Addiction Nation: Controversial or Disputed Research

This post is part of a series about my brother’s upcoming book Addiction Nation: What the Opioid Crisis Reveals about Us, discussing some of the science and stats he used throughout the books. Read the intro post here, part 1 here, part 2 here, or (best of all) pre-order the book on Amazon here.

Okay, so last week you heard about how Tim had to change a few things around when we read the actual research. Today I wanted to talk about a few pieces of research that were included in the book that have some controversy around them. While there’s only so much you can fit in a book, we thought the blog might be a good place to expand a little on some of the studies quoted. How does that sound brother?

Tim: Perfect! This was another tricky area of wading through a lot of conflicting information. One thing that I don’t think your readers will be surprised by is that the reason some of these studies are controversial is not always about the studies themselves but the claims or coverage that comes out of them.

For example, the claim “environmental factors play a role in addiction” isn’t controversial. What is controversial is when a study is used, or it’s author claims, that they have demonstrated that environment is ALL or most of what matters.

My general standard was to imagine a reader diving into a specific study in more detail. As they read, would they feel like they were learning nuance and adding texture? Or would the feel like they were misled?

That sounds like a pretty reasonable standard to me! And yes, “blame the journalist” has been a catchphrase on this blog since the very beginning. Coverage of studies can certainly skew perception of the study in ways authors never intended.

Alright, first up, a study I’ve actually blogged about before “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century“. Before we get to the meat of this, I gotta point out brother, you actually got the name of this study wrong in your citation list. You called it “Rising morbidity and mortality, US Whites”. I mean I know I’m the only one who’s gonna read through all your citations, but GET. IT. TOGETHER. Luckily for you the author, journal, year, and DOI number were all correct, so I’ll let this one slide.

Edited even before Tim could reply: I actually just figured out how this happened. On the study page I just linked to if you click “citation manager” it changes the name of the study to the one Tim used

I take it all back brother, you’re okay.

Tim: Oh dear readers… You have no idea how sweet this is. I tried to find an emoji for the feelings you feel when your sister who is always right isn’t right but I just couldn’t find one that could encapsulate how great I feel right now. 

Okay, okay, simmer down here kiddo. I actually was right. The name of the paper you used in your citation list isn’t the one it was published under. I was just clarifying that your error wasn’t your fault.

Anyway, your quote in the book about this study (Chapter 7) is this:

After decades  of declining mortality rates – primarily because of gains in treating cancer and heart disease – the likelihood of a white person dying between the ages of forty-five and fifty four has gone up. A similar trend has not been seen in any of the world’s wealthiest nations……The change was driven was driven almost entirely by drug -and alcohol-related liver disease, and suicides.

You use the study above to support this quote, and you accurately state what the study concluded. However, there have been a few follow ups that I blogged about here.

First, Andrew Gelman questioned the findings of the initial study, citing cohort effects as possible confounders. Then, another study came out that suggested that the overdose increase was real, but not the suicide rate increase.  Then in 2018 the CDC released a report that showed that suicide rates were at a 50-year peak. They didn’t specifically quantify based on race, but they did show that rural areas (which tend to be whiter) were more vulnerable.

There’s a lot going on here, but I think overall it seemed like a reasonable quote for you to leave in. I’d say one of the big challenges of editing a non-science book for scientific accuracy is how to explain things like this without derailing the whole book. The point of your chapter was supposed to be Despair and Acedia, not demographic trends.  It seemed like the initial study got enough right that it was worth quoting, but I still feel like we’re refining the details. Personally, I would have put more of that in, but I know you had space limitations.  Any thoughts on this?

Tim: More got cut from this book than made it in the final copy. Final word count is around 70,000 and I left 100,000 words on the cutting room floor. That isn’t just rewrites but all the sections and chapters that didn’t make the final cut. It is tough to figure out how much space you can dedicate to the nuances or follow ups of specific studies.  

And with the specific details of which “deaths of despair” were most responsible, it gets pretty complicated. My guess is there will be some back and forth about this for a while because of how hard it is to feel confident in how deaths are categorized.  

There is a real human somewhere who needs to go through and catalog cause of death. And, whether or not someone died by suicide or via an accidental overdose is a line that is not always clear. Social norms or even the kind of reporting forms used can influence how these numbers are counted. 

We will also likely see studies in the future that see what sort of effects the high overdose rate will have on those who might have died later from alcohol-related health issues or by suicide. The main question there being whether or not these deaths are concentrating when in previous cohorts they would have spread more evenly over several decades. 

The lines are blurry enough for me that I felt the overall point about “deaths of despair” stands even as researchers try to parse out in greater detail what is going on. 

Alright, next up we have the infamous Rat Park study. From the work of Bruce Alexandar, this is one of the most quoted studies on addiction. Basically, the researchers put rats in empty cages with morphine and noted that the rats became addicted very quickly. They then put them in a nice environment and discovered that they rarely got addicted to morphine. This study is often used to prove that when it comes to addiction, environment matters more than exposure to drugs.

Now while I agree this study is interesting, I do have some concerns. Scott Alexander over at Slate Star Codex raised some issues with this study a few years ago with this post. He points out that while some studies have mostly replicated the effect, other studies have not. More than that though, the two things that seemed to most stand out where:

  1. Genetics studies that produce results like this:
  2. The pretty observable fact that the rich and famous still have drug and alcohol problems. As the SSC post points out, Celebrity Rehab with Dr. Drew was canceled by the host after he said “he was tired of the criticism leveled at him after celebrities he treated had relapsed into addiction and died”. Given that celebrities have access to some of the nicest environments in the world, it seems hard to says it’s all about environment.

You nod to the controversy in the book with this note:

Alexander doesn’t deny that a wide range of other factors including genetics, life experience and individual choice plays a role, but he believes they need to be put into the background because of the power of the social forces at play.

That’s a good note, and you devoted a ton of time to the other factors elsewhere in the book. You seemed to end up with a pretty “big tent” view of addiction, acknowledging that pretty much every theory has some truth and value, but none are exactly right. It’s hard to express this in any one chapter though, without constantly caveating yourself. How did you end up feeling about this process? Any general thoughts on how much context people should give to studies like these, where the general premise is probably broadly true, but some of the specifics have questions?

Tim: After reading some of the critiques of this study, I considered taking it out. But then I got annoyed by some of the critics who claimed that the study had NEVER been replicated when it was actually mixed results from replications. 

I read Alexander’s book, The Globalization of Addiction, and felt comfortable that there is a pretty wide body of research establishing significant environmental effects when it comes to addiction. And, in the popular press and general cultural understanding of addiction, I still think these factors are not well understood or well known. 

This is why I included the study about returning Vietnam service members and indigenous populations. Different scientists, different approaches but affirming the same general points. 

I did have another paragraph providing a caveat about the role of poverty and that if wealth were all you needed then you’d never see the same celebrity on MTV Cribs and in the tabloids going off to rehab. But there was a longer section there that didn’t make the cut. 

The best framework isn’t connecting poverty and addiction but stress and addiction. Poverty is just one of the highly stressful experiences common in our world. But so was serving in Vietnam and, while I have no first-hand experience, so is being a celebrity.  

Another interesting area of inquiry is that there is good reason to believe that intermittent access to resources is actually more stressful than a consistent lack of resources. Our bodies respond poorly to highly fluctuating environments. That area of research could have been a whole chapter on its own. The one other area I touch on it is my chapter on the “body” where I look briefly at genetic/epigenetic factors related to addiction. 

Yeah, those are good points. The idea that stress and environment can play a roll in addiction seems pretty clear, though even your own story shows that can be complicated. You got addicted due mostly to large quantities of pain medication prescribed for a real need, but the tumultousness of your life at the time can’t have helped. For any critique of this study, even Scott Alexendar ended up saying the idea that ultimately unhappy people probably do more drugs than happy people seemed to be relatively self evident.  So I think there’s something to this, though clearly it’s not the whole story. Addiction is not something that happens in a vacuum, even if there’s more going on. As they say, genetics loads the gun, environment pulls the trigger.

Alright, so that’s it for this week! Come back next week for our final post, and in the meantime enjoy this picture of me holding the actual book my brother signed for me! GETTING EXCITED!!!!


Addiction Nation: What Hurts, What Helps

This post is part of a series on my brother’s upcoming book Addiction Nation: What the Opioid Crisis Reveals about Us, discussing some of the science and stats he used throughout the books. Read the intro post here, part 1 here, or (best of all) pre-order the book on Amazon here.

Okay, so this week’s post is kind of a big topic. I think it’s fair to say that most of your book is actually about “what hurts and what helps” addiction, so this post is really just to talk about two of the interesting studies you used in the course of all of those chapters. I included one that had a pretty surprising conclusion and two that I know we discussed at length and you ended up doing some rewrites on. Does that sound good?

Tim: Perfect! And this is probably a good time to point out that this book probably took twice as long to write because of you. There are sometimes that authors have a point they want to make and so they start searching around until they can find a study that seems to back up the point they want to make. 

Instead, I really wanted to take the time to understand multiple different models and viewpoints for understanding addiction. That meant spending a lot of time with opposing viewpoints. And, when I found a study that I thought was interesting or exciting, I had the specter of my older sister looking over my shoulder reminding me to go back to the source material. 

Unfortunately, there are a lot of people out there who don’t have sisters who wouldn’t mind calling them out publicly for being sloppy with their research. In Chapter 9, I highlight the destructive game of scientific telephone that turned a small letter to the editor in the New England Journal of Medicine into a “landmark study” that Purdue Pharma used to claim that fear of opioid addiction was overblown. 

If only they all had sister’s to give them a healthy dose of neuroticism…

Note to authors: if you’re lacking a sister to keep you honest, I’m available for hire!

Alright first up, the study that was surprising. I would love to take credit for how you introduced this study, but I actually have to admit you did this phrasing all on your own. For some context, this is on page 35 after you talk about how hearing your doctor say that your addiction wasn’t your fault was so valuable to your own recovery. You say a few things about the disease model of addiction, then you say this:

But the disease model isn’t the only way to understand addiction. In fact, there are limitations. At least one study shows that alcoholics who believe their alcoholism is a disease are more likely to relapse than those who don’t.

That was some great context. So many people get concerned with making a strong statement that they forget/ignore counter evidence. At the same time, noting that it was “one study” helps give the reader some useful context about how widely this has been found. Nice job brother!

Tim: This was a big area of learning for me. When I first started learning more about addiction  I thought of there being two opposing camps. The first represented the old outdated model of addiction as a moral failing. Then there was the new wave of scientific research that showed addiction is a disease. 

While the disease model dominates addiction science, I started to read a lot of great authors and researchers who either explicitly argued against that theory or were offering important correctives to it. These folks include Bruce Alexander, Marc Lewis, Carl Hart, William Miller and Maia Szalavitz (who you first introduced me to.) While I don’t always frame what I write as a critique of the disease model, there is a lot that comes from authors and researchers who are doing exactly that. 

A scientific model is a framework that is used to understand a complex phenomenon. Models can have benefits and limitations. In theological language, you can talk about an “icon”. It is an image that points to or is analogous to a reality that transcends it. An “idol” is when you believe that what you are looking is the greater truth itself. 

The study you mention is this one here “What predicts relapse? Prospective testing of
antecedent models“. It was done on 122 alcoholics who entered recovery, then were assessed for a bunch of different things pre-treatment and then every 2 months through a year to see what types of things correlated with relapsing. Here’s the finding you mention:

I highlighted the Bonferroni adjustment part because I think that’s an important note for how rigorous this study was. The authors did a ton of comparisons/correlations to see what factors might be relevant. They highlighted both those that came up as significant (and thus might be worth exploring) but also noted that due to how many correlations they were running they really should have used a higher cutoff. This is a great way of doing initial data analysis on a topic like this and shows they were really interested in getting to the truth. So basically the disease model issue had some initial evidence but needed more study to be proven.

They then pulled all the data to look at just this factor and showed that the disease model belief was associated with relapse at every time point. This gives even more statistical weight to the theory. They also give this caveat:

The direction of causality cannot be determined from these data. It is possible that belief in alcoholism as a loss- of-control disease predisposes clients to relapse, or that repeated relapses reinforce clients’ beliefs in the disease model. In any event, endorsement of traditional disease model precepts was prospectively predictive of relapse.

That seems like a reasonable conclusion, and certainly intriguing. Not sure what we really do with that information though, other than work it in the way you did. Any thoughts?

Tim: I think this speaks to the power of language in our lives. When we, as a society, understand the ways that addiction is like a disease, we are motivated to look at the social, economic and medical factors at play. It motivates all of us to look at the public health possibilities that can make a difference like increasing access to treatment in general, MAT (medically assisted treatment), harm reduction and other social supports. 

However, it is also reasonable to assume that some people might use the language of disease and assume that puts the responsibility for recovery solely on outside factors. JD Vance, in Hillbilly Elegy, describes his own interpersonal frustration with his mother who used disease language to justify her abusive behavior toward her children. 

Maia Szalavitz, in the book you recommended to me, uses the language of addiction as a learning disorder. Recovery isn’t a simple “choice” in the way we normally use the word. But that doesn’t mean there aren’t tactics and strategies a person can learn that help them overcome and compensate for the harm addiction can cause.

Final thought on this one is that addiction comes in lots of different shapes and sizes. One direction I hope addiction research goes is not just asking, does this work for a general population? But, are there specific kinds of addictions and backgrounds that make specific approaches, language, and treatment more effective?

For example, Bill Wilson was a relatively wealthy banker who should have “had it made” but lost everything for a while because of his alcoholism. There is a whole category of people, like him, who might need to start with addiction as a disease and learning their own powerlessness. 

But what about those who had an addiction with roots in an abusive childhood in which they always experienced themselves as powerless and their world as out of control? Maybe the place they would need to start is with their own agency. 

That’s a good point. We often think of treatment as “working for people” or “not working for people”, but the effect may not be consistent across all populations. This actually an excellent intro to the next study I wanted to talk about….

There were two studies that we probably discussed more than almost any others: “The forest and the trees: relational and specific factors in addiction treatment” and “Effect of Counselor Expectations on Alcoholic Recovery“. I objected to your initial framing of the findings in these, and you ended up changing how you presented them. In these two studies, it was found that counselor empathy and counselor’s belief that the client was going to succeed impacted the outcomes for the addict. In the first study, they showed that treatment approach mattered less than the counselors “accurate empathy” level, and the second found that when counselors were told the addict was likely to succeed (on a scale that was actually randomly assigned) they did better.

Now normally this point is just made as a sort of “counselors, be better” without any further nuance. When I dug in to the papers though, I got concerned that there was a pretty big caveat. In another paper that reviewed the findings of the previous two papers (Rediscovering Fire: Small Interventions, Large Effects) the authors point out that this effect didn’t come from changing the behavior of some or even most counselors. Instead, they said:

Therapists’ experimentally induced expectancies about their clients
become self-fulfilling prophecies in treatment outcomes (Leake & King, 1977), and patient retention rates are predictable even from the tone of voice a doctor uses when talking about alcoholics (Milmoe, Rosenthal, Blane, Chafetz, & Wolf, 1967). At least two studies suggest that therapist effects may reflect the impact of a relatively small number of counselors whose clients show particularly poor outcomes (McLellan, Woody, Luborsky, & Goehl, 1988; Project MATCH Research Group, 1998). In our first study of therapist effects (Miller et al., 1980), clients seen by counselors low in empathy fared worse than those given brief intervention and sent home with self-help materials.

So basically it’s not your average counselor who needs to change, it’s actually your burnt out or otherwise low performing ones who may need to be addressed. You added this caveat to both your citations (Chapters 19 and 21), and I think it’s a stronger point for it. It’s amazing how often these two things get cited without the nuance, so I’m kinda proud you got it in there. How did you feel about it?

Tim: Annoyed. I had to go back and rewrite stuff because of you and your pesky attention to detail and facts. 

This is an area where at first I was worried that the study would somehow lose rhetorical power but the caveat, but it actually deepens the point. The important change isn’t large scale training to get a counselor from an 8 to a 9 on the empathy scale. It is a broader scale distinction between someone who is clearly burned out and has stopped caring with those who are generally empathetic and trying. This specificity in the research actually led me to want to make two broader points more strongly. 

First, I write a lot about empathy and understanding for those who struggle with addiction. This study points to the need to support those who work every day with those who struggle with addiction. First responders, medical staff, social workers and so many others on the front line are getting burned out. We need to make sure they are supported. The work they are doing isn’t easy. 

Second, while I’m going well beyond the bounds of the study now, I think it illustrates the importance of societal attitudes toward addiction. If struggling with addiction continues to be a “Scarlett A” that marks a person for life, then we create a world in which that addiction is more likely to stay with a person for life. If our fundamental assumption is that redemption and growth is always possible and that struggle and setback is not a curse of the few but a description of what it means to be human, then we are creating a world where recovery is more likely to be a reality. 

I’m glad you ended up feeling that way about it. I think that with many scientific findings, the nuanced truth is often more interesting than the initial simple point you were going for. Life is messy, so is the data, as I always say. (Actually I think I made that up just now, but I like it and it may be my new thing.)

Alright, I think we’re done here! Next week we have even more debating to do, as we’re going to cover two studies that actually have produced a lot of debate in the popular press. Hope you’ll join us!

Addiction Nation: The Numbers Behind the Crisis

This post is part of a series on my brother’s upcoming book Addiction Nation: What the Opioid Crisis Reveals about Us, discussing some of the science and stats he used throughout the books. Read the intro post here, or find the book here.

Okay! So last week Tim couldn’t introduce himself because he was busy getting married, so let’s kick off with a few words of introduction from Tim. Say hi to the nice people Tim!

Tim: Greetings Graph Paper Diary readers! If any of you have ever wondered if correcting other’s use of data and scientific research is something BS King only does on her blog, I can tell you it is a passion she pursues in all areas of her life. Luckily, I figured out how to take my older sister’s insistence on always being right into a way of getting her to do my homework for me. 

That assistance made a huge difference. Addiction is an area that is rife with a poor understanding of science or a complete disregard for it. This can be especially true when looking at the mixture of faith/spirituality and addiction recovery. Since parts of the book draw on my own religious experiences, I wanted to be especially careful not to make some big category errors. 

You say “getting her to do my homework” I say “pointing out your faults by request”.

Sibling rivalry aside, I wanted to start off this week by talking about how big the opioid crisis actually is and why we’re all suddenly hearing about it. The blurb for your book actually starts with the stat “Opioids claim the lives of 115 people per day. One of them could have been me.” so let’s start there.

What amazes me about this stat is that it actually is already outdated…the current numbers from the CDC say it’s 130/day. That’s a big jump in just a year or two.

Tim: Ya. The first time I published on the topic was 2016 and the number I was using then was 78 a day. Overall drug overdoses were at 110 a day when I was working on that article.

There’s a paper you start off with that has some really interesting graphics about the crisis, “Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016“. You weren’t able to include the graphs in the book, but this image here is quite striking:

So basically for most of our childhood, the rates of overdose deaths were 2-4 deaths per 100,000. Since 2001 though, the death rate has quadrupled. No wonder we’re hearing so much about it.

The next graph is interesting too, as it shows big increases in heroin ODs in the 20-40 age range, but also big increases in prescription opioid overdoses in the 40-60 age range. Heroin overdoses for the 40-60 year old crowd are now more common than they were in the 20-40 year age range even 10 years ago. That’s crazy.

The weirdest part about this paper is that it specifically cites 2010, the year you got sick, as sort of a turning point for prescription opioids. It’s apparently when they started to crack down, but also when deaths started going up. As the authors say:

Since 2010, the mortality curves for all drug types have been increasing, except for methadone and for unspecified drugs and narcotics. Each drug’s mortality curve shows some variability. For example, the mortality rate from prescription opioids decreased slightly in 2012, whereas the mortality rates from heroin and synthetic opioids have been increasing rapidly. These trends may be related because several epidemic interventions may have reduced the impact of prescription opioids around 2010, including the reformulation of OxyContin in 2010 (6), implementation of pain clinic laws and mandatory checking of Prescription Drug Monitoring Program data by prescribers (7), the reduction in the amount of opioids prescribed (8), and the rescheduling of hydrocodone compounds in 2014 (9). Although these changes may have reduced the overdose deaths from prescription opioids, it is possible that they may have led some opioid-dependent persons to switch to illicit opioids, such as heroin and fentanyl.

That’s kind of scary, because it really highlights how a good public health measure can have unintended consequences. Your own doctor’s wisdom in partnering with you to slowly easing you off prescription pain killers keeps looking wiser and wiser.

Tim: Unintended but not necessarily unexpected. Those early reforms only focused on the supply side of the problem. The demand for the drugs was still there so the black market grew. That market then became incredibly profitable, completely unregulated and exponentially more dangerous. Take a highly motivated market of people who are ready to buy and a large pool of people who see a shot for an income they otherwise couldn’t dream of, and you are creating the perfect conditions to intensifying the problem.

Yeah, it’s clear the worst part is those reforms didn’t even do much to stem the tide (Tim: and actively made things worse), as between 2013 synthetic opioid overdoses would go from 1 death per 100k to almost 6 in the next 3 years.

Going back to the heat map above though, I was interested to see how regional some drug problems are. Any thoughts on why that is?

Tim: High population-wide levels of addiction seem to have a whole confluence of factors from economic and political to social and cultural. Sam Quinones does an excellent job tracking some of these factors in his book Dreamland.

  • Stress: High-stress environments, especially those that result in childhood trauma, are going to be petri dishes for addictions to grow. There is good reason to believe that living in an environment with intermittent access to resources creates a higher level of ongoing stress than a low resource environment. Poverty is often a driver of this kind of stress, but not necessarily so.
  • Cultural: Binge drinking is known to spike among college students, but only those who live on campus. Cultural expectations and levels of usage shift dramatically based on your peers.
  • Social: We’ll dive into this one in a future post but there is good reason to believe that social dislocation is a primary driver behind addiction.
  • Supply: While I note before that only focusing on supply is a recipe for disaster, supply is still a factor. Drugs needs supply chains and distributors. These can take a while to set up. The higher the demand, the higher the profit and the more risks people will be willing to take to move into new markets.

Interesting! One region that’s been particularly hard hit of course is the state we grew up in, New Hampshire. New Hampshire had the dubious distinction of skyrocketing to the top of the state opioid overdose list. You cited a report by Dartmouth School of Medicine that said that a bag of fentanyl laced heroin was selling for less in New Hampshire than a 6 pack of beer. Wow. New Hampshire is where us Massachusetts folks go to get our cheap beer.

Apparently though, New Hampshire is also where Massachusetts drug dealers send a lot of fentanyl. According to the report, they can charge higher prices in NH. There have been some major busts trying to stop this pipeline, but NH appears to be a bit of a target. Any idea why that is?

Tim: The Dartmouth researchers noted that NH is a standout in being a pretty wealthy state in comparison to many of the others that have been hardest hit. One possible explanation is that NH has small pockets of poverty spread throughout the state and these are the communities that have shifted statewide averages. They also note that NH has one of the lowest per capita spending for recovery services in the country. 

But one other theory they posit is, in essence, the “Live Free or Die” mentality. I’m proud of the state motto and love the sense of independence in our home state. But, it can have a dark side. One of the ideas I explore in the book is that addiction began for me not in a loss of control but in my seeking of control. 

When I was in the hospital, one of the few things I could control was my ability to push a button for more narcotics. It wasn’t just relief from pain but a sense of comfort and as if I still had agency in my life. 

I would not be surprised if some of my fellow Granite-Staters, from a variety of different circumstances, might have started there own addictions out of wanting to maintain a sense of independence and control in their own lives. Then later, the solution they relied on, slowly unraveled.

That theory makes a lot of sense! New Hampshire definitely seems to have something going on. It’s interesting that while you went through most of your addiction journey in and around Washington DC, it was actually moving back to New Hampshire that clued you into the extent of the crisis. DC and New Hampshire overdose rates are shockingly similar given that DC is totally urban and New Hampshire is not. Normally those are two populations we’d avoid comparing due to the dramatic differences, but here they seem to have converged. Not a good sign for NH.

It looks like overall it’s pretty clear the crisis has been growing, though it does appear things may be leveling off slightly. All the sources seem to point to an increase in the number of available prescription and synthetic opioids, but there’s clearly something societal going on as well. I know that’s a lot of what your book is about, but any quick thoughts on just the scope of these numbers before we wrap up?

Tim: To put some of these numbers in perspective. More Americans will die from a drug overdose this year than those who died in the Vietnam and Korean Wars combined. More Americans will die from the opioid crisis than all of World War II. 

When we open up the lens a little more and realize that the opioid crisis is just one part of a broader failure of how we understand and treat addiction, the numbers continue to climb. Millions of more lives are lost in a criminal justice system that can exacerbate addiciton, not cure it. 

Man, that’s a depressing thought. Hopefully in the next few posts we’ll get more in to some things that do and don’t work.

PS: Great text from my brother after we finished this. Someone’s a little nervous about getting his facts straight!


Addiction Nation: The Data Behind the Book (Intro Post)

Well hello hello good people! I’ve got some exciting news here on the blog today, as this marks the begging of a new and somewhat personal blog series here on GPD.

For those of you who have been reading for some time now, you may remember me mentioning my brother’s article about his experience with opioid addiction, and my subsequent references to the book deal that came out of it.  That little manuscript has finally taken shape in to a full fledged book called Addiction Nation, and is due out June 11th.

In honor of its publication we thought it would be fun to do some blog posts on some of the studies he uses throughout the book. I got to play science editor during the writing process, and my brother and I talked for months about how to properly represent studies in a book that wasn’t actually a science book. In this blog series I wanted to actually go a little further in to some of those conversations….you know, what made it in, what got cut, why certain things are phrased the way they are, why certain studies were picked for use. The whole book writing and editing process was totally unfamiliar to me until I went through it by proxy, so I thought it would be fun to share some of the discussions we had along the way. Tim will be joining me on these posts to tell you a little more about his thought process while writing as well.

Want to know more? Okay, here are the details!

The book itself:
The full title is “Addiction Nation: What the Opioid Crisis Reveals about us”, and it’s got a good cover:

The book is part memoir/part sociology of addiction/part theological treatise/part a lot of things. Here’s how Tim explains it in his intro:

But this is not a memoir, although it does tell parts of my story. Nor is this a self-help book, although I do hope it is helpful. Addiction Nation is not a complete history of the opioid crisis or public policy manifesto, although it will provide insight into both. It is not a scientific analysis or a medical diagnostic manual, but it does try to use the perspectives as tools.

This book is the story of someone who has stood at the edge. It is an exploration of what this crisis says about us, all of us.

My involvement:
Since I’ve been correcting the science citations of everyone around me for years, my brother thought it would be wise to let me read during the editing phase rather than after the fact when it was too late to change anything. Despite science not really being the point of the book, my brother didn’t want to fall in to the “attempt to use science to bolster your claims but don’t get anything right but the name of the paper” trap so many nonfiction writers fall in to.

I had intended to have Tim introduce himself this week, but he actually got married yesterday (congrats bro!!!!) and was a little too preoccupied to write anything. Excuses excuses.

Alright, so there you have it! We have four posts planned so far on a few different topics (links added as the posts are written):

  1. Week 1: The Numbers Behind the Crisis
  2. Week 2: What Hurts, What Helps
  3. Week 3: Controversial or Disputed Research
  4. Week 4: Recovery and Hope

Looking forward to introducing my bro next week!

Rubin Vase Reporting

Jesse Singal had an interesting post in his (subscriber only) newsletter this week about a some articles promoting an Amnesty International report that ran under the headline “Amnesty reveals alarming impact of online abuse against women“.  I was intrigued because I love dissections of survey data, and this didn’t disappoint. He noted some inappropriate extrapolations from the results (the Mozilla article claimed that data showed women were harassed more than men online, but the Amnesty survey didn’t survey any men and thus has no comparison), and also that the numbers were a little lower than he thought. Overall in 8 countries, an average of 23% of women had experienced online harassment, with an average of 11% saying they’d experienced online harassment more than once.

This statistic struck me as interesting, because it sounds really different depending on how you phrase it. From the Amnesty article:

Nearly a quarter (23%) of the women surveyed across these eight countries said they had experienced online abuse or harassment at least once, ranging from 16% in Italy to 33% in the US.

If you reverse the language, it reads like this:

“Over three quarters (77%) of the women surveyed across these eight countries said they had never experienced online abuse or harassment even once, ranging from 84% in Italy to 67% in the US.”

Now it is possible those two paragraphs sound exactly the same to you, but to me they give slightly different impressions. By shifting the focus from the positive responses to the negative, two reporters could report the exact same data but give slightly different impressions.

While reading this, all I could think of was the famous Rubin Vase illusion. If you don’t recognize the name, you will almost certainly recognize the picture: 

It struck me as a good analogy for a certain type of statistics reporting, enough so that I decided to give it a name:

Rubin Vase Reporting: The practice of grounding a statistic in either the positive (i.e. % who said yes) or negative (i.e. % who said no) responses in order to influence the way the statistic is read and what it appears to show.

Now of course not every statistic is reported this way intentionally (after all you really do have to pick one way to report most statistics and then stick with it), but it is something to be aware of. Flipping statistics around to see how you feel about them when they’re said in the reverse can be an interesting practice.

Also, I have officially updated my GPD Lexicon page, so if you’re looking for more of these you may want to check that out! I have 19 of these now and have been pondering putting them in to some sort of ebook with illustrations, just for fun. Thoughts on that also welcome.

What I’m Reading: April 2019

Familiar topics in this Nature article, but a good title….the Four Horsemen of the Reproducibility Crisis. P-hacking, low power, publication bias and HARKing (oh my!).

Given my ongoing interest in YouTube search results, I found this profile of the YouTube CEO quite fascinating.

A little late to the party, but I loved the WaPo “Mueller Book Report” take.

Related to the two above, a Twitter thread about which videos about the Mueller report got recommended the most by YouTube.

This article debates the current assertion that religious affiliation is going down, and caused a lot of discussion in an email group I’m part of this week. The basic argument seems to be that the rise of the “no affiliation” label is coming mostly by way of those who previously claimed to be religious but reported they never went to church, so the core of religious sentiment remains unchanged. I’ll admit I’m unconvinced by this. The underlying paper suggests that religious behavior (going to church, etc) are holding steady among the religious, which goes counter to the idea that the label-without-participating people are the only ones who left. If they were, we’d expect to see the remaining religious people engaging in MORE religious behavior, as the lower tier wouldn’t be bringing down the average any more. Still, it isn’t wrong to point out that the typical “nones are on the rise!” story may have been oversold.

The Calling Bullshit guys posted that there’s a new entry in to the field of bullshit studies: Bullshitters, who are they and what do we know about their lives? This clever paper asked people about themselves, then asked them about their knowledge levels for 16 statistical/mathematical techniques. 3 of them (Proper Number, Subjective Scaling and Declarative Fraction) were fake. The study was done on teenagers in 9 countries. Findings: boys are much more likely to bullshit than girls in all countries, high socioeconomic status kids were more likely to bullshit than lower SES kids in all countries, immigrants are sometimes more likely to bullshit, sometimes not depending on the country, the US and Canada are huge bullshitters. Bullshitters were more to rank themselves as good in other things (popularity, mathematical ability) and interestingly, more likely to give “right” answers when asked how they would solve a problem. For example, when asked what they’d do if their cell phone broke, they say they’d first consult the manual rather than “push all the buttons to see if it turns back on”. Now to note: all countries studied were WEIRD, but still an interesting paper.



When Bad Stats Mean Good Things

As someone who has to pay attention to blood/infectious disease issues for work, I’m on a couple email lists that report current issues. I got one of these this week that really caught my eye, with a headline that stated that the incidence of hemophilia appears to be going up.

Since hemophilia is a genetic disorder, I was curious why this would be. Clicking on the article, I was surprised to find that the researchers actually believe this is a positive development caused by getting a better handle on HIV and infectious disease standards. For those unfamiliar with hemophilia, it’s a disorder that impacts your blood’s ability to clot. Though in some rare cases women can some forms of it, the disorder is almost exclusively found in men. Men with this require blood transfusions frequently, and thus were impacted when HIV in the 80s before blood and blood donors were screened with the standards we use today. Ryan White, whose case prompted many of the legal protections we have for people diagnosed with HIV today, was one such case. The first person I knew who had HIV (Norm Cataract) was another such case. He was a friend of my parents and dedicated the last few years of his life to giving public talks about how HIV was acquired and trying to reduce fear. It’s hard to remember now, but in the late 80s there was a lot of misinformation about HIV floating around, and with no treatment available it was met with a lot of hostility. I’ve never forgotten Norm’s bravery in fighting for understanding and right information. It’s a shame he didn’t live long enough to see HIV become more manageable disease.

Anyway, now that HIV is more manageable, the blood supply is cleaner, and hemophilia is a less risky disease. The less risky it is, the more likely hemophiliacs are to actually live and have children, which given the genetic nature of the disease means there will be more hemophiliacs. In other words, despite the negative connotations of “rates going up”, this is all a good thing.

A couple other examples of “bad” stats hiding good things:

  • More wounded veterans. Previously more men died on the battlefield or shortly thereafter due to a lack of medical care in the field, now 90% of men wounded in battle survive.
  • Smoking rates (possibly). Working in a cancer hospital, I have a lot of coworkers who (pretty understandably) dislike smokers. I like to remind them that smoking rates are very high among recovering addicts, so we don’t always know if the smoking was a bad choice or a good choice. Smoking isn’t healthy, but I think we can all agree it’s better than heroin.

I don’t have a clever name for this, but I’d be open to suggestions!