says 20-50 millions), mainly civilians. There were other rebellions (the estimates for the Miao one are also several millions), famines due to the general unrest which are not easy to take into account.

          Total estimate for China in the well-known Black Book of Communism is 65 millions deaths.

        • Nornagest says:

          The Opium Wars had a lot to do with trade, but very little to do with free trade in the modern sense of the word. To oversimplify: the British East India Company wanted a trading partner in China, but China had a well-developed local economy at the time and wasn’t trading substantially in anything except raw specie, which Britain was reluctant to sell in quantity because it destabilized the metals-based currency system of the time. So the Company decided to create a trade good in opium, which was legal in Britain at the time (it was outlawed in China, but the ban was not widely enforced). This fostered opiate addiction in China (accounts of exactly how widespread this was vary) and created a trade imbalance in the opposite direction. China attempted to enforce its ban by blockading opium ships, and the British government then broke the blockade by force and imposed highly favorable (not “free”) trade terms on China in the aftermath.

          Direct casualties were relatively light, but the event was one of many that lead to the exceptionally messy breakup of the Qing dynasty over the next seventy years or so.

  5. Sniffnoy says:

    At this point I think our best option is to ask the paraconsistent logic people to figure out something that’s neither government nor not-government, then put that in charge of everything.

    You want intuitionistic/constructive logic; paraconsistent logic will give you something that’s both government and not-government.

    • RCF says:

      But according to paraconsistent logic, we cannot conclude from the fact that it is both government and not-government, that it is not also neither government nor not-government.

  6. DanielLC says:

    “but the best guesses by outside observers is that about 80% to 90% of their graduates relapse within a couple of years. Even this paints too rosy a picture, because it excludes the people who gave up halfway through.”

    Does it? Some of them will quit in the next couple of years. I wouldn’t be surprised if including them improved things.

  7. drunkenrabbit says:

    Tight-knit communities can be functional or dysfunctional. Conservatives admire networks of social support and control in Amish country, but not in Jonestown.

    If I had to hazard a guess at the main differences between functional and dysfunctional communities, I’d say,
    1. Functional communities are hierarchical, but dysfunctional communities are despotic. Places like the Army or the aforementioned Amish have people with stakes and responsibilities at every level, whereas cults or cultish treatment programs have an individual or small inner circle dominating an undifferentiated mass of cowed subjects.
    2. Functional communities have reasonable goals and make allowance for human weakness. They know that whatever their goal is (elite fighting force, pious religious community) can’t achieve perfection, so there’s sliding scales of punishment and reward, and an understanding that fuckups will happen. Dysfunctional communities have unrealistic expectations, and if someone isn’t toeing the line perfectly then they’re a menace that needs to be purged.

    I don’t think the tight-knight community model is especially useful for rehab, because for tight-knight communities to work, they need to be participatory, and most people in rehab are capable of participating in their own treatment and the treatment of those around them (I know very little about rehab, I could be wrong about that).

    • Tarrou says:

      I’d add that these communities need a goal that binds them together. To the degree that the BS groups work, it is this goal of getting clean that drives it. But just getting back to a normal life isn’t much of a goal, and once achieved, there is no longer a need for the group.

      Upon reflection, I think it is that successful communities have unrealistic goals, which can never be achieved. Breaking addiction is too simple. This is why AA probably has their “once an addict always an addict” line. In religious communities, everyone is imperfect, a sinner. In the military, the country will never be totally secure, there are always threats. Hence there is always a struggle for an unattainable perfection.

      • William O. B'Livion says:

        AA has “once and addict always an addict” because with many alcoholics “one drink is not enough, two is too many”. It’s not a struggle for perfection, it’s a struggle to resist the siren song of oblivion.

        The military strives for perfection, not because “the country will never be totally secure”, but because very few officers and senior enlisted are sociopaths, and they want their men to survive contact with the enemy, thus the constant goal of a little faster, a little smoother, a little more accurate.

        There is a saying about combat/fighting. You do not rise to the level of your training, you sink to it.

      • drunkenrabbit says:

        I mean, having an unrealistic goal probably helps, but genuinely expecting that goal to be realized and attempting to punish people when they fail to do it is disastrous. A 1SG who wants a perfectly clean barracks and a 1SG who revokes leave when there isn’t a perfectly clean barracks are worlds apart.

  8. Tom Hunt says:

    On “The value of ritual and community”: Perhaps one of the factors is simply that when you take a group that is 100% selected for being criminals, they’re worse at pretty much everything. I would venture that if you reinstated the older program of forcing them through a two-year (or whatever) Army hitch, it would have far better results, due to 1. a sizable contingent in the army of people with no more than average dysfunction, and 2. continuity with a longstanding tradition of effective community, including cadre of authorities with experience (and who are working for a purpose that isn’t just “wrangle dysfunctional people”).

    On libertarianism, I would guess that there’s not actually a strong incentive in these programs to be effective. If they’re state-mandated, they’ll never lack for customers effectiveness or not, and there’s not necessarily the ability among their customers, to the degree to which there is a choice between programs, to select the ones which are best. (Or, for that matter, the desire; if, say, a program that was highly regimented and controlling showed the best ratings, it seems the desire among those court-ordered to attend any program would be to avoid it in favor of less-rigorous but less-effective ones. (Note also that I’m not saying that this relationship would actually hold; it’s just an example.)) It would be interesting to know what, if any, efforts are made to create incentives for successful treatment among these programs.

    Regarding society/biology, it certainly seems that this problem like most others has increased enormously over the course of the twentieth century. Was there actually a biological change? Because it does strike me as the sort of thing which “the qualities of the surrounding society” could have an enormous effect on, which would apply regardless of what local social incentive program people tried to create.

    • Wrong Species says:

      If we were living in a libertarian society then it wouldn’t even be an issue since suboxone would be legal. But then, so would heroin…

    • Tarrou says:

      The increase in the drug problem is the developed world being victimized by its own success. There have always been addicts, but the social and economic price for being one was so exorbitant that only the serious basket cases went that route. We’ve created enough of a social safety net that you can be an addict and not starve to death. And we’ve created enough surplus economic growth that even the poorest have abundant free time to need entertainment.

      These are all good things, but they lead to an increase in a lot of risky behavior, from “Xtreme” sports to drug usage. Think of it like the rise in cancer fatalities. We cured all the things that used to kill people, so now a lot more people live long enough to get cancer! We cured all the economic problems that used to kill people, so now they try to kill themselves!

      • Tom Hunt says:

        I would guess, off the top of my head, that drug crimes likely increased for pretty much the same reason all other crimes increased, over the course of the twentieth century. I’m not sure you could characterize that as “because of greater affluence”, though it’s difficult to tease out exactly why it was. The neoreactionary case is that it’s due to a combination of social breakdown (causing more alienation) and governmental laxity (reducing the counter-incentives); IIRC Scott had a theory that it was yet another biodeterminist thing, maybe related to fatty acids or something. But it would violate Ockham to say that one factor caused all these other crimes to increase, while a completely different factor was responsible for the parallel increase in drug crimes.

        • Doug S. says:

          I like the leaded gasoline theory… I don’t know if it’s correct, but I like it!

        • Viliam Búr says:

          for pretty much the same reason all other crimes increased, over the course of the twentieth century

          Did they really?

        • Tarrou says:

          Given that drugs weren’t really regulated prior to the 20th century, and weren’t regulated much for the first half, and combine with the fact that many of these drugs were invented during the 20th century, and you have a big answer for why this “drug crime increase” happened. Before that, most of these drugs didn’t exist, and where they did, they weren’t illegal. Drug prohibition is a social failing to deal with a technological innovation. It is specific to modern times, because the technology to make a heroin didn’t exist two hundred years back.

        • Tarrou says:

          Also, all other crimes did not increase over the course of the 20th century. Property crimes have dropped heavily, violent crime was low, rose drastically, then dropped again. Sex crimes plateaued for a long time (accounting for reporting disparities over time), then dropped. There is no general rise in all crime to be explained.

  9. Daniel says:

    I think any community has a “carrying capacity”, a maximum rate of new arrivals or disruptive members it can acculturate to its norms. A country that can handle 1% immigration per year might collapse under 100% immigration per year. An army that can easily train 5% new arrivals per year will lose both morale and effectiveness at 50% new arrivals per year.

    Drug rehab groups probably have a low carrying capacity and a high rate of new arrivals. They represent a very challenging test for “solve this problem by introducing people to a community,” because the community isn’t especially strong to start with *and* it has lots of new arrivals at any point.

    Also I think drug rehab groups have an “anti-inductive” membership problem. The better you respond to social suasion against using drugs, the less likely you are to need to be in or have to stay in a drug rehab group.

    So where most social groups attract the most perfectly aligned members and expand outward, drug rehab groups are tailored for some of the least perfectly aligned members.

    • Tarrou says:

      Interesting…..

    • DrBeat says:

      This brings to mind an analogy to “the mythical man-month”, wherein it is said that adding more manpower to a late project makes it later.

      • fubarobfusco says:

        I would expect that depends on the sort of project. Brooks was writing about software engineering, not ditch-digging.

        Some sorts of project require greater coordination among the workers than others do, and adding another worker increases the amount of coordination required.

        (We actually observe the same thing in software systems themselves these days. There are many workloads that are highly parallelizable: adding more worker threads and more CPUs will speed the task up. But that doesn’t work if each worker thread has to communicate with all the others, or contend with them for a finite shared resource.)

        • DrBeat says:

          Actually, if you had a major ditch-digging project that was late, and you added a bunch more people to it, I would totally expect that to make it later. Everyone would be smacking their shovels into each other, nobody would know where to go, even less work would be done.

      • William O. B'Livion says:

        No matter how many women you add, it still takes 9 months to make a baby 🙂

        • JadeNekotenshi says:

          I know you’re being snarky, here, but isn’t that saying more about problems with fixed latency, rather than coordination overhead?

          (ten women can have ten(*) children in nine months, after all…)

          (*) – discounting multiples, stillbirths and all the other things that can ker-weird-ulate this number.

    • Harald K says:

      Yeah, this is one reason why I can’t share Scott’s outrage at the clinic that refused his suboxone patient.

      The problem is relapse. Everyone in drug treatment knows that, the drug addicts know it too. The physical addiction is trivial to beat by comparison. Just about every opiate addict has gone through withdrawal several times, willingly or unwillingly. What makes them addicts is that they start again.

      Someone who needs suboxone, can’t beat physical addiction on his own. Or at least, that’s what they (or his doctor) think. How easy is it to take part in a project where you try to motivate each other to stay off drugs, if you believe that even the physical part is impossible for you? (that belief may even be right, but that doesn’t help matters at the clinic.)

    • Anonymous says:

      Dunbar would agree with you.

    • Nathan says:

      That’s not anti-inductive. You’re not talking about a case of drug addicts resisting your attempts to understand them, you’re just talking about drug addicts being selected for negative qualities.

  10. Wrong Species says:

    Do we know why some exceed when the majority fail?

  11. The_other_guy says:

    A few thoughts here.

    First, it would probably be more appropriate to say that “our government ACTS LIKE a fricking idiot”. I strongly suspect that if you peel back the surface, you will see a pretty sophisticated network of lobbyists and interest groups pushing agendas that explicitly help make it easy for drugs like Oxy to be prescribed, and either (a) that first group maneuvering to disadvantage suboxone or (b) no large group doing much anything for suboxone. This need not strictly be driven by a profit motive… as you’ve identified elsewhere there may be religious institutions and other pressure groups pushing against suboxolone.

    Also, I would say the statement “People have tried everything to fix drug abuse” is a bit too extreme. To my knowledge, over the past decade people were working on developing a ‘cure’ for cocaine addiction… it is a cure in that for the active life of the injection (several years at a time?) the person cannot get a high from cocaine use. The injection can be thought of as a ‘vaccine’ against cocaine, if people prefer that analogy. I hope this drug is still under development though I’ve lost track of it.

    Additionally, in terms of classical conditioning, I don’t think we’ve tried anything loosely equivalent to Pavlov’s near drowning of dogs and other experiments to give them complete nervous breakdowns. There were questionable ethics with Pavlov’s experiments on animals… to do these things on humans seems outside the question. (Some may think of Clockwork Orange here.) If I am wrong about this, certainly let me know.

    By the way, The Economist ran an interesting piece on opiate addition in the US, a couple of months ago

    http://www.economist.com/news/united-states/21633819-old-sickness-has-returned-haunt-new-generation-great-american-relapse

    • Harald K says:

      To my knowledge, over the past decade people were working on developing a ‘cure’ for cocaine addiction… it is a cure in that for the active life of the injection (several years at a time?) the person cannot get a high from cocaine use. The injection can be thought of as a ‘vaccine’ against cocaine, if people prefer that analogy.

      Such promises have been common since disulfiram was discovered in the 1920s. They have always disappointed. You can give people an averse reaction to a drug, or block its effect, but the main problem an addict has is that he really wants the drug (or rather, an elusive and complicated feeling connected to it). You don’t stop wanting something just because you can’t have it. Often it’s exactly the opposite.

      • The_other_guy says:

        This is a very interesting point. My understanding of the (latest?) cocaine ‘vaccine’ was that for its useful life, it neutralized the euphoria associated with cocaine use completely and consistently — consistency over a significant time frame is quite important.

        This should be a victory from an operant conditioning standpoint. There may be lingering classical (or other) conditioning concerns here though.

  12. RCF says:

    “Rehab problems make every effort to obfuscate”

    replace(problems, programs)?

    “The (generally safe) treatment for addiction is more highly regulated than the (very dangerous) addictive drugs it is supposed to replace.”

    Huh? Is it easier to prescribe heroin than prescribe suboxone?

    “I’m not sure whether this represents a basic failure in the idea of tight communities, or whether it just means that you can’t force them to exist ex nihilo over a couple of months.”

    Surgery is an effective treatment for many conditions, but randomly poking people with knives is not.

    “This should be a perfect setup for a hundred different models blooming, experimenting, and then selecting for excellence as consumers drift towards the most effective centers.”

    There is a brand a libertarianism that says that markets always solve problems, but that thesis is not essential to libertarianism. Libertarianism just says that the government shouldn’t interfere with the market, not that there is no reason for the government to interfere.

    I wonder whether there are legal avenues towards challenging these programs. Could an ADA challenge be made against the “no drugs” policies? If a court orders someone into a program, and he only programs available are religious, then a First Amendment challenge could be made. Or make an Eighth Amendment argument against requiring someone to give up an effective drug treatment to stay out of jail.

    • Scott Alexander says:

      “Huh? Is it easier to prescribe heroin than prescribe suboxone?”

      This is a good question, and I can’t find the answer anywhere.

      In the UK, heroin is sometimes prescribed as a painkiller in special situations. I’m not sure exactly what the rules are there. In the United States, heroin is schedule 1, which means it is not considered a medicine and cannot be prescribed.

      Suboxone is, however, more regulated than a lot of other opiates like Oxycontin, fentanyl, morphine, etc.

      I was going to add “…and more regulated than cocaine”, but I think cocaine is a special case. It’s legal to prescribe, but in practice it’s only useful for certain very specialized anaesthetic uses in an injectable form – I think only in hospitals and clinics. I don’t think anyone prescribes oral cocaine to patients to take on their own. I’m not sure what would happen if you tried. Probably the pharmacies just wouldn’t have it.

  13. Steve Sailer says:

    Does this pill work for painkiller addiction too?

    • Anonymous says:

      Yes, all opiates. That’s why he compared the regulation of suboxone to the regulation of oxycodone, “the (very dangerous) addictive drugs it is supposed to replace.”

  14. What are the advantages of Suboxone over Heroin, aside from the fact that Heroin is illegal? My understanding is that medical grade heroin also has no serious side effects. Am I mistaken? That’s mostly based on a conversation with an apparently knowledgeable physician many years ago. He said the most serious side effect was constipation and that addicts usually went off the drug at (this is by memory) about forty.

    • Nesh says:

      Suboxone has a maximum effect strength which mean if you have already have sufficient opioid tolerance you can’t overdose on it, or generally speaking any other opioid with a lower binding affinity. But there have been Heroin based maintenance programs in other countries with decent success rates.

    • Harald K says:

      The side effect of heroin use is that it’s addictive. First in the “physical” (immediate) sense that you suffer painful withdrawals. As Scott explained, this is less of a problem with suboxone (and methadone) since they act slower. You keep the withdrawal problems away for longer on suboxone, and it’s harder to accidentally build tolerance.

      Second, in the “psychological” sense. This has little to do with the drug’s chemical properties, but works much like gambling addiction or gaming addiction or any other addiction. As you care more about achieving an elusive feeling, other things in your life that you care about tend to get pushed out. Realizing this is what causes many drug addicts to seek help.

      On suboxone, you will still have the latter problem – and yes, people “fail” in suboxone treatments too, seeking out drugs that will give them highs as opposed to just the maintenance dose that keeps withdrawal away. Still, since withdrawal pains are a great motivator to go out and satisfy your psychological addiction, keeping the former away may help with the latter.

      By the way, constipation isn’t as innocent as it sounds at heroin abuser levels.

      So to sum up subuxone’s advantages: Doesn’t give the same high, unlikely to give a psychological addiction by itself. Doesn’t help with the psychological addiction you already have, except by keeping the physical addiction at bay, but doesn’t make it worse either. Does not give crippling, vomit-inducing constipation.

    • Scott Alexander says:

      To repeat what some other people have said:

      1. Suboxone has much lower risk of deadly overdose
      2. Suboxone doesn’t make you high (and so is less addictive)
      3. Suboxone is oral (technically sublingual), which is safer than injectable
      4. Because of (2) and (3), you can prescribe suboxone to people without worrying as much that they’ll sell it on the street. A big problem with heroin maintenance programs is that you can’t just give addicts heroin, because a lot of them will sell it. That means they have to go to clinic every day, which is really annoying.
      5. Suboxone doesn’t show up on standard urine tests (!) so you can give suboxone but also check if they’re using other opiates, which is useful if they’re in some kind of probation program.
      6. Suboxone has a longer half-life so it feels “steady”-er.

      • What I was trying to suggest was not a maintenance program but legalization. In that context:

        1. The risk of overdose would be much smaller, arguably negligible, if heroin were legal. Quality control in illegal markets tends to be poor.

        2. A problem only to the extent that Heroin use is a problem, which is part of what I was asking about. One could, after all, claim that essentially the same problem exists for chocolate, ice cream, peanut butter, SSC, … .

        4. Problem vanishes if it is legal.

        So does 5 if “probation” means “for a drug use offense.”

        3 and 6 sound like advantages to Suboxone, but I am not sure they are adequate to justify a policy of making Heroin illegal and offering Suboxone as a substitute.

        • Harald K says:

          “The risk of overdose would be much smaller, arguably negligible, if heroin were legal.”

          Yeah, it’s a problem for drug users that purities vary. But no, control on that would not be nearly enough to eliminate overdoses.

          Take a look at the drug Scott complains is so easy to get/prescribe compared to suboxone: oxycontin. It’s not quite libertarian-legal, but it’s easy to get. It’s also produced according to pharmaceutical standards, so it has very predictable purity. Are there overdose deaths on it? Hell yeah! Tens of thousands of deaths, hundreds of thousands of emergency room visits every year.

          For a while, Norway had more overdose deaths from methadone than heroin. That was also for the overwhelming part pharmaceutically produced methadone, either diverted from maintenance/drug-assisted recovery programs, or used in them.

          The problem does NOT vanish if it’s legal. The case to study here is the tobacco industry and the alcohol industry. If you’re in these industries, you make most or all of your money on harmful and self-destructive use (yes, alcohol too). You make money by making people suffer, by convincing them to make horrible life decisions. If you don’t admit that, you’re going to be out-competed by those who do.

          • haishan says:

            For reference, in the USA in 2013 there were about 16,000 overdose deaths involving pharmaceutical opioids. (Source). I don’t know if these statistics include deaths from combined drug intoxication (opioid + depressant = bad time), and some proportion of them are intentional, but these are problems we’d still see with heroin.

            You could maybe make a good case that legalizing heroin will decrease heroin overdoses relative to the current level of heroin overdoses. It won’t reduce it to anywhere close to 0.

    • Anonymous says:

      DF: “What are the advantages of Suboxone over Heroin, aside from the fact that Heroin is illegal?”

      The biggest advantage of Suboxone over herion is that you can stop taking Sunoxone any time you want without getting sick. In effect, as long as Suboxone is available, physical addiction to opiates is not a problem.
      Perhaps those who oppose heroin on ideological grounds may also oppose Suboxone because it makes heroin less dangerous.

  15. Tmick.wtg says:

    Do you know anything about ibogaine? I have long wanted credible information about ibogaine.

    • Geirr says:

      One of my friends used to take it about twice a year, recreationally. They now take LSD instead and think it’s much better. The first four or so hours are like the worst hangover you have ever had, with added vomiting and massive paranoia and feelings of worthlessness. Then there’s a brief period of more or less normalcy followed by feelings of peace and euphoria. It’s a deeply moving spiritual experience.

      For more in the same line look up erowid.

      • MichaelT says:

        He means ibogaine for treating opiate addiction. There is some anecdotal accounts of it being very effective at doing this, but as far as I know there haven’t been any scientific studies on it due to its Schedule I classification.

    • Anonymous says:

      No studies, but I know one person who successfully treated addiction with it, and one who treated depression/general sense of meaninglessness. And one person I don’t really know but have met, who got severely depressed and didn’t leave the house for six months after taking it. I’d be very curious what his subjective experience of the trip was.

      I am really curious about it myself, because the trips I heard described were so interesting, but my intuition screams at me not to go near the stuff every time I think about it. And I’m unusually sensitive to hallucinogens and don’t dare mess around with them. I’d never go against that instinct. Presumably curiosity isn’t a good reason.

  16. JYJ says:

    This may be interesting context for SSC readers and those who work in (addiction, psychiatric, or internal) medicine in particular.

    Title: “Buprenorphine and Buprenorphine/Naloxone Diversion, Misuse, and Illicit Use: An International Review”

    “While the ultimate goal of substance abuse treatment is abstinence, opioid addiction is a chronic, relapsing medical condition. In this article, we take a harm reduction approach to analyze the use of buprenorphine and buprenorphine/naloxone by opioid users.”

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154701/

  17. haishan says:

    Pssh, like “the health care system not being very good at using medications effectively” isn’t something we discuss here a lot?

  18. Dumky says:

    You make it sound like competitive pressure should be very effective at raising the quality of treatment centers. What are your hypothesis to explain the persistent lack of quality?

    -Is it that the patients don’t have a choice or lack incentive to choose better centers?
    -Is it that short of using suboxone, all the other treatments are pretty ineffective?
    -Is it that people who realize the problem exist and qualified to do something about it favor putting their skills after solving some other problems?
    -Is it that quality is very hard to objectively measure in this area (it seems that relapse rate would be rather easy) or that the perceived quality by patients is something else altogether?

  19. John Schilling says:

    This should be a perfect setup for a hundred different models blooming, experimenting, and then selecting for excellence as consumers drift towards the most effective centers.

    It isn’t necessarily the consumers who are the relevant agents. Who are the customers? Who actually writes the many-thousand-dollar checks, and who is making the decision as to where the checks go?

    If the answer is that the addicts write the checks as an alternative to going to prison, and they go to whichever approved rehab center the addict chooses, then who writes the list of approved rehab centers, who decides which addicts have to write the checks, and who decides when they can stop?

    Whoever these people are, and I do not know but I suspect they are mostly not heroin addicts, they are the ones who are buying what the rehab centers are selling, and it is their demands that will be met. I would like to better understand what it is that these people want.

  20. Jim says:

    (in case you think maybe the government just honestly believes the drug is dangerous – nope. You’re allowed to prescribe without restriction for any reason except opiate addiction)

    “You’re addicted to heroin? That must be very depressing. Here, let me write you a prescription to help with that depression…”

    • Meredith L. Patterson says:

      That was my immediate thought — why not diagnose depression and prescribe suboxone off-label?

      • Scott Alexander says:

        While I’m sure this happens to some degree, the DEA are actually pretty competent when it comes to monitoring doctors, and if you make a habit of this I think they’ll figure it out and you’ll get in big trouble.

  21. Anthony says:

    This should be a perfect setup for a hundred different models blooming, experimenting, and then selecting for excellence as consumers drift towards the most effective centers.

    Except that specific government agents choose which centers various “customers” will be required to go to. And those specific agents (usually judges?) don’t necessarily pay attention to the research on the matter, often because warehousing addicts is only a small part of their job. Then there’s the insurance companies – if they’re willing to pay at all, they’re going to choose mostly using criteria like “how much does this cost, and how much liability are we setting ourselves up for if we send the patient there?”, rather than “does this actually work?”.

    I suspect that if there were treatment centers who only took patients who voluntarily chose to go there, and were paying their own way, that they’d evolve towards more effective models. Unless there were some other variable which led to higher revenues or profits. How effective *is* the Betty Ford Center anyway?

  22. david says:

    Singapore legalized suboxone as substitution therapy in 2002, with the (relatively liberal) Ministry of Health winning a surprise policy victory over the (relatively conservative) Central Narcotics Bureau. Initially it only required a prescription according to (non-binding) guidelines. It was a public policy and public relations disaster – it created an injection culture where it had been previously absent, the Singapore Medical Council proved unable to effectively discipline rogue doctors peddling large quantities of suboxone, and even requiring doctors to physically monitor individual sublingual administration and register each prescription (to prevent doctor-hopping) could not control illicit sale/diversion. In 2006 buprenorphine (suboxone) was discontinued and made illegal, even for monitored rehabilitation under detention.

    There’s a lot of dispute over how exactly it went wrong, even in a relatively controlled policy environment, but I think it’s worth thinking about which organizations were designed to police what, and the support base they draw upon to do so. Medical councils are not well-placed to discipline rogue doctors; they are especially poor for enforcing discipline through inconvenient preventative monitoring rather than after-the-fact prosecution. The NGOs that focus on reducing the social impacts of addiction (theft, dangerous injection) find their focus harder, not easier, with illicit suboxone availability – suboxone does cost money, after all. The NGOs that focus on separating addicts from a social network/lifestyle of fellow drug abusers likewise finds their goal more difficult, even if all their clients are licitly on suboxone. The narcotics agencies resent having to distinguish suspicious-behaviour-due-to-illegality and suspicious-behaviour-due-to-social-censure-of-legal-addiction, since they depend on such rough heuristics to identify problem spots.

    You’d probably have to create a whole parallel bureaucratic network to implement start-to-finish substitution therapy, but that’s just straightforwardly expensive.

    • Anonymous says:

      What’s that about an “injection culture”? Were people crushing the tablets and injecting them?

      • david says:

        Yes:

        4 In 2002, doctors began prescribing buprenorphine hydrochloride or Subutex to opiate-dependent drug abusers to aid them in their recovery. Over the years, we observed that instead of helping to “reduce” their addiction, Subutex actually fuelled it. Far worse, addicts abused Subutex intravenously by mixing it with sleeping pills and other drugs. The emergence of a needle culture, something which we did not see even at the height of the heroin abuse problem in the 1970s, was cause for public concern. Much remedial effort on the part of the Government and the community was expended to stamp out Subutex abuse, including requiring Subutex-dependent addicts to go for rehabilitation.

        Hence the later (insufficiently effective) shift to in-person monitored administration.

        I’m aware that there are technical ways to discourage illicit needle usage, or to make their use safer, but these encourage a sub-industry in ingenious unsafe workarounds and are less desirable than simply not having an underground injection culture.

        • haishan says:

          Isn’t this why manufacturers today combine bupe with naloxone? To make it hard to get high from injection? This seems like a solved problem to a great extent.

          Ed: oh, I guess this was already pointed out. Meh.

    • Raoul says:

      My understanding is that the difference between Subutex (as apparently used in Singapore) and Suboxone is that Suboxone also contains naloxone to discourage injection (see Wikipedia or http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154701/). (Admittedly I have no idea how effectively it discourages it.)

    • Scott Alexander says:

      As Raoul said, actual suboxone is not injectable. When taken orally, it is pretty hard to get high on – it’s a partial agonist, which means that if you take 20 mg, 50 mg, or 500 mg, it’s going to stimulate the receptors the same amount, which is usually below the “high” threshold in most opiate-exposed people.

      • david says:

        The absence of a high for opiate-exposed people doesn’t seem sufficient to deter illicit distribution and associated problems, though, or for that matter the difficulties posed by licit users to doctors, NGOs, narcotics enforcement, etc. The group that unambiguously gains is pretty much just the group of opiate-dependent individuals who choose (or are legally bound into) substitution therapy.

        I guess it depends on one’s position. Outside government, one would lobby to place a greater priority on this group. Within government, however, the challenge is to craft a policy bargain that satisfies the concerns of a sufficiently large coalition of stakeholders whilst (ideally) placing the highest priority on this group that can be achieved with remaining political capital. Just saying “prescription should be easier” only exacerbates the concerns. The concerns of the other groups I alluded towards (heavy-touch regulation of doctors by other doctors, difficulties for NGOs in implementing their own goals in an imperfect world that requires imperfect techniques, difficulties for law enforcement in implementing their own goals in an imperfect world that requires imperfect techniques) are only rendered worse, the easier that prescription is.

        I am in no position to assess the empirical claim that naloxone is effective in deterring injection, but I should observe that naloxone’s effectiveness in deterring injections for opiate-exposed people would not deter its use as a gateway intravenous substance for non-exposed people, which is presumably exactly how an injection culture is imported from the West.

      • Harald K says:

        This is a point, and certainly a reason to prefer suboxone over subutex, but addict cultures are capable of quite a bit of clever chemisty when the motive is there. I have heard (but it’s hard to verify) that separating the naloxone from the burprenorphine is possible.

  23. caryatis says:

    “If I want to give out OxyContin like candy, I have no limits but the number of pages on my prescription pad. If I want to prescribe you Walter-White-level quantities of methamphetamine for weight loss, nothing is stopping me but common sense.”

    And the threat of criminal prosecution by the DEA.

    http://www.deadiversion.usdoj.gov/crim_admin_actions/

    • Scott Alexander says:

      By my understanding, DEA will prosecute you if:

      1. You give out opiates without actually seeing patients. I occasionally hear stories of doctors who basically have a thing where you walk in, say “I feel pain”, they give you a prescription, you walk out, all within five minutes. The DEA reasonably assumes at that point you’re not a real doctor, you’re just a person with an MD providing the service of opiate prescriptions for a price.

      2. You give opiates to people who have nothing remotely resembling pain or another indication for opiates.

      DEA doesn’t really police if doctors do a good job with their opiate prescriptions, they police when doctors stop being doctors and just use their position to exploit the system.

      • Phlinn says:

        I’m not sure the DEA is actually as trustworthy here as you think. It could be similar to the issues with bad cops in general, where if one bad decision is made at a low level the superiors back them all the way to the court. Richard Paey, for example, got higher doses of opiates in prison than the amounts used to convict him of distributing opiates. Which may be more of an issue with the legal definition of possession with intent to sell not involving any actual evidence of intent. The following is a better write up than I could produce myself.

        http://www.huffingtonpost.com/radley-balko/prescription-painkillers_b_1240722.html

        http://www.huffingtonpost.com/radley-balko/us-painkillers-abuse_b_1263565.html

      • I don’t know what if anything it means, but a psychiatrist told me that he expected to face DEA action and lose his license if he prescribed modafinil for depression–after all, it was off label.

        (So instead I paid him $400 to do nothing at all. Good racket he has going.)

        • Anonymous says:

          There is a legitimate concern that he could acquire a reputation as a pushover if he gives drugs requested by name to first-time patients. But he was probably lying about
          expecting prosecution for a single patient with an off-label scheduled drug.

  24. Daublin says:

    I don’t think your claim about rehab centers generalizes very well. For example, the Ford Clinic seems to use buprenorphine, which is the active ingredient of suboxone. As well, searching for suboxone treatment and/or suboxone rehab center turns up an absurb number of leads.

    That means your claim about market solutions is also not based on what is actually happening. I’m not denying the rehab centers that you have seen, and it’s interesting to read about it, but there seem to be centers out there that work more like you would like. They might be expensive, but expensive is different from unavailable.

  25. Blue says:

    It’s funny, because when I first read the Huff Po article a few days ago, my thought was back to “beware the man of one study” arguments, and that “Scott would probably rip their presumption to shreds, and show why this new wonder drug is somewhat effective, but the evidence is only as good as many other methods, including the rehabs this article denigrates.”

    Guess not. Guess sometimes there is a free lunch.

    ***

    When talking about conservative communitarianism, there are a lot of valid benefits and costs to that model, and I think the model is underdiscussed. But it’s really not a comprehensive solution.

    In particular, this sort of tribalism suffers from Ship of Theseus problems. Yes the *community* looks strong and happy, but it does this often by ejecting anyone who doesn’t fit, and ignoring their personal unhappiness. A rehab program might look like it’s making great progress after all — when they only see the faces of the people still in the program, and forget the dropouts or graduated recidivists.

    This is all well and good if you need a tight-knit group to accomplish something (like conquer an enemy, or put on a play.) It is likely to be successful. But if you are measuring “does it increase happiness”, you have to take account of all the people it failed and who are too easily forgotten.

    • gattsuru says:

      There do seem to be a small subset of patients that find buprenorphine and especially methadone “more” addictive than heroin and with worse predicted withdrawal effects, and this is well-enough known and described in drug culture that some addicts will refuse to take the partial agonists. It also shares many of the health risks that heroin does, especially a fatal respiratory mode when mixed with depressants, making it difficult to advocate in the wild for patients likely to drink alcohol.

      But the rehabs are very nearly ineffective, so the above really is praising with faint damns by comparison. Like e-cigs, they don’t have to be effective — they just have to not be as bad.

  26. Qiaochu Yuan says:

    I was reading two articles today and hoping that you’d write a post about one or both of them, and this was one! The other one is this one.

  27. John says:

    […] libertarianism. Also about the rehabs. They’re minimally regulated. There’s no credentialing process or anything. There are many different kinds, each privately led, and low entry costs to creating a new one. They can be very profitable – pretty much any rehab will cost thousands of dollars, and the big-name ones cost much more. This should be a perfect setup for a hundred different models blooming, experimenting, and then selecting for excellence as consumers drift towards the most effective centers. Instead, we get rampant abuse, charlatanry, and uselessness.

    Well, you say earlier:

    Problem is, a lot of these [rehab programs] are closely integrated with the social services and legal system. […] Judge says go to a treatment program or go to jail.

    Which tells me the rehab programs are not exactly private entities under a libertarian system; some portion of their customers are forced (under threat of being put in jail, which is physical violence) to attend. I would wonder also if the judge gives the defendant a list of approved or recommended treatment programs, in which case the programs’ real customer is the judge, or if geographical proximity is a very important factor for many of the patients (as you mention earlier), which would limit their choice…

    Generally speaking, a regulation can limit the damage done by some other government intervention. But I would say that the solution is not to introduce the regulation, but to eliminate the original intervention.

    • James Picone says:

      Surely people are forced to buy food, water and shelter under threat of dying of starvation/thirst/exposure? Similarly forced to buy medical treatment under threat of death.

      Obviously not a perfect analogy because you can grow your own food, collect your own water (well, in a pretty large chunk of the countries in the world), sleep out in the open under a bunch of blankets, or trade off maintenance medical care now against emergency medical care n years from now. That said, I think there’s still an argument that food, water, shelter and healthcare always have an element of compulsion in that they’re needs. If markets don’t work when there’s a compulsion to buy, then markets don’t work in those four cases.

      Although I guess the argument is that the customers here aren’t the addicts, the customers are the bureaucrats, and they don’t care much about effectiveness as compared to liability and ability to sell the rehab program to voters.

      • Lupis42 says:

        You got to the core of my reply in your last paragraph, but I’ll lay it out a little more fully:

        Markets tend to work when the entity gaining the benefit is making the decision and paying the price, and tend to fail when those three features are split, e.g. when the judge is making the decision and the addict is merely stuck with the benefit and price.

        I find this maps surprisingly well onto most politicized examples of market failure.

      • vV_Vv says:

        Surely people are forced to buy food, water and shelter under threat of dying of starvation/thirst/exposure? Similarly forced to buy medical treatment under threat of death.

        Note that food production, drinking water distribution, construction and health care are business sectors with strict quality regulations, various forms of certification requirements and often some forms direct government intervention.

  28. Pingback: On the abysmal state of current heroin addiction treatment | The Daily Pochemuchka

  29. Caleb says:

    But modern rehab programs seem like a really damning counterexample.

    It’s only a relevant counterexample if the conservative proposition in question is: “ALL rituals, and ALL tight communities are virtuous, regardless of their content. (norms, procedures, membership, ect.) Which is absurd. No one (on the right) argues that.

    “Ritual”, “culture”, “community”, ect. are not content-neutral categories when conservatives use them to describe virtuous social organizational principles. They are not saying that any form of “tight community” is virtuous. They are saying that certain types are, and they probably have something fairly specific in mind when they make that assertion. That you can point to both virtuous and degenerate “tight communities” can be seen as evidence FOR the actual conservative argument: Culture matters. Not just that it must exist, but that it must exist in certain, very particular, virtuous forms.

  30. BD Sixsmith says:

    If you read the article, you will see that this rehabs are trying their best to create a tightly-integrated religiously-inspired community…

    Conservatives tend to admire communities that have evolved over time rather than being forced into existence. You could take two random adults and two random kids and call them a family but it seems improbable that they have the value of a married couple with their own children.

    To be fair, that doesn’t let us off the hook, because while it might be argued that close-knit communities make it less likely that you will become an addict they might not have an answer for your addiction. People who subscribe to a constrained view of our nature should accept that communities as well as individuals are imperfect and special cases may require special treatment.

  31. Anonymous says:

    “People have tried everything to fix drug abuse. (…) Being unusually nice.” What is the most supporting environment anyone with a problem has ever been placed in? I still believe that there is a saint-like level of non-judging, non-pity and genuine appreciation for you as a person that people around you can have that would make you start behaving in your own best interest. It’s pretty hard for someone to stay unaffected though, when you are shouting at them because of the pain you experience. Usually the support is temporarily suspended at that point.

  32. Sarah says:

    Does the medical community have a special obsession with the evils of opiates?

    I’m not surprised that they freak out about “abusable” drugs, but I’m a little surprised that oxycodone and methamphetamine are easier to get than suboxone. Where does this come from? What makes opiates scarier than all the other addictive dangerous drugs?

    • Harald K says:

      Oxycodone is an opioid, so it’s not that. Most likely it’s that the pharmaceutical industry lobbies on behalf of their own proprietary products, but not others. Oxycodone is patented, suboxone has generic versions as of two years ago.

      • Anonymous says:

        So you would predict that Suboxone only ran into troubles a couple of years ago? Is that true?

        It is true that no one makes a generic drug to compete with OxyContin, but the patent situation is complicated. Oxycodone is a century old and is available in many formulations. OxyContin, an extended-release formulation, was approved by FDA in 1995, so it must be off patent by now. The manufacturer keeps adding anti-abuse mechanisms, so the current formulation is patented. But it is not clear to me why no one makes a generic version, perhaps by adding their own anti-abuse mechanism.

        Another hypothesis along these lines is that OxyContin is marketed to old, hence, rich people, while Suboxone is for addicts, probably poor. Or that medicare pays more than medicaid.

    • Elissa says:

      Oxycodone is an opioid. It’s not that. Best I can tell, people are worried about suboxone because of some combination of it’s newish, it has a long half-life, and it’s being prescribed to people who we know to abuse drugs.

      • Harald K says:

        “it’s being prescribed to people who we know to abuse drugs”

        This is not entirely unreasonable. If suboxone has abuse potential, I guarantee you that the experimental addict community will find it.

        As for the countermeasures drug companies come up with, I wonder how much they actually believe in them, and how much it’s about “good enough to convince regulators to allow a laxer control regime”, or “good enough to get a new patent”.

    • Scott Alexander says:

      As the other two said, but also: people are much more okay with giving sick people drugs that happen to be addictive, then with giving drugs for addiction. When methadone first came out, there was a big outcry along the lines of “You’re going to use our tax dollars to give heroin addicts their fix?!” Think the objections to the clean needle exchange program, except now those needles are full of opiates. Methadone treatment is still underused and controversial for this reason. Suboxone, which is kind of next-generation methadone, has inherited this suspicion, and so when it got approved, it was only through a political compromise where it would be very heavily regulated.

  33. vV_Vv says:

    My love-hate relationship with libertarianism. Also about the rehabs. They’re minimally regulated. There’s no credentialing process or anything. There are many different kinds, each privately led, and low entry costs to creating a new one. They can be very profitable – pretty much any rehab will cost thousands of dollars, and the big-name ones cost much more. This should be a perfect setup for a hundred different models blooming, experimenting, and then selecting for excellence as consumers drift towards the most effective centers. Instead, we get rampant abuse, charlatanry, and uselessness.

    Well, I’m not a libertarian, but I can note that rehabs have a relative lack of freedom of purchase, they have information asymmetry and perverse incentives (a rehab center that largely reduced drug addiction in its area would kill its own business). These are conditions far from ideal free market assumptions.

    Some businesses, such as health care, law enforcement, fire fighters, etc. also operate under similar conditions, and in fact they are either highly regulated or entirely state-owned.

    On the other hand, when the government rode in on a white horse to try to fix things, all they did was take the one effective treatment, regulate it practically out of existence, then ride right back out again.

    Keep in mind that the government may operate according to values that are not necessarily your values.

    As a doctor, your main goal is treatment of individual patients. As long as a patient has no symptoms that cause them discomfort or interfere with their normal functioning, you have achieved your goal, even if they need a relatively expensive therapy for life.

    The government has to trade the welfare of drug addicts with other values, such as the financial cost of therapy and some deep moral intuitions of large segments of the population that consider drug addiction immoral by itself, or consider using taxpayer money to fund therapy for drug addiction immoral.
    Therefore, the government wants to minimize the number of people who become drug addicts to begin with, even if this requires throwing under the bus a large number of drug addicts so that they live a shitty and short life which supposedly acts as a deterrent for more people to become drug addicts.

  34. stillnotking says:

    What’s the anti-suboxone argument? Just that it’s replacing one addiction with another? If so, isn’t that an entirely Pavlovian response to the word “addiction”? Not all addictions are equal. I’m addicted to caffeine — I get headaches without my morning coffee. But I’m not going to seek treatment for it, or even see it as a problem, because coffee is cheap, plentiful, harmless, and delicious.

    It seems to me that replacing a harmful addiction with a harmless one is about as close to a free lunch as it gets.

    • caryatis says:

      I agree, but there’s more to the anti-suboxone/methadone argument. I think the Dalrymple article someone mentioned is relevant. Sometimes people sell the substitute drug, sometimes they take heroin when they can afford it and the substitute when they can’t…in other words addicts who take anti-withdrawal drugs don’t magically become non-addicted, nor do they become non-criminal, productive members of society. Some sort of moral choice, as Dalrymple might put it, is required before they are going to truly change their lives.

      http://www.dailymail.co.uk/health/article-476208/Heroin-addiction-isnt-illness–stop-spending-millions-treating-it.html

      Edit: So when Scott says that drugs deal with the physical half of addiction, leaving the psychological half up to the addict…he’s right, except that the psychological part is way more than half. Hence why people who are sufficiently psychologically motivated can stop using heroin without the drugs. Becoming and staying addicted is a choice, which can only be reversed at an individual level.

  35. Arthur B. says:

    Rehab centers who get customers by court orders issued for victimless crimes fail to offer a highly regulated treatment… and somehow you see this as a shortcoming of libertarianism o_O? Sure, those centers still have room to compete and offer better treatments, but they may simply be trying to appeal to judges, not addicts.

    I don’t want to play: “ah but not true libertarian society” here, but this not exactly the best example of a shortcoming of the free market.

  36. onyomi says:

    Are these profitable rehab centers accepting government money of any kind, either directly or indirectly (medicaid, etc.)?

  37. Jos says:

    I wondered why some docs are dropping out of Medicaid and selling suboxone for cash – it didn’t make much sense that people were paying cash for a drug that supposedly didn’t even get them high.

    I didn’t know the story on limited supply – thanks!

  38. aesthete says:

    “modern rehab programs seem like a really damning counterexample. If you read the article, you will see that this rehabs are trying their best to create a tightly-integrated religiously-inspired community of exactly that sort, and they have abilities to control their members and force their conformity – sometimes in ways that approach outright abuse – that most institutions can’t even dream of. But their effectiveness is abysmal.”

    I don’t see why it would. There aren’t a whole lot of effective approaches to homelessness or mental/substance abuse problems besides, as you say, treating the problem directly as opposed to via society. Conservatives would not suggest that all problems (or even most problems) are fixable via these institutions; merely that they work well for resolving a certain set of problems over liberal institutions.

    “This should be a perfect setup for a hundred different models blooming, experimenting, and then selecting for excellence as consumers drift towards the most effective centers. Instead, we get rampant abuse, charlatanry, and uselessness.”

    Consumer choice is highly decoupled from where the money goes, vis a vis rehabs. It’s not a very good example to use for the same reason that private prisons aren’t.

    That said, the naive libertarian response to deregulate is silly in this instance.

  39. Patrick says:

    Have to say, kinda amused by the passive voice re supply and demand increasing price when supply is restricted.

    The actual method is that you or those like you, probably via the institutions you work for or the pharmacies with whom you interact, know that if you can only sell X of a product, you might as well price it at the highest price that X permits on a supply/demand curve.

    These things don’t just happen by magic. Maybe you’re not to blame; maybe no one is to blame. But the mechanism is still the profit motive of an identifiable group of people. And acknowledging that is just as important to understanding the medical system as is anything about the FDA.

  40. The American Drug Distribution Cartel is a power political force in the USA. Never heard of them? Of course not, they are a very careful, covert organization. How powerful are they? Of the $500 billion spent on recreational pharmaceuticals in this country every year, 10% goes to the wholesale importers. So all that hype you hear about the powerful Latin American drug cartels is just that. The real power is right here in the USA, and that’s why getting anything changed regarding drugs is dang near impossible.
    Is any of this true? Well, I don’t have any sources, but I’ve been looking around and this is best theory I have been able to come up with.

  41. Pingback: 1p – Suboxone appears to effectively treat heroin addiction – blog.offeryour.com

  42. Bram Cohen says:

    Ibogaine is a very promising drug for treatment for heroin, and is of course schedule 1. Do you have any thoughts on that drug?

  43. Bram Cohen says:

    Any thoughts on straight up buprenorphine vs. suboxone? Suboxone is buprenorphine plus another drug to blunt it, and buprenorphine was schedule 5 until right before suboxone came out, at which point it was rescheduled to 3, the time of which was of course entirely coincidental and not in any way suspicious.

  44. Anonymous says:

    A bunch of self-funded, unaccountable rehab programs turn out to be mostly unable to change behavior? I hope none of them give up and close down, because then we’d have to declare heroin addiction biologically determined from birth. The Supreme Court may have to decide whether heroin users are a protected class and if they should thus be immune to laws deemed to possess ‘animus’.

  45. Albatross says:

    Not taking the rehab industries side, however I would think that rehab places that serve heroin addicts are going to be in communities with very low access to doctors, therapists and mental health specialists. Do they ban drugs like suboxone because they don’t believe they work or because they know they have no chance of getting a suboxone approved doctor? How many doctors would they need? How many properly trained professionals would they need to hire to do a good job? Guessing that most of these highly trained medical professionals the rehab industry needs to hire already have high paying jobs. Yes, the govt should deregulate suboxone. And they also need to get thousands more doctors for rural and poor communities. If these rehab directors need to drive 30 miles to talk to a pro-suboxone doctor the treatment will never catch on.

  46. Jim says:

    “The Army, which essentially hazes people with boot camp, ritualizes every aspect of their life, then demands strict obedience and ideological conformity, is a good example.”

    This certainly doesn’t comport with my experience of basic training (NOT Boot Camp! That’s what the Marines do. But you’re a civilian who doesn’t know much about these things, so it’s close enough.) Basic training is not hazing, it is re-enculturation. Recruits come out a market society and their Ferengi-style, looking out for number one cultural values don’t fit in the collectivism of the Army.

    “ritualizes every aspect of their life,” – this is just another way of saying they conform to new cultural norms. All cultural norms are ritualistic, including the ones that are so familiar that you think they are just natural rather than ritualistic.

    “then demands strict obedience” except where it legally demands disobedience, as in the face of an illegal order. But even in other less fraught situations. Subordinates are expected to voice their objections right up to the point the decision is made. In fact it’s considered something tier owe their boss. and even after the decision is made, it is followed for the good of the group, not for the leader’s sake. And by the way, if that decision turns out to have been stupid and results in disaster, there is always the threat/corrective measure of fragging.

    And as for ideological conformity – just no. Soldiers, all ranks, are supposed to have no ideological or political positions, comforming or otherwise, that would get in the way of carrying out their oath. They are supposed to back no side in domestic politics. The secret ballot is a thing, but then again, soldiers vote in very small numbers anyway.

    • Anonymous says:

      They are supposeto not take sides in politics? But soldiers have the vote. The military vote is an issue in elections.

      • Tarrou says:

        Of course soldiers can vote, although few are able to given operational constraints, and the Dems usually find a way to suppress them, because the military votes heavily Republican. What soldiers cannot do is campaign as soldiers for a specific candidate or issue. You can’t wear your uniform in an advert, you can’t identify yourself as a soldier supporting a particular party or candidate. Soldiers are welcome to their private political opinions, and to vote based on these (votes which will be put on the proverbial slow boat to china and never counted, but there you are). They are not welcome to use the aegis of the military for political advantage.

        • Jiro says:

          If the votes of soldiers are never counted (either literally or defacto), why would the Democrats bother trying to suppress them?

          • Anonymous says:

            the two points are synonymous. the votes are not counted because the democrats acted for them not to be counted.

          • Tarrou says:

            There are two systems here, the bureaucratic incompetence of the Army (one election while I was in saw all the votes from Europe be placed on a ship and safely delivered stateside, two months past the deadline). The other is that certain political parties who traditionally receive less than 20% of the military vote trundle through lesser bureaucratic mistakes to disqualify any that sneak through. While Al Gore was crowing about “counting every vote” in Florida in ’00, his lawyers were in court trying to get all the military bases thrown out.

  47. Eric Rall says:

    At this point I think our best option is to ask the paraconsistent logic people to figure out something that’s neither government nor not-government, then put that in charge of everything.

    I suggest Batman for this role.

    • Anonymous says:

      But how do we make Batman? I mean, every time people have tried, they invariably end up putting the Joker in charge of things, and then we get dynamite cakes instead of bat-justice…

  48. Anonymous says:

    Scott, are you familiar with this essay by another Alexander (hm, you have referenced other Scotts but have you ever referenced an Alexander?)? (What is the proper formatting for parenthetical questions within non-parenthetical questions?)

    The Myth of Drug-Induced Addiction (Bruce K. Alexander)
    http://www.parl.gc.ca/content/sen/committee/371/ille/presentation/alexender-e.htm

    • Anonymous says:

      Parentheses fully support nesting, so ‘?)?’ is a valid way to end a parenthetical question inside a non-parenthetical question. The trailing period or comma is usually omitted when you have a complete parenthetical sentence, because the closing parenthesis functions as a plain stop; any stop that carries additional content (‘?’, ‘!’, ‘…’, etc…) should not be omitted, because they transmit more information than just the closing parenthesis.

    • Anonymous says:

      indeed!

      sorry to break it to you Scott, but…

      psychiatric disorders and addiction are social problems not medical problems. the only thing that works is a change in the social environment of the mad man or addict, but this is a lot harder than pills.

      alcohol, benzo, and barbiturate withdrawal are medical problems however.

      the medicalization of social problems is just ideology, and you’re a commissar.

      • Scott Alexander says:

        People get depressed because of poverty and racism. Giving those people Prozac still helps just as much as it helps anyone else. It’s not a substitute for solving poverty and racism, but it does mean that until someone does that, poor people just have to deal with poverty and racism and not poverty and racism and depression.

        Likewise, suboxone works. Ending poverty might also work, but I can prescribe suboxone and I can’t prescribe ending poverty.

        Also, it’s kind of weird that all of these things which are purely social problems with no biological component at all tend to run in families, can be traced to particular genes, are worst in people exposed to certain infections in utero, et cetera.

        Learn about the biopsychosocial model. Every part matters.

        • Anonymous says:

          poverty and racism are two social problems. i meant “social problems” in the widest sense. basically every way in which modern life is different from the life of the primitive band.

          in the case of SCZ the “social problems” are, inter alia:
          1. the insignificance of the individual in large modern societies.
          2. the complexity of modern societies which makes understanding them difficult or impossible.
          3. the isolation of individuals in modern societies.
          4. the artificial diets and physical activity levels.
          5. the meaninglessness of so many activities which are socially required.
          etc.

          Diogenes would have made an excellent psychiatrist.

          that various psychiatric disorders or addiction are heritable is no more meaningful than that the Pima have the highest rate of diabetes type ii in the world.

          that is, it’s totally meaningless, blame the victim ideology.

          you should read Kaczynski.

    • Anonymous says:

      I would be extremely interested in Scott’s response as well.

  49. Mike says:

    Isn’t the problem with rehab the awful mix of government and private?

    Unregulated entities that governments (through the courts) supply with non-market forces contracts? Isn’t that kinda the heart of libertarian argument, that the confluence of government and business is what is truly evil?

  50. Steven says:

    This should be a perfect setup for a hundred different models blooming, experimenting, and then selecting for excellence as consumers drift towards the most effective centers. Instead, we get rampant abuse, charlatanry, and uselessness.

    If rehab doesn’t work, the market cannot deliver effective rehab, any more than it can deliver a perpetual motion machine. Blaming the market because it’s not omnipotent reality-defying magic is pretty irrational.

    Now, assuming rehab doesn’t work, we would expect that people who provide rehab services will witness evidence for that uselessness almost every single working day. Which means in the end, the only people providing rehab will fall into two categories. One group is the people who realize (at some point) that it doesn’t work, but are willing to stay in the business knowing they are engaging in charlatanry. The second is is the people so stubbornly committed to the idea of rehab they close their minds to the reality in front of them.

    Now, you’re trained in psychology; what sort of rehab would you expect to be provided by people in those two groups? Would it actually matter whether the rehab is organizationally a function of businesses in open market competition, or a monopoly government bureau, or churches and mutual benefit societies, or any other method?

    • Mr. Breakfast says:

      ” One group is the people who realize (at some point) that it doesn’t work, but are willing to stay in the business knowing they are engaging in charlatanry. The second is is the people so stubbornly committed to the idea of rehab they close their minds to the reality in front of them. “

      You missed the third group; people who come into the rehab cult as patients and buy into the promise of bourgeois bliss that is offered there only to find that the most promising avenue open to them is a career in rehab.

      AA and Amway have a lot in common, not least of all a comet trail of brainwashed working class victims.

  51. Eggo says:

    “(T)rying their best to create a tightly-integrated religiously-inspired community of exactly that sort”.

    I believe the conservative argument is that such communities grow naturally, and can’t simply be “replanted” like a clear-cut forest.
    Hence their conservatism re. smashing Chesterton’s fence; while a liberal might say “we’ll just rebuild it if it turns out to be important”, you can’t do that with communities any more than you can resurrect the victim of a mistaken execution.

    Getting excessively snarky here, but attempts to rebuild communities from atomized individuals usually end up putting everyone in orange robes, and I haven’t seen the local priest since the hippies burned their last wicker man…

  52. CzerniLabut says:

    I feel like Jason Cherkis could’ve pulled a Harry Frankfurt and turned his HuffPo project page into a 100 page short book. It probably would’ve gotten wider exposure that way.

    Also I bring up Frankfurt, because most religious based rehab programs, as well as FDA/DEA bureaucrats, provide a textbook example of his theory of Bullshit.

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  54. geoffrey says:

    Suboxone, like methadone, is a substitute for opiates such as heroin and Oxycontin. Main differences are that it is long lasting opposed to 4-6 hours for heroin and it is legal with a prescription. So the person addicted to a difficult to acquire and illegal and questionable as to its contents (heroin) can have something to fulfill most needs except getting pleasantly high and temporarily immune to the slings and arrows of outrageous stuff. So to analyze it honestly, we can come to the conclusion that it is one answer to the problem of addiction. Adding therapy and other forms of becoming mindful would be helpful. Being able to find work that is satisfying and financially compensated would also help. But we need to be honest about what we are doing.

  55. Michael Dubriwny MD says:

    Suboxone would put many rehab facilities out of business which provides a powerful incentive for opposing the use of Suboxone. Most motivated opiate dependent individuals can easily be treated outpatient with appropriate clinical support.

  56. Lavendar Bubble Tea says:

    I’ve heard that “Quorn” can provoke allergic reactions and has other issues. I can’t really comment on it since I’m not a mycologist or doctor but my reaction was “Scott, no! Quorn could be really bad!”

  57. Caelum says:

    When getting approval to do a study at my University using buprenorphine, there were initially a ton of obstacles, until the IRB found out that we just wanted to give it to healthy individuals to measure behavioral outcomes. They were less concerned about giving participants MDMA.

    Weird.

  58. Kim Brandt FNP says:

    Two other thoughts:
    1. Another part of the access problem is that for reasons never explained to me, nurse practitioners and physician assistants are not allowed to prescribe buprenorphine or Suboxone, for ANY reason. Even though we do a huge share of primary care and are allowed to prescribe all other scheduled meds including methadone, as long as it’s for pain and not addiction. Why and how to fix this?
    2. Depo-naltrexone has some good evidence for removing cravings and is NOT addictive, but exceptionally expensive.

  59. Mr. Breakfast says:

    Regarding treatment programs:

    We shouldn’t be suprised that a process does not produce a benefit when the people designing and implementing it are not incentivised to produce value in their “client”‘s estimation. Instead they are constrained to reinforce two unquestionable process endpoints:

    1) All people who take drugs not explicitly permitted by law are wrong/sick/bad/out-of-control.
    2) Such people are only redeemed (and their agency again respected) when they stop taking drugs entirely and permanently.

    These judgements come from nowhere at all, they are just soft-headed moralizing.

  60. Rodney Handsfield, M.D. says:

    Excellent comments from Dr. Alexander. As a practicing addictionologist I am dismayed by the inpatient addiction business and their cozy relationship with the insurance industry. The relapse (failure) rate of the thirty day “wonder” programs is close to 100 %, at least 50% within a month of discharge. Where is the “evidence based” evidence on which these ineffective treatment programs are based?

  61. emely says:

    I have nothing useful to add to the discussion, but wanted to note that even with all the regulation in place, it’s comparatively easy to get buprenorphine for my cats to treat pain.

    Nowadays the vet (or vet pharmacy) compounds it with various flavors – the theoretical abuser would have to be pretty fond of chicken or tuna – but as recently as a year ago they’d just send you home with vial of buprenex, although not in quantities sufficient enough to be of real street value, or provide therapeutic value to a human, without raising real questions as to why your cat needs a re-up every two days.

  62. Art says:

    SA: “On the other hand, when the government rode in on a white horse to try to fix things, all they did was take the one effective treatment, regulate it practically out of existence, then ride right back out again.”

    “Regulate it practically out of existence” is an exageration but making it expensive and less available is certainly causing a lot of harm.
    When I needed Suboxone, finding local doctors who could sell a prescribtion whas not hard.
    But they don’t sell them cheap. I had to pay $250 for the 10 day prescription, plus the cost of Suboxone.
    It was well wort it. Made withdrawal painless.

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  64. Julien Couvreur says:

    Along the same lines, you’ll be interested in Dr. Lance Dodes’s analysis of various rehab programs (AA in particular, but others like it too). He cites a 5 to 10 percent success rate.

    http://www.npr.org/2014/03/23/291405829/with-sobering-science-doctor-debunks-12-step-recovery
    http://tomwoods.com/podcast/ep-342-the-truth-about-the-rehab-industry-and-12-step/

    The part that is not clear is how much more successful are other treatment approaches (mainly psychotherapy).

  65. Jeanne says:

    To the author: You are correct, so write the drug ‘off label’ for depression and bypass the thirty-a-year limit.