Overdose Deaths in the USA and Portugal

I’d like to take a break from posting on all cause mortality in the US and its relationship to COVID deaths to post about a different subset of deaths. Drug overdose deaths are unequivocally on the rise this year, going from about 78,056 between May 2019 and April 2020 to 100,306 in between May 2020 to April 2021. Since I am obsessed with state level data, here’s the CDC breakdown of where the jumps occurred:

This was of interest to me because (as I have posted previously) my brother has an unfortunate amount of experience with opioid addiction, and has written a book about it. With the opioid crisis in the US continuing to worsen, it’s no surprise he’s started trying to look at other countries to see how they have addressed things and if anything they’ve done has made a difference.

Enter Portugal.

If you read anything about our handling of drugs, particularly any of the cases around drug legalization, Portugal is bound to get cited. The basic narrative goes something like this: in 2001 Portugal decriminalized the consumption of all drugs. Most critics thought this would lead to worsening drug abuse/deaths, but instead drug related deaths fells, incarceration rates fell, and drug use was not impacted. Here’s an advocacy organization making this case. Here’s Time Magazine making this case. Here’s the Cato Institute making this case. Here’s the Obama White House complaining about everyone who’s making this case.

When I first heard about Portugal, I’ll admit I took this all at face value. After all, even the White House resorted to kind of nitpicking the statistics. But a few weeks ago I stumbled on to this Twitter thread from Lyman Stone that left me with more questions than answers. He started by pointing to the Global Health Data Exchange, where you can pull all sorts of mortality data for all sorts of countries. First, here’s Portugal’s deaths from drug use disorders:

Not bad. Looking at the source data, nothing for 2000 is available, so we skip from 1999 to 2001 and we do see a drop between those two years. So far so good. However, Lyman pointed out that drug use disorder deaths are one of two types of deaths filed under “substance use disorder deaths”. The other is alcohol related deaths. Here they are plotted together:
So….the same year the drug related deaths started to drop, alcohol deaths went up by an approximately equal amount. So what happened here? Did people start taking alcohol less seriously when drugs were legalized, or did some deaths that previously would have been called drug deaths get filed as alcohol deaths? Or is it all a coincidence? I actually don’t know. I couldn’t find anyone addressing this. It does appear Portugal has a legitimately alarming rate of alcohol consumption, so any explanation appears somewhat plausible. What we do know is that other countries nearby did not see the same increase in alcohol related deaths, even as they saw their drug deaths decrease:
If you lump them all together, we see that Spain has seen a decrease (though is higher) and Portugal has been steadily increasing since 1990. If you use the DALY’s (those account for age), things look even worse for Portugal:
I went to Wikipedia to see if I could get any general insight on the topic, and the opening paragraph caught my eye. Per Wiki, the purpose of the policy change in 2001 was actually to focus on HIV deaths. There isn’t a solid citation for this so I’m not sure if this is true, but I will note other articles tend to say this was “part of a broader health initiative” so it seems plausible. If it is true, then it’s actually pretty confusing what happened next:
Throwing in a few comparison countries (including the US), we note that every other country had a precipitous drop in HIV deaths in the late 90s. Portugal has had a much slower decline. Note the order of magnitude as well: right now Portugal appears to have over twice as many people dying of HIV as they do of substance use. I have no idea what happened here, but we did not see this in Spain or Italy.

Wiki did add to the drug overdose death mystery as well, noting that in this 2010 paper it stated that “the subsequent increase has been attributed by local informants to a shift in measurement practices, namely an increase in the number of toxicological autopsies performed (from 1,166 in 2002 to 2,805 in 2008), which increased the probability that people would be found to have drugs in their bodies at death.” To note: I have no idea if Portugal is now testing more people than most countries or fewer. This is why international comparisons are hard.

The same paper actually clarifies a different question that I had. Lyman Stone brought up the fact that despite decriminalizing everything in 2001, in 2008 the laws were amended to recriminalize large amounts of drugs. Not being very familiar with drugs/amounts, I wasn’t clear how much a “large amount” was. It turns out it’s a “10 day supply” which is apparently defined as “0.1 g heroin, 0.1 g ecstasy, 0.1 g amphetamines, 0.2 g cocaine or 2.5 g cannabis”. Now obviously there is not a super standardized measurement for heroin, but based on a bunch of Googling (that may have permanently flagged my account somewhere) I found that in Ithaca, New York one gram of heroin is typically divided in to 20 bags. A bag is $20, or a bundles for $180. So two bags of heroin would land you back in criminal territory.

This clarifies why the incarceration/conviction rate went up, as I assume 2 bags may not be a super unusual occurrence.

So basically, here are the questions I’m left with: why did Portugal experience such a spike in alcohol deaths right after they decriminalized the consumption of drugs? Why haven’t their HIV deaths come down like most other countries? Did the recriminalization really only catch dealers, or were a lot of regular users caught up in this as well? If anyone knows any good sources on any of this, I would appreciate hearing from you!

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!!!!

 

5 Things to Remember About Prescription Drugs

This past week, I had the tremendous pleasure of seeing one of my brother’s articles on the cover of the December issue of Christianity Today as part of a feature on pain killers. While my brother has done a lot of writing for various places over the years, his article “How Realizing My Addiction Had Chosen Me Began My Road to Recovery” was particularly special to see. In it, he recounts his story of getting addicted to pain killers after a medical crisis, and details his road to recovery. Most of the story is behind a paywall, but if you want a full copy leave me a comment or use the get in touch form and I’ll send you the word document.

As someone who was intimately involved with all of the events relayed in the article, it’s pretty self evident why I enjoyed reading it as much as I did. On a less personal note though, I thought he did a great job bringing awareness to an often overlooked pathway to addiction: a legitimate medical crisis. My brother’s story didn’t start at a party or with anything even remotely approaching “a good time”. His story started in the ER, moved to the ICU, and had about 7 months of not being able to eat food by mouth at the end. His bout with necrotizing pancreatitis was brutal, and we were on edge for several months as his prognosis shifted between “terrible” and “pretty bad”.

Through all that, the doctors had made decisions to put him on some major pain killers. Months later, when things were supposed to be improving, he found that his stomach was still having trouble, and went back to his doctor for more treatment. It was only then that he was told he had become an addict. The drugs that had helped save his life were now his problem.

Obviously he tells the rest of the story (well, all of the story) better than I do, so you should really go read it if your interested. What I want to focus on is the prescribing part of this. When talking about things like “the opioid crisis”, it’s tempting for many people to label these drugs as “good” or “bad”, and I think that misses the point (note to my brother who will read this: you didn’t make this mistake. I’m just talking in general here. Don’t complain about me to mom. That whole “stop sciencing at your brother” lecture is getting old). There’s a lot that goes in to the equation of whether or not a drug should be prescribed or even approved by the FDA, and a shift in one can change the whole equation.  Also, quick note, I’m covering ideal situations here. I am not covering when someone just plain screws up, though that clearly does happen:

  1. Immediate risk (acute vs chronic condition) In the middle of a crisis when life is on the line, it shouldn’t surprise anyone that “keeping you alive” because the primary endpoint. This should be obvious, but after a few years of working in an ER, I realized it’s not always so clear to people. For example, you would not believe the number of people who come in to the ER unconscious after a car accident or something who later come in and complain that their clothes were cut off. In retrospect it feels obvious to them that a few extra minutes could have been taken to preserve their clothing, but the doctors who saw them in that moment almost always feel differently. Losing even one life because you were attempting to preserve a pair of jeans is not something most medical people are willing to do. A similar thing happens with medications. If there is a concern your life is in danger, the math is heavily weighted in favor of throwing the most powerful stuff we have at the problem and figuring out the consequences later. This is what kicked off the situation my brother went through. At points in his illness they put his odds of making it through the night at 50-50. Thinking about long term consequences was a luxury he wasn’t always able to afford.
  2. Side effects vs effect of condition The old saying “the cure is worse than the disease” speaks to this one, and sometimes it’s unfortunately true. Side effects of a drug always have to be weighed against the severity of the condition they are treating. The more severe the condition, the more severe the allowable side effects. A medication that treats the common cold has to be safer than a medication that treats cancer. However, just because the side effects are less severe than the condition doesn’t mean they are okay or can’t be dangerous themselves (again, think chemotherapy for cancer), but for severe conditions trade offs are frequently made.  My brother had the misfortune of having one of the most painful conditions we know of, and the pain would have literally overwhelmed his system if nothing had been done. Prescription drugs don’t appear out of nowhere, and always must be compared to what they are treating when deciding if they are “good” or “bad”.
  3. Physical vs psychological/emotional consequences One of the more interesting grey areas of prescription drug assessment is the trade off between physical consequences vs psychological and emotional consequences. For better or worse, physical consequences are almost always given a higher weight than psychological/emotional consequences. This is one of the reasons we don’t have male birth control. For women, pregnancy is a physical health risk, for men, it’s not. If hormonal birth control increases a woman’s chances of getting blood clots, that’s okay as long as it’s still less impactful than pregnancy. For men however, there’s no such physical consequence and therefore the safety standards are higher. The fact that many people might actually be willing to risk physical consequences to prevent the emotional/psychological/financial consequences isn’t given as much weight as you might think. The fact that my brother got a doctor who helped him manage both of these was fantastic. His physical crutch had become a mental and emotional crutch, and the beauty of his doctor was that he didn’t underestimate the power of that.
  4. Available alternatives Drugs are not prescribed in vacuum, and it’s important to remember they are not the end all be all of care. If other drugs (or lifestyle changes) are proven to work just as well with fewer side effects, those may be recommended. In the case of my brother, his doctor helped him realize that mild pain was actually better than the side effects of the drugs he was taking. For those with chronic back pain, yoga may be preferable. This of course is also one of the arguments for things like legalized marijuana, as it’s getting harder to argue that those side effects are worse than those of opioids.
  5. Timing (course of condition and life span) As you can see from 1-4 above, there are lots of balls in the air when it comes to prescribing various drugs. Most of these factors actually vary over time, so a decision that is right one day may not be right the next. This was the crux of my brother’s story. Prescribing him high doses of narcotics was unequivocally the right choice when he initially got sick. However as time went on the math changed and the choice became different. One of the keys to his recovery was having his doctor clearly explain that this was not a binary….the choice to take the drug was right for months, and then it became wrong. No one screwed up, but his condition got better and the balance changed. This also can come in to play in the broader lifespan…treatments given to children are typically screened more carefully for long term side effects than those given to the elderly.

Those are the basic building blocks right there. As I said before, when one shifts, the math shifts. For my brother, I’m just glad the odds all worked in his favor.