Tuesday, November 29, 2016

A Few Philosophical Reflections On Dreamland: The True Tale of America's Opiate Epidemic

I just finished reading Sam Quinones's astonishing book Dreamland. Dreamland tells the story of the story of America's recent opiate epidemic, but it is also about a million other things like modern American culture, the ethics of health care, late capitalism, the role of government, the nature of pain, and the timeless dilemma of human existence: can you make things better for people without also, somehow, making them worse?

This post isn't an overview of important themes from Dreamland. For that you'll have to read the book. And you should read the book. If you're not sure, start by listening to the author talk about it on the WTF podcast or check out more info here.

Anyway, this is just a discussion of a few things I personally found philosophically interesting, relevant, and thought-provoking.

1. Philosophy of science: evidence and social epistemology

One of the central aspects of the epidemic was the sudden rise in prescriptions for opioid pain relievers and particularly Oxycontin. For a long time it was part of health care orthodoxy that opioids are highly addictive and thus dangerous, and so should only be prescribed in special circumstances like after surgery or when someone is near death. But Oxy tried to change all that.

Oxycontin was formulated as a time-release pill made up of the opioid oxycodone intended to eliminate the euphoria and make the drug non-addictive. It is not surprising that Oxycontin was aggressively marketed as non-addictive: in the nature of things, the makers of the drug stood to make more money the more it was prescribed, and this is what companies do.

What is surprising, and indeed utterly shocking, is how many people went along with it -- with a belief that challenged everything they thought they knew -- on the basis of virtually no evidence. Doctors believed it, med school profs started to teach it, massive health care decisions were made on its basis. And, of course, it turned out to be wildly false. So: what the hell?

As with so many things, it turns out that the answers are complex. The drug arrived in the middle of a shift away from thinking of pain as something to be endured no matter how awful and toward thinking of pain as something that ought to treated. That shift probably would have been a good thing, except that at the same time, insurance companies didn't want to pay for the multidimensional treatments known to help with pain. The producers of Oxy spent a fortune conducting huge conferences that trained drug reps and reinforced the message.

These reps were trained to cite, as evidence, a text known as "Porter and Jick." This text, which was refereed to as a study and sometimes described as a large or important study, was supposed to show that opiods aren't so addictive after all. But Porter and Jick isn't a study at all. In fact, it turned out to be a one-paragraph letter to the editor, written in 1980, to the New England Journal of Medicine, in which a doctor with a taste for data wrote out an informal observation of patients at the hospital where he worked. Not only wasn't it a study, it described patients in a highly controlled environment receiving drugs before the rethinking of pain treatment was underway.

No one questioned "Porter and Jick" -- at least for a long time. People shared the info, passed it along. Quinones points out that everyone thought everyone else had read it; before the journal archives were put online in 2010, finding out what Porter and Jick really was would have required going to the library and looking it up -- something doctors just didn't have time to do. Interestingly, when I tried to use PubMed to view Porter and Jick, I saw the image at the top of this post -- no associated abstract even! -- and Google Scholar offers only a citation. It is still not an easy text to find!

Don't you find it profoundly disturbing that people can cite something crucial, and build on it, and teach it, and share it, without really knowing what it is? I do. And yet, I expect that this -- or something like it -- happens a lot. We know that science proceeds in a highly social way, and that scientists trust one another. People appropriately subject some beliefs to much more crucial scrutiny than others, because they are relying on a sense of what is, and isn't, already known and what is, or isn't, important to revisit. You couldn't require everyone to check everything going back all the way at every stage, or nothing would move forward. It's complicated.

Of course, when it comes to actual pharmaceuticals, you could build in specific checks on things. This article points out that the current US scheme -- in which advertising has to be submitted to, but not reviewed by, the FDA before it can be used -- is a big part of the problem.

2. Capitalism and philosophy of economics

The story of the opiate epidemic is, in some ways, the story of capitalism going where capitalism had never gone before. If you leave out the "people dying in droves" problem, the story of Oxy is a story of business success. And Dreamland describes how a guys from one town in Mexico create a kind of pizza-delivery model for black tar heroin, where you call and there's a guy, and there's quality control and customer service and so on.

I'm constantly trying to convince people that economics is not value-free: that our definitional choices affect our conclusions, that this process is not value-neutral, that assumptions about what is and is not important are hidden behind seemingly objective principles.

The opiate situation is a perfect illustration. The story we always hear about capitalist exchange is that when A and B  make a voluntary transaction, overall well-being improves: since A and B are both getting what they prefer, they are both better off.

As Adam Smith well knew, this is true only in certain contexts and against certain backdrops, and ethical questions and economic ones are deeply intertwined. If you allow that people buying Oxy and black tar heroin, becoming addicted, and often dying is a "bad thing," then you immediately face several deep questions: How is this exchange unlike others? What is the theory of "well-being" in which Coca-Cola makes you better off but Oxy doesn't? What is the theory of "voluntary" that makes addiction incompatible with free choice?

In her wonderful 1962 book Economic Philosophy, the economist Joan Robinson uses the example of addiction to showcase the problems with the standard economic view in which the theory of revealed preferences -- whatever the person chose must, tautologically, be what they wanted -- comes together with the theory of well-being as preference-satisfaction -- whatever the person preferred must, tautologically, have been what would improve their well-being.

"But [addicts] should be cured," she writes, "[and] children should go to school. How do we decide which preferences should be respected and what restrained unless we judge the preferences themselves"

Sure, highly addictive drugs are an extreme example. But you can't rule them out without a some thinking about what preferences matter and why, that is, about what is good for people and what isn't. And once you're going down that road, well -- pretty soon you're asking what is a good life and what matters and why. You're far from rational choice theory and revealed preferences, and there's no telling where you'll end up.

3. Is the human experience essentially a pain?

When it comes to the pains of human existence, there are two types of people in the world. There are people who think things are naturally OK and only become fucked up when bad things happen, and there are people who think that the human experience itself is essentially a problem. In case you haven't noticed, I'm the second type.
In Dreamland, Quinones talks about the dilemma of all attempts to kill pain: can you have the heaven of pain-killing without the hell of addiction? The thing I'm talking about is related to that but goes beyond pain and pleasure into general human existence questions.

As the opiate crisis deepened, many of the people who got addicted were young privileged white people from well-to-do families -- kids growing up in leafy suburbs, with their own bedrooms and cars and TVs and so on. In some cases they started because of sports injuries, but a lot of them were just looking for a good time.

If you think things are naturally OK and become fucked up only when bad things happen, it seems difficult to explain these kids deciding to take drugs. Why take those risks? For what? But if you think human existence is naturally difficult, exhausting, irritating, and boring, it makes all the sense in the world. People are constantly trying to escape their own consciousness, and they always have.

What this ultimately shows, I think, is that while freedom and autonomy are wonderful things, desires don't just come out of nowhere, and most people aren't going to do very well when left alone to their own devices.


Anonymous said...

Great post! Things and people are naturally f-ed up.

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