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The Opioid Crisis Is About More Than Corporate Greed

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Zachary Siegel reports in the New Republic:

“Just like Doritos keep eating. We’ll make more.”

“It’s like people are addicted to these things or something. Oh, wait, people are…”

These lines are from emails sent between opioid manufacturers and distributors, recently pried loose by attorneys general suing Big Pharma for its role in fueling a massive wave of overdose deaths. Similar to the damning internal memos revealing that Big Tobacco knew that cigarettes indeed caused cancer, these emails appear to show that Big Pharma knew that a significant share of their product was landing in the street, feeding addiction. And yet they kept shipping out obscene quantities to rural towns across America, creating even more demand.

Nearly every step of the pharmaceutical supply chain is implicated in the soaring death rate. According to the Centers for Disease Control and Prevention, prescription opioids killed 218,000 people from 1999 to 2017. Many of the companies—from Johnson & Johnson to obscure distributors like Cardinal Health—are listed as defendants in hundreds of lawsuits filed by nearly every state in the country. The government thinks these corporations should pay up and treat the addiction their products caused. But the companies claim to have been acting legally and in compliance with federal regulators like the Drug Enforcement Administration (DEA). Was it all, technically, legal?

What the opioid crisis illustrates is not that there are a few bad apples in the pharmaceutical industry, but that the country’s entire health care system is driven by profit at the expense of public health and safety. Drug manufacturers, pharmacy chains, drug distributors, and insurance companies got rich while people, especially people lower down the income ladder, suffered—and the DEA, through neglect or incompetence or a mix of both, watched it all happen.


While there are significant similarities between Big Pharma and Big Tobacco, there is also a key difference that makes today’s story of corporate malfeasance even worse: namely, that the supply chain for tobacco is much simpler than opioids, which are, theoretically, tightly controlled substances that pass through a dizzying array of actors and regulators.

First, a doctor must write a prescription, which must be filled at a pharmacy, and is likely paid for by an insurance company. Depending on the needs of their customers, pharmacies place orders for these drugs (customers, it turns out, need a lot of them). Shipping companies then go between the pharmacy and the drug manufacturers. Overseeing this entire system is the DEA, which sets the quota for how many opioids a company is allowed to manufacture, and tracks where those pills go.

While politicians are making hay out of Big Pharma’s wanton greed and recklessness, far less attention has been paid to the DEA. Attorneys general suing Big Pharma recently unearthed a database that both the corporations and the government—each for their own self-interested reasons—fought to keep sealed, called the Automation of Reports and Consolidated Orders System (ARCOS). Mammoth in size and granular in detail, ARCOS tracks the shipments of every single controlled substance, from the company that manufactured it, to the company that shipped it, to the pharmacy that received it. It is the world atlas for how the opioid crisis began.

All told, from 2006 to 2012, roughly 76 billion oxycodone and hydrocodone pills criss-crossed America, according to a Washington Post analysis. While many of these pills went to legitimate patients, millions more were showered on troubled communities with a voracious thirst for pain relief. While drug manufacturers produced more and more opioids (approved by the DEA), and distributors shipped those pills to pharmacies all over the country (tracked by the DEA), drug companies saw record profits—and America’s overdose death rate soared off the charts.

“I think this [database] brings home what we all knew,” says Corey Davis, an attorney and public health expert at the Network for Public Health Law. “This wasn’t just incompetence on the part of the DEA and the Department of Justice, it was knowing and intentional failure to do what most people think is their jobs.”

What is the DEA’s job, exactly? Its first task, and the one most associated with the agency, is the Sicario-esque disruption of illicit flows of drugs coming into the U.S. from abroad, like intercepting speedboats filled with cocaine. Its other major responsibility is controlling licit pharmaceuticals. “The whole goal of the prescription system is to make sure that patients are getting their medications, and that medications are not going to those who aren’t patients,” which is called “diversion,” says Bryce Pardo, a drug policy researcher at the RAND Corporation. “That’s the whole point of the system, which was invented a hundred years ago. Clearly, the system broke. The system failed.”

Pardo points out, in the DEA’s defense, the story of a so-called DEA whistle-blower blaming a pharma-backed piece of legislation passed by Congress in 2016, which prevented agents from stopping suspicious shipments of opioids, and stunted investigations into the very corporations that are now being villainized and sued. Just as DEA agents were working their way up the pharmaceutical supply chain, much as they would in a case against any transnational crime organization, Congress hamstrung their enforcement efforts.

Or so the story goes—but that’s not the whole of it. “These companies, often times acting legally, were asking for preclearance from the DEA to go about their business,” says Leo Beletsky, a professor of law and health sciences at Northeastern University (where I’m currently a journalism fellow). “Now, the DEA is saying their hands were tied when, in fact, their hands were not tied. They were completely asleep at the wheel. And by the time the DEA began constricting the [prescription] supply and targeting certain doctors and distributors, it was too late.”


In drug policy scholarship, there is a concept called the “balloon hypothesis.” When one end of a balloon gets squeezed, the air inside, rather than disappearing, rushes to fill the other end of the balloon. The balloon hypothesis is used to describe, often critically, America’s drug enforcement strategy. If cocaine production in Colombia is stamped out, production will shift to, say, Peru. If the Dark Web’s Silk Road gets shut down, a new Dark Web market pops up. The air has to go somewhere.

The balloon hypothesis also applies to the ever-shifting demand for drugs. “Over a period of 20 years, the DEA provided the green light to a 39-fold increase in the oxycodone quota and a 12-fold increase in the hydrocodone quota, even as our opioid epidemic unfolded,” Senator Dick Durbin wrote in a letter to the editor to The Washington Post. 

In other words, the prescription balloon expanded, under the DEA’s watch, big time. But starting in 2011, the prescription market finally began to shrink after Purdue Pharma reformulated its blockbuster drug OxyContin with so-called abuse deterrent technology, and pill mills serving the black market were shut down. The supply was squeezed. The air still had to go somewhere, and it rushed to deadlier opioids like heroin spiked with illicit fentanyl. With enforcement focused on prescription opioids, the overdose crisis got worse.

Dan Ciccarone, a physician-researcher at the University of California, San Francisco who studies heroin use, says the crisis unfolded in three waves:  . . .

Continue reading. There’s much more, including some pertinent observations on reducing demand (which ultimately is the only solution).

The Four Ordinary People Who Took On Big Pharma

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Beth Macy writes in the NY Times:

In the beginning, there were just four: the Godfather from Philly, the Army sergeant from Georgia, the professor from California and the feisty mom from Florida.

It was the early 2000s, and they usually talked over old-school computer message boards. Occasionally they gathered in person, carrying posters of their children and middle-aged spouses — all dead from OxyContin overdoses.

Today we know just how dangerous this drug is. Purdue Pharma, the company that made OxyContin, the first extended-release opioid to be widely prescribed, may finally be held to account. Some 200,000 people have died from overdosing on prescription opioids, and around 2,000 lawsuits attempting to make opioid makers and distributors pay for the damage unleashed by careless overprescribing are wending their way through the courts. But experts predict it will take more than $100 billion to turn the crisis around, and it’s hard to feel optimistic when you know the story of how long and hard these four labored in obscurity before anyone listened to them.

The four called themselves RAPP, short for Relatives Against Purdue Pharma, and they testified at hearings, lent support at whistle-blower trials and marched outside pharmaceutical-funded physician meetings at fancy resorts. They were outgunned at every pass — by a pharma-funded phalanx of lawyers and by doctors who had become paid spokesmen for the company. One resort even turned a sprinkler on them. But they picked up new members by the week.

Their leader was Ed Bisch, an I.T. worker from Philadelphia who’d lost his 18-year-old son, Eddie, in 2001. They called him the Godfather because he’d brought them together in the first place, via his website, OxyKills, shortly after Eddie’s death.

Mr. Bisch had wanted to believe Purdue’s excuses at first. He was persuaded, even, to change the name of his message board to OxyAbuseKills, after the company approached him about softening his tone, then gave him a $10,000 grant to put toward his education efforts. “They kept blaming it on the ‘abusers,’ but finally I said, ‘Look, at least 50 percent of my emails are from relatives of peoplewho are patients who are either dead or addicted,’” Mr. Bisch recalled. “It took me a while to realize how evil this company was.”

Barbara Van Rooyan, a professor of counseling at Folsom Lake College in California until she retired in 2012, told Mr. Bisch recently that finding his website “saved my life and gave me hope that the grief could be used for some good.” Her 24-year-old son, Patrick, died after taking OxyContin at a Fourth of July party in 2004. “It’s kind of like a muscle relaxant, and it’s F.D.A.-approved, so it’s safe,” the friend told Patrick.

The following year, with support from RAPP, Ms. Van Rooyan petitioned the Food and Drug Administration to recall OxyContin until it could be reformulated to make it harder for abusers to crush or dissolve the pills for a more intense high; she also wanted the drug restricted to end-of-life care and to treatment of cancer and other severe pain. It took eight years before the F.D.A. responded by noting that Purdue had voluntarily reformulated the drug in 2010 (so that point was moot), and her restriction petition was denied.

By 2007, RAPP numbered in the hundreds. That August scores of them converged in the rain outside a tiny federal courthouse in Abingdon, Va., because they wanted “to look evil in the face,” as the Florida mother, Lee Nuss, put it. Three of Purdue’s top executives had flown in to be sentenced on misdemeanor misbranding charges. Purdue’s parent company pleaded guilty to a felony misbranding charge, admitting that for six years it had fraudulently marketed OxyContin as being less prone to abuse and having fewer narcotic side effects than competing drugs.

All four of the original members of RAPP spoke at the hearing. They knew one another so well by then that they car-pooled to Abingdon and doubled up in hotel rooms to save money. One of them, Ed Vanicky, had fed evidence to the Virginia prosecutors — including a now-infamous cassette tape of a public-relations conference in which a Purdue spokesman brushed off the problems of OxyContin in Appalachia by saying, “The fact is, these rural areas have had problems with prescription drug abuse since the Civil War.” (In other words, the hillbillies, not Purdue’s drug, were defective.)

Mr. Vanicky was an Army sergeant in 2000 when he found his 44-year-old wife, Mary Jo, in bed dead after taking OxyContin for a herniated disc. He had just returned home from a yearlong posting in Korea and had never even heard the word OxyContin until the coroner who performed his wife’s autopsy inquired about it.

As she stepped down from the Abingdon witness stand, the Florida mother, Ms. Nuss, brandished a small brass urn containing some of the ashes of her son, Randall, who was 18 when he overdosed on OxyContin. There was a metal detector in the courthouse, and her friends still can’t figure out how she managed to sneak in that urn.

In the end, the company was forced to pay some $634 million in fines. A pittance, compared to the billions it had earned on the drug.

That fine is still the largest paid by Purdue to date, and it would do nothing to slow the epidemic. Not a single executive went to jail, and none of the settlement money went to treatment. OxyContin sales surged in its aftermath, topping $2 billion in 2008.

When Purdue finally reformulated OxyContin to make it abuse-resistant, the pill-addicted switched to heroin and, later, fentanyl to keep their dopesickness at bay. Within another decade, nearly 400,000 people would be deadMore than 2.6 million Americans are now addicted.

Today, the group’s prescience is clear. But they are sad, and they are tired. They still believe the company’s owners, the Sackler family, and executives should go to jail. But more than anything, they want the judges overseeing the lawsuits to make sure Purdue and the family use their riches to guarantee Americans access to treatment.

Recent news of the company’s misdeeds — like the allegation from New York’s attorney general, Letitia James, that Sackler family members moved hundreds of millions of dollars into private or offshore accounts, paying themselves when they knew the company was already insolvent or close to it — only confirms what the four have long believed.

In March, Oklahoma settled its case against Purdue and the Sacklers for $270 million — in part because the company was contemplating filing bankruptcy, and the state feared bankruptcy claims would insulate it from paying restitution. That meant all the documents in the case would remain sealed — a fate RAPP laments because it allows the company to hide its tactics from public scrutiny, occluding the dangers of the drug. “I have been saying for years that sealing the lawsuits let them get away with murder,” Mr. Bisch said.

This summer Vanity Fair published a rare interview with David Sackler, grandson of one of the three brothers who founded Purdue Pharma, who said his family had suffered “endless castigation,” including the taunting of his 4-year-old at nursery school. With a tone-deafness reserved for people who can afford to surround themselves with sycophants, he told the writer Bethany McLean, “Look at all the good Purdue has done.”

Mr. Vanicky read the article and told me, “I bet it sucks to be a Sackler these days.” He has personally called the offices of many attorneys general to thank them for filing suit against the Sacklers and Purdue.

Now 72,  . . .

Continue reading.

Written by LeisureGuy

21 July 2019 at 3:27 pm

It’s bad when the government lies to the public: Most Heroin Addicts Didn’t Start By Being Prescribed Pain Pills, Despite Drug Czar’s Claims

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Philip Smith reports in Drug War Chronicles:

As part of its campaign to stem opioid addiction and overdoses, the White House Office of National Drug Control Policy (ONDCP — the drug czar’s office) has launched an education campaign called The Truth About Opioids, but some of the material it is presenting has more than a whiff of spin to it — and could imperil the ability of pain patients to get the relief they need.

The web site declares in big, bold letters that “80% of heroin users started with a prescription painkiller,” and highlights the words “80%,” “heroin,” “started,” and “prescription” in lurid purple. The graphic suggests that heroin users were prescribed opioids, developed a habit, and then went on to junk, with the further implication that a way to reduce heroin addiction is to tighten and reduce the prescribing of opioids.

The web site then asks readers if they are “shocked,” “ah-ha,” “outraged,” or “fired up” by the information. It is only if readers scroll down the page that they are informed that the basis for the statistic is a 2013 study of “Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers.” (Emphasis added.)

That’s right, even though the graphic shouts out that people prescribed opioids then went on to become heroin addicts, the science it uses to back its claim is about recreational pain pill users. That’s deceptive.

Misleading claims about prescribing opioids and the potential for opioid addiction are, of course, nothing new. Twenty years ago, PurduePharma infamously claimed that the risk of addiction from OxyContin was so low as to be negligible, a marketing tactic that helped kick into overdrive the pain pill phase of the current wave of opioid use.

But the drug czar’s office, with its misleading suggestion that being prescribed opioids leads to heroin addiction, tips the pendulum too far in the other direction. There are real world consequences to using such faulty information. The Drug Enforcement Administration cited that 80% figure last year when it ordered steep decreases in the supply of prescription opioids, and it claimed in the Federal Register that patients got addicted “after first obtaining these drugs from their health care providers.”

“The 80% statistic is misleading and encourages faulty assumptions about the overdose crisis and medical care,” Pain News Network columnist Roger Chriss argued in a column last year.

And now, a new study from researchers at Penn State University published in the Journal of Addictive Studies bolsters that claim. Concentrating on southwestern Pennsylvania, an area with high levels of addiction, the researchers conducted surveys and in-depth interviews with drug users to determine their drug using histories. The sample size was small, with 125 people surveyed and 30 interviewed, but the results were illuminating.

The researchers found that two out of three of those interviewed got their first prescription opioids not from a doctor’s prescription, but either bought or stole it from a family member or friend. Another 7 percent bought their drugs from a stranger or a dealer. And only one out of four (26 percent) began with opioid medications prescribed by a doctor.

“What emerged from our study — and really emerged because we decided to do these qualitative interviews in addition to a survey component — was a pretty different narrative than the national one. There’s a lot about that narrative that I think is an overly simplistic way of thinking about this,” said lead author Ashton Verdery, PhD, an assistant professor of sociology, demography and social data analytics at Penn State.

“We found that most people initiated through a pattern of recreational use because of people around them. They got them from either siblings, friends or romantic partners,” he continued. “Participants repeatedly reported having a peer or caregiver in their childhood who had a substance use problem. Stories from childhood of witnessing one of these people selling, preparing, or using drugs were very common. Being exposed to others’ substance use at an early age was often cited as a turning point for OMI (opioid misuse) and of drug use in general.”

Among study participants, recreational drug use — or polysubstance abuse, in public health speak — was common, Verdery noted, and usually began not with prescription opioids but with drugs such as alcohol, marijuana, cocaine, methamphetamine, and prescription sedatives and stimulants.

“It is important to note that interviewees universally reported initiating OMI only after previously starting their substance use career with another drug (e.g., alcohol, marijuana, cocaine). Opioids were never the first drug used, suggesting that OMI is likely associated with being further along in one’s drug using career,” he added.

Researchers studying opioid addiction need to be aware of the role other substances play in the process, Verdery said. Understanding how opioid addiction is intertwined with other drug use is necessary to figure out the correct steps to take to prevent addiction before it takes hold. . .

Continue reading.

Written by LeisureGuy

21 June 2019 at 10:23 am

The War on Cocaine Only Strengthens Drug Cartels, Study Finds

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Philip Smith reports in Drug War Chronicles:

If you’ve spent nearly a half-century and $250 billion trying to stop the flow of cocaine into the US and the white powder is now cheaper and more plentiful than ever, maybe it’s time to rethink. That’s the implicit lesson lurking behind a new study on the impact of drug interdiction efforts on drug trafficking organizations.

Interdiction is the supply side approach to reducing drug use. Rather than reducing demand through education, prevention, and treatment, interdiction seeks to reduce the supply of drugs available domestically by blocking them en route to the US or at the border.

Published in the Proceedings of the National Academy of Sciences and conducted by scientists from a half-dozen American universities, the study relied on a computer model called NarcoLogic that shows how drug traffickers respond to interdiction strategies and tactics. More sophisticated than previous attempts to simulate the drug trade, NarcoLogic models local- and network-level trafficking dynamics at the same time.

“Our team consists of researchers who worked in different parts of Central America during the 2000s and witnessed a massive surge of drugs into the region that coincided with a reinvigoration of the war on drugs,” David Wrathall of Oregon State University’s College of Earth, Ocean and Atmospheric Sciences said in a press release announcing the research results. “We asked ourselves: did drug interdiction push drug traffickers into these places?”

The short answer is yes, and that has implications that go far beyond drug policy. The Central American migrants who are at the center of the current “border crisis” are fleeing not only poverty but also high levels of violence generated by the movement of Mexican drug trafficking groups into the region a decade ago as they faced increasing interdiction efforts at home and from US authorities.

In fact, although it is not addressed in this new research, it was earlier interdiction efforts aimed at Colombian cocaine trafficking groups in the 1980s that led directly to the transformation of formerly small-scale Mexican cross-border smuggling organizations into the Frankenstein’s monster of drug prohibition that the cartels are today. With the Colombians under intense pressure, Mexican traffickers rose to the occasion and have been making billions of dollars a year ever since.

This despite five decades of US interdiction efforts with an average annual expenditure of $5 billion. Instead of curbing the flow of cocaine into the United States, all that has been accomplished is making the drug trafficking operations more widespread and harder to eradicate. Putting pressure on one route or location simply leads traffickers to scatter and regroup. This is the “balloon effect,” where suppressing traffic or production in one area prompts it to pop up elsewhere, and the “cockroach effect,” where traffickers simply decentralize their operations.

“Between 1996 and 2017, the Western Hemisphere transit zone grew from 2 million to 7 million square miles, making it more difficult and costly for law enforcement to track and disrupt trafficking networks,” Wrathall said. “But as trafficking spread, it triggered a host of smuggling-related collateral damages: violence, corruption, proliferation of weapons, and extensive and rapid environmental destruction.”

And for all that effort, the impact on cocaine price and availability has been negligible — or even perverse.

“Wholesale cocaine prices in the United States have actually dropped significantly since 1980, deaths from cocaine overdose are rising, and counterdrug forces intercept cocaine shipments at a low rate. More cocaine entered the United States in 2015 than in any other year,” Wrathall said. “And one thing people who support interdiction and those who don’t can agree on is that change is needed. This model can help determine what that change should look like.”

The main takeaway from the study is not that drug trafficking became more widespread and resilient because of ineffective interdiction efforts, but because of interdiction itself. The policy aimed at suppressing the drug trade has only made it stronger and wealthier. . .

Continue reading.

Written by LeisureGuy

11 April 2019 at 9:27 am

Portugal’s Path to Breaking Drug Addiction

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Rob Waters has a very interesting article in Craftsmanship magazine. It begins:

For the past 50 years, Italy, Portugal and the United States have taken radically different approaches to drug enforcement and to the epidemics of drug use and addiction that have afflicted each country. One, the U.S., has emphasized punishment. It leads the world in incarcerating people—and at burying them after drug overdoses. Another, Portugal, has decriminalized drugs and created a model for effective drug treatment. Italy, meanwhile, has veered wildly between these two poles, never settling on a clear approach.

This is the story of how Portugal has dealt with its drug problems and largely succeeded, while the U.S. and Italy, despite pockets of success—like the San Patrignano rehabilitation community in northern Italy described in another article in this issue—have mostly failed.

For all three countries, the modern epidemic of hardcore drugs began with a dramatic rise in the use of heroin. In the U.S., heroin use surged during the Vietnam War, as American soldiers experimented with Southeast Asian heroin and many became addicted. When they came home, drug syndicates saw a market and filled it, putting large quantities of heroin onto the streets of U.S. cities.

Heroin came to Italy in the mid-1970s and its use grew rapidly, striking all social classes. By the late 1980s, Milan alone had an estimated 100,000 heroin users, according to a 1989 article in the New York Times, which noted that in 1988,  809 Italians died of overdoses.

At its peak in the late 1990s, Portugal had one of the highest rates of heroin addiction and fatal overdoses in the world. About one percent of Portugese people were using heroin and one person a day was dying of an overdose—in a country of just 10 million. Then Portugal changed course and took a radical step, eliminating criminal penalties for drug use and possession and making a commitment to provide treatment to all who want it. Today, Portugal has arguably the world’s most enlightened set of drug policies.

As in the U.S., Portugal’s heroin experience began with war. Throughout the 1960s and early 1970s, Portugal deployed hundreds of thousands of soldiers to suppress uprisings in the country’s African colonies. Like the Americans’ experience in Vietnam, these soldiers were exposed to marijuana and other drugs. Then, in 1974, a military coup struck Portugal, followed by a peaceful popular uprising (the “Carnation Revolution”). Almost overnight, decades of rule by a right-wing dictatorship were brought to an end.

A young doctor named João Goulão was then working in the Algarve area of southern Portugal. He had a front-row seat to what happened next.

“Suddenly almost a million soldiers and settlers came back to the mainland, bringing literally tons of cannabis, and there was an explosion of experimentation,” Goulão, who now runs the country’s drug agency, told me in a recent interview. Portugal at the time was going through an extraordinary upheaval, creating a new government and new laws. Young people and returning soldiers savored their new freedom by experimenting with drugs as marijuana, heroin, cocaine and LSD flooded in. “We were completely naïve about drugs,” says Goulão, “and completely unprepared to deal with it.”

FROM BAD TO WORSE

In a flash, Portugal went from having one of the lowest rates of drug use among European countries to having perhaps the highest. The biggest problem was heroin.

“Heroin spread very fast and among all social groups,” says Goulão. “It was not something that happened only among marginalized people and minorities, or in ghettoes. Suddenly everybody knew someone who had problems with drugs.”

As heroin use grew, so did overdoses. Doctors and public health professionals throughout the country began setting up treatment programs. After his daughter died of an overdose, the Minister of Justice set up treatment centers in three large cities. Private programs popped up as well, but Goulão says most were of poor quality and many ripped off the patients and families who came to them for help.

These efforts amounted to Band-Aids, not a concerted national policy. The number of providers and treatment programs kept growing but heroin use grew even faster. The sharing of needles also spread AIDS, adding to the death toll. With drug possession and sales seen as crimes, the prison population soared. And since drugs circulated widely within prisons, it had little effect on the underlying problem.

“People could spend two or three years in jail and come back worse than when they went there,” says Goulão. “The situation was getting worse every day.”

STEP ONE: DECRIMINALIZATION

In 1998, Portugal Prime Minister António Guterres, (now secretary-general of the United Nations) convened a group of nine experts—judges, psychologists and health professionals including Goulão—to develop a national strategy for addressing the crisis. The group visited other European countries, interviewed professionals and researched different approaches. In the end, they concluded they could do relatively little to address the supply of drugs—but could do a lot to address the demand.

The committee developed a set of concrete proposals focused largely on “prevention, treatment, harm reduction, and the reintegration of people,” Goulão says. “All of it was based in the idea that we were dealing with a health and social condition rather than a criminal one.”

The committee’s most radical proposal was to eliminate criminal penalties for the use and possession of drugs. Government leaders accepted the proposal but it also required the approval of Parliament. So Goulão and his colleagues took their case to the public and spent the next year presenting their plan in dozens of forums and discussions.

Their proposal was opposed by right-wing parties and Goulão remembers their arguments: “Portugal will become a paradise for drug addicts and drug users from all over the world. We will have planes coming to Lisbon every day with people to use drugs. Our children will start using drugs at early ages.”

But support from the public and, surprisingly, from the Catholic Church carried the day—in 2001, Parliament passed the sweeping changes. “Using drugs in Portugal was no longer a crime,” Goulão says.

STEP TWO: MULTIPLE OPTIONS FOR TREATMENT

Today, some 40 programs in Portugal provide detoxification and long-term treatment, with 1600 beds in residential treatment programs known as “therapeutic communities,” Goulão says. Most are run by nonprofit agencies, under contract with the government. They employ a variety of treatment approaches, but all must provide  . . .

Continue reading.

Written by LeisureGuy

29 March 2019 at 4:58 pm

A belief in meritocracy is not only false: it’s bad for you

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Clifton Mark, who writes about political theory, psychology, and other lifestyle-related topics and lives in Toronto, Ontario, writes in Aeon:

‘We are true to our creed when a little girl born into the bleakest poverty knows that she has the same chance to succeed as anybody else …’ Barack Obama, inaugural address, 2013

‘We must create a level playing field for American companies and workers.’ Donald Trump, inaugural address, 2017

Meritocracy has become a leading social ideal. Politicians across the ideological spectrum continually return to the theme that the rewards of life – money, power, jobs, university admission – should be distributed according to skill and effort. The most common metaphor is the ‘even playing field’ upon which players can rise to the position that fits their merit. Conceptually and morally, meritocracy is presented as the opposite of systems such as hereditary aristocracy, in which one’s social position is determined by the lottery of birth. Under meritocracy, wealth and advantage are merit’s rightful compensation, not the fortuitous windfall of external events.

Most people don’t just think the world should be run meritocratically, they think it is meritocratic. In the UK, 84 per cent of respondents to the 2009 British Social Attitudes survey stated that hard work is either ‘essential’ or ‘very important’ when it comes to getting ahead, and in 2016 the Brookings Institute found that 69 per cent of Americans believe that people are rewarded for intelligence and skill. Respondents in both countries believe that external factors, such as luck and coming from a wealthy family, are much less important. While these ideas are most pronounced in these two countries, they are popular across the globe.

Although widely held, the belief that merit rather than luck determines success or failure in the world is demonstrably false. This is not least because merit itself is, in large part, the result of luck. Talent and the capacity for determined effort, sometimes called ‘grit’, depend a great deal on one’s genetic endowments and upbringing.

This is to say nothing of the fortuitous circumstances that figure into every success story. In his book Success and Luck (2016), the US economist Robert Frank recounts the long-shots and coincidences that led to Bill Gates’s stellar rise as Microsoft’s founder, as well as to Frank’s own success as an academic. Luck intervenes by granting people merit, and again by furnishing circumstances in which merit can translate into success. This is not to deny the industry and talent of successful people. However, it does demonstrate that the link between merit and outcome is tenuous and indirect at best.

According to Frank, this is especially true where the success in question is great, and where the context in which it is achieved is competitive. There are certainly programmers nearly as skilful as Gates who nonetheless failed to become the richest person on Earth. In competitive contexts, many have merit, but few succeed. What separates the two is luck.

In addition to being false, a growing body of research in psychology and neuroscience suggests that believing in meritocracy makes people more selfish, less self-critical and even more prone to acting in discriminatory ways. Meritocracy is not only wrong; it’s bad.

The ‘ultimatum game’ is an experiment, common in psychological labs, in which one player (the proposer) is given a sum of money and told to propose a division between him and another player (the responder), who may accept the offer or reject it. If the responder rejects the offer, neither player gets anything. The experiment has been replicated thousands of times, and usually the proposer offers a relatively even split. If the amount to be shared is $100, most offers fall between $40-$50.

One variation on this game shows that believing one is more skilled leads to more selfish behaviour. In research at Beijing Normal University, participants played a fake game of skill before making offers in the ultimatum game. Players who were (falsely) led to believe they had ‘won’ claimed more for themselves than those who did not play the skill game. Other studies confirm this finding. The economists Aldo Rustichini at the University of Minnesota and Alexander Vostroknutov at Maastricht University in the Netherlands found that subjects who first engaged in a game of skill were much less likely to support the redistribution of prizes than those who engaged in games of chance. Just having the idea of skill in mind makes people more tolerant of unequal outcomes. While this was found to be true of all participants, the effect was much more pronounced among the ‘winners’.

By contrast, research on gratitude indicates that remembering the role of luck increases generosity. Frank cites a study in which simply asking subjects to recall the external factors (luck, help from others) that had contributed to their successes in life made them much more likely to give to charity than those who were asked to remember the internal factors (effort, skill).

Perhaps more disturbing, simply holding meritocracy as a value seems to promote discriminatory behaviour. The management scholar Emilio Castilla at the Massachusetts Institute of Technology and the sociologist Stephen Benard at Indiana University studied attempts to implement meritocratic practices, such as performance-based compensation in private companies. They found that, in companies that explicitly held meritocracy as a core value, managers assigned greater rewards to male employees over female employees with identical performance evaluations. This preference disappeared where meritocracy was not explicitly adopted as a value.

This is surprising because impartiality is the core of meritocracy’s moral appeal. The ‘even playing field’ is intended to avoid unfair inequalities based on gender, race and the like. Yet Castilla and Benard found that, ironically, attempts to implement meritocracy leads to just the kinds of inequalities that it aims to eliminate. They suggest that this ‘paradox of meritocracy’ occurs because explicitly adopting meritocracy as a value convinces subjects of their own moral bona fides. Satisfied that they are just, they become less inclined to examine their own behaviour for signs of prejudice.

Meritocracy is a false and not very salutary belief. As with any ideology, part of its draw is that it justifies the status quo, explaining why people belong where they happen to be in the social order. It is a well-established psychological principle that people prefer to believe that the world is just.

However, in addition to legitimation, meritocracy also offers flattery.  . .

Continue reading.

Written by LeisureGuy

14 March 2019 at 7:09 pm

How rehab recruiters are luring recovering opioid addicts into a deadly cycle.

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Julia Lurie writes in Mother Jones:

The offer was too good to resist: Go to rehab for a week, get $1,000 in cash. It was early 2017, and Brianne, a 20-year-old from a woody Atlanta suburb, had come to South Florida to leave her heroin addiction behind. At a residential facility called Recovery Villas of the Treasure Coast, she was approached by a charismatic guy I’ll call Daniel, a Pennsylvania native six years her elder. He could relate to her troubles—he’d struggled with addiction himself—and he could get her into another rehab after Recovery Villas. He would even pay her: $1,000 for the first week of her stay and $500 each week thereafter. That money could buy Brianne a whole lot of heroin.

Brianne, whose full name has been withheld to protect her privacy, could be a poster child for the opioid crisis: a blond, green-eyed former softball star who experimented with pills from the medicine cabinet with her high school boyfriend and within a few years was plunging needles into her veins. In 2016, she broke down and admitted to her mom, a software executive named Jen, that she needed help. They made a plan: Brianne would go to treatment for a few months, sober up, and then return home to study at Chattahoochee Technical College.

That never happened. Brianne took Daniel up on his offer and, over the next 18 months, did more than a dozen stints at Florida rehab centers from Palm Beach to Miami. She mainly flitted between Recovery Villas—which in addition to group therapy and 12-step meetings offered apartment housing and a pool—and Compass Detox, which felt like somewhere between a hospital and a hotel.

Sometimes, between stays, Daniel rented a room for Brianne and a few other “clients” at a Super 8 or Comfort Inn and supplied them with heroin and the overdose reversal medication Narcan, just in case. When the drugs ran out, Brianne would head into a detox program with dirty urine, an admission requirement for some facilities. Other times, she coordinated directly with rehab staffers who called her “honey” and “sweetie” and arranged free transportation—Ubers, flights if need be—to their centers. Daniel encouraged Brianne to try her hand at recruiting: For every patient she steered his way, he would pay her $400. After she started dating a recovering user who lacked health insurance, Daniel found rehabs that would take her boyfriend for free as long as Brianne attended with her Aetna insurance card, a practice known as “piggybacking.”

The addiction community has a name for what happened to Brianne. It’s called the “Florida shuffle,” a cycle wherein recovering users are wooed aggressively by rehabs and freelance “patient brokers” in an effort to fill beds and collect insurance money. The brokers, often current or former drug users, troll for customers on social media, at Narcotics Anonymous meetings, and on the streets of treatment hubs such as the Florida coast and Southern California’s “Rehab Riviera.” The rehabs themselves exist in a quasi-medical realm where evidence-based care is rare, licensed medical staffers are optional, conflicts of interest are rampant, and regulation is stunningly lax.

While experts say the practices described in this story are widespread, it is important to note that there are plenty of responsible treatment providers, and not all the facilities named engage in all the practices described. Recovery Villas, which was raided by Florida authorities last summer on suspicion of insurance fraud and is now under investigation by the state, did not respond to my questions. A Compass Detox spokesman said that paying clients for treatment and giving them drugs between rehab stints “is illegal and we don’t do that.” Compass obeys all relevant laws and regulations, he emphasized.

Drug addiction rates have skyrocketed over the past decade: If every American addicted to opioids lived in one city, it would be nearly the size of Houston(pop. 2.3 million). The demand for treatment, the increasingly white face of addiction, and recent laws requiring insurers to cover substance use services have all resulted in a surge in rehab spending and private investment. But as the Braff Group, which tracks health care trends, warned investors in a 2014 brief, “It’s not all kittens and rainbows. As we have seen countless times in other frenzied health care sectors, when the money flows in, so do the ne’er-do-wells, which can bring the sector the kind of attention it doesn’t want.”

It’s a given in the world of addiction treatment that relapses are likelyobstacles on the road to recovery. But for rehab owners and brokers who make money each time a patient is admitted, relapses can be a profit center. Dozens of drug users and parents I spoke with had tales like Brianne’s, and “there are probably thousands” of others, according to Karen Hardy, a Maine addiction counselor whose own son shuffled among dozens of rehabs. “Some end in death. Some don’t,” she says. “It’s Russian roulette.”

For Jen, Brianne’s recovery saga has been a nightmarish roller-coaster ride. At work one morning in June 2017, she received a text from an unrecognized number that made her blood run cold: “I OVERDOSED CALL ME NOW.” Over the phone, Brianne frantically explained she was at a hospital near Palm Beach after overdosing for the first time—in a motel room, with heroin provided by Daniel. There were more panicked calls that summer: Brianne at a gas station, without shoes, money, or transportation. Brianne bawling after yet another friend overdosed. (She lost 15 friends in a single year, Jen says.) The sounds of sickening shrieks and thumps as her boyfriend flew into a violent rage. Brianne overdosing again. Back home, her 13-year-old sister filled an Ugg shoebox with prayers jotted on slips of paper, begging God not to let Brianne die.

The amounts billed to Jen’s insurance company seemed outlandish: $3,000 for a routine drug test and, in one case, $22,000 in rehab charges in a single day. (Residential rehabs often charge private insurers $50,000 to $100,000 per month of treatment.) . . .

Continue reading. There’s much more.

The US seems increasingly dysfunctional.

Written by LeisureGuy

1 March 2019 at 9:29 am

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