Doctors and drugs: when we can’t trust the white coats

Sometimes you can see a policy change coming a mile off. For about the last two decades, drug legalisation looked like such a case.

The positive results of decriminalisation in Portugal, and the examples of marijuana legalisation in Uruguay and various states of the US were becoming more widely known. The Penington report in 1996 argued for decriminalisation of marijuana and when Victorian Premier Jeff Kennett ignored its recommendations it was seen as a stance justified only by retail politics.

It seemed only a matter of time before expert recommendations on decriminalisation and legalisation  were taken on board by Australia and nations across the world.  An armistice was about to be announced in the increasingly stupid war on drugs. So it seemed.

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Then the opiates crisis began. America is in the grip of a really shocking wave of premature mortality, caused by addiction to opiates. The scale of it is really awful – at 32,000 deaths a year, roughly equal to the numbers killed by firearms in that country.

(If you’d like your faith in journalism to be restored utterly while your heart is smashed into a million irrevocable pieces, I recommend this piece, Seven Days Of Heroin, from the Cincinatti Enquirer.)

The US opiates crisis has forced some hard thinking on the merits of legalisation (for drugs beyond talking about drugs beyond marijuana, mostly.)

The rethinking of legalisation has come from the left, like this piece at Vox: I used to support legalizing all drugs. Then the opioid epidemic happened.

And from the right, like this piece at the National Review: The Opioid Crisis Should Kill the Call to Legalize Hard Drugs

Opiates are not only a gateway to heroin abuse but a problem in themselves. Legal opiates accounted for 20,101 overdose deaths in the USA in 2015 compared to 12,990 related to heroin. If a legal drug, tightly controlled by law and available only under prescription, can be abused in a way that spirals way out of control, what does that say about the prospects of ending prohibition of drugs?

TOO MUCH TRUST

With legalisation, nothing is going to end up as available as buying flour at the supermarket. There will always be controls – regulation, licensing, etc. Choosing them is critical. But there is one shortcut we tend to take.

We love to rely on doctors as one of those controls. “Only available via prescription” sounds like a big barrier to drug availability. We have a lot of trust in doctors at a personal care level and that transfers over to a policy level.

But a look at the US medical marijuana system reveals that prescriptions are available ridiculously easily, over the internet, for trivial complaints. The controls in Canada are not much tighter. Doctors are like anyone and are subject to incentives. If they can make money writing quick and dirty prescriptions, some will.

Meanwhile, even the best-intentioned doctors are at the mercy of a pharmaceutical system that is itself far from perfect.

(If you’d like your faith in journalism to further cement while your faith in capitalism is smashed into a million irrevocable pieces, I recommend this piece, ‘You want a description of hell?’ OxyContin’s 12-hour problem, from the LA Times. It describes how a big Pharmaceutical companies lies about its products, got loads of people hooked on opiates and evaded a whole lot of systems designed to stop exactly that from happening.)

To some extent this is like the story on Elon Musk yesterday. It bothers me when too much trust is vested in an entity, person or institution that doesn’t deserve it. And nobody deserves as much trust as we invest in doctors without an panopticon of ombudsmans, review committees and inspectors.

I think we can move towards legalisation of drugs. But what is crucial in regulating anything is the fine details of the way they are controlled.

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Hoops to jump through

I wrote about this in The Right Amount of Smoking. Finding the exact sweet spot for control and legalisation is hard. You can fiddle with public and private ownership of suppliers, taxation, occupational licensing, sales licensing and controls on consumption.

At this stage, we probably don’t have enough controls for gambling, and we have too many of the wrong kinds for most drugs.

Finding the right kinds of control is hard and requires ongoing adjustment of the policy settings. Trying to outsource the difficulty we have in solving that to doctors is an attractive shortcut, but not the answer.

 

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thomasthethinkengine

Thomas the Think Engine is the blog of a trained economist. It comes to you from Melbourne Australia.

7 thoughts on “Doctors and drugs: when we can’t trust the white coats”

  1. Not to mention that doctors also have an already long list of things to deal with. If we add to that the responsibility of prescribing these types of drugs, patient numbers will increase and time spent with patients decrease (and at what cost to the public? poor patient care as a result of less time spent with a patient will likely see more people admitted to hospital, and then I imagine the medicare payments to see a doctor just to get marijuana is money that could be better spent). It would be less of a headache to just do nothing, it’s not as though any drug is hard to come by if one wanted it (Victoria Street, Richmond is a prime example). On a broader government revenue side though, how has legal marijuana been taxed in other jurisdictions? Is it so high that your local dealer remains in business?

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  2. From what I understand, legalisation and taxation has led to huge price drops because the price of evading detection was previously so high. Seems liek you can set the tax rate at a fat level.

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  3. After all the effort going into reducing tobacco addiction, we stand on the threshold of opening up a whole new area of drug addiction…it will not end well! Joints are as tarry if not more so than tobacco, I’m told, so stand by for lung cancer to shoot up again.
    Making a drug illegal raises the economic cost of obtaining and using it (e.g. spending personal time in jail, paying fines, etc). Put the ‘war on drugs’ aside (its akin to the ‘war on theft’), putting a cost pressure on drug use is a social function that has to continue to minimise the downside of mass consumption. The fewer consumers, the smaller the social problem.

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  4. On oxycontin: I was prescribed this recently; hated it. Sure it knocked the pain out for a few hours (nowhere near 12), but the dominant effect for me was vertigo, even while lying down! Horrible. I stopped taking it when the pain had minimally reduced to a tolerable level; happily it was only a couple of days.

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  5. Congrats on trying to write a balanced piece on the trials and tribulations Franchising. Sadly it failed, but every effort is likely to fail unless you write a War and Peace style version of it. I’ve had the pleasure of being at both ends of the franchising spectrum, ie, Franchisee, and then Franchisor,(and doing both concurrently for a while as well). For all it’s good intentions the Franchising Code of Conduct is a measure that elicits fear and deceit. When I began as a franchisee there was no Code. Life was actually simpler then as a franchisee, because I had more relevant information (I use the word ‘relevant’ quite specifically) than I would have had today. As Franchisor, I recall it’s introduction and the countless hours spent trying to comply and not risk failure. After many legal briefings and guidance we developed a 100 page document call the Franchise Disclosure Document. It was unwieldy and only good for insomniacs (which includes legal and accounting people) – it was a prescriptive document as required under the Code! And now people wonder why there are uncountable failures. I’m not suggesting franchising was better in the old days – but the Franchising Code of Conduct is so full of bureaucratic bullshit, a layperson (let alone a recently arrive citizen) would struggle to understand it. The risk of falling foul of the misleading and deceptive conduct provisions where so great, it interfered with creating a better, more helpful document that could be used to improve purchase decisions. So what was trumpeted to protect has, in my view, served to deceive and fail the people it needed to protect the most. Now we have another Franchising Inquiry that will no doubt look to tighten the Franchising Code of Conduct and the Franchise Disclosure Document to become more prescriptive and more unwieldy. And so the cycle will continue.

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      1. Ask away – franchising has so many divergent issues – it is classic human relationships

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