Have severe pain? It’s quite unlikely you’ll get addicted to opioids

Obviously, opioid addiction is a very serious problem that we should treat very seriously.  That said, misinformation on the matter is not particularly helpful.  And for the substantial majority of users opioids are not some incredibly addictive monster that once you start using them for that back pain, post-surgery pain, etc., dooms you to a horrible addiction.

Of course, a lot of this comes from us mis-understanding the nature of addiction.  Maia Szalavitz with a great piece on Vice on the actual reality of opioids and their abuse:

Yes, the drug companies irresponsibly and reprehensibly misused the legitimate concern that pain was being undertreated to sell massive amounts of product. Yes, Purdue Pharma inaccurately claimed that Oxycontin was a less addictive opioid—and that its effects lasted longer than they really did. Yes, salespeople pressured many doctors into prescribing far more than made sense.

“The simple story is that addiction happens all the time when people get opioids for pain and that simple story is clearly wrong,” says Stefan Kertesz, associate professor of preventive medicine at the University of Alabama.

The research actually shows that people who developed new addictions in recent years were overwhelmingly not pain patients. Instead, they were mainly friends, relatives, and others to whom those pills were diverted—typically young people. Among the older patients, many who appeared to be newly addicted had actually relapsed or never recovered from prior addictions: [emphasis mine] some faked pain to get pills from well-meaning doctors; others got them from pill mills where shady physicians wrote prescriptions for cash…

So, what is the real risk to pain patients from being prescribed opioids? This is a hotly debated topic, with the Centers of Disease Control and Prevention and news media being fond of saying that “up to 26 percent” of people exposed become addicted. This is pretty much the scariest figure available, but note that this means that nearly three-quarters don’t get hooked.

But this number cannot possibly be accurate. Some 70 percent of the population is exposed to medical opioids during their lifetime. If 26 percent of these people became addicted, we’d expect to see tens of millions of people with opioid addiction and hundreds of thousands of overdose deaths. The true addiction figure is roughly 2.5 million, or about 1 percent of the adult population, and the actual number of fatalities is horrifying enough, but it was just around 33,000 deaths in 2015…

Moreover, among patients who just take opioids short-term—such as those who have acute pain from surgery or dental work—studies find that the risk is even lower. For example, one study of more than 640,000 surgical patients who had never previously taken opioids found that few used the drugs for more than three months after recovery from surgery: rates varied from less than 0.12 percent for people who had C-sections up to 1.4 percent for those who had knee surgery. And keep in mind that most of this long-term use—as we can see from the other studies—isn’t addiction, just pain treatment…

Nonetheless, the idea that patients who take medications as prescribed are the cause of this problem is inaccurate. While the media loves to highlight “innocent victims” who became addicted through medicine, the fact is that this group is a minority. Medical use surely increased access to the drugs—but the people who got hooked tended to do so while using medication that was either prescribed for someone else or otherwise distributed illegally. [emphasis mine]

The point here is not to stigmatize those addicted to opioids, or to pretend that opioid addiction isn’t a real problem (one we could address so much more smartly), but using mis-leading narratives to address genuine public health and public policy problems doesn’t help anybody.

Chart of the day

I’m no international relations expert, but I don’t think you have to be to recognize it is in America’s interest to have people in other nations favorably disposed towards us.  Alas, under Trump, not so much:

Legislative tactical skill can’t solve everything

Okay, the Senate health bill is not dead, but it looks a lot worse off than it did a week ago.  As Sarah Kliff writes, there are still strong imperatives for Republicans to pass something:

The lessons I took from the House debate were threefold.

First, Republican legislators are really motivated to deliver on the bigpicture goal of Obamacare repeal even if it doesn’t tackle the issues they purport to have with the health law. Case in point: Republicans have lamented the Affordable Care Act’s too-high deductibles as unaffordable. They passed a bill that would raise deductibles. The key thing seemed to be passing something called Obamacare repeal even if it didn’t address the specific problems legislators had raised about the law.

Second, Republican legislators are not deterred by a lack of outside validators. We saw groups ranging from the American Medical Association to the American Hospital Association oppose the House health care bill. Conservative academics who are no fans of Obamacare joined the pile-on, too. Still, Republicans pressed forward undeterred. The conventional wisdom that a health bill needs widespread buy-in to move forward in Washington was seriously undercut.

Third, coming around to this point of view does take time. It took Republicans in the House a month and a half to wrap their minds around a major piece of legislation, make some changes, and decide to pass it. Part of this was about making substantive policy changes, but part of it also seemed to be having a few weeks to think about the alternative to this bill — which was likely passing no Obamacare repeal bill at all. Many members decided that simply wasn’t an option.

That said, no matter how much a master Senate tactician he is, McConnell is nonetheless human and trying to balance the very-much opposed of Senate conservatives and “moderates” is no easy task.  They all want to vote for a “repeal” but the conservatives want an actual repeal that truly guts Obamacare and the “moderates” seem to have at least some genuine modicum of concern for real people and their health.  That said, we saw how easy some House “moderates” were bought off with a tiny fig leaf and I worry about a similar dynamic in the Senate.  From a nice Vox discussion:

The topline from the CBO was bad news — 22 million fewer Americans having insurance — but there was a silver lining for McConnell. For reasons I won’t go into, CBO showed that he has about $200 billion to play with and still meet the savings targets he must under the procedural shortcut Republicans are using to pass the bill without any Democrats.

$200 billion is a lot of money! Especially when crucial swing votes like Rob Portman and Shelley Moore Capito have asked for nearly $50 billion in opioids funding and the bill currently contains only $2 billion.

Money might not solve all problems, especially for conservatives who want to undo more of Obamacare’s insurance regulations. But that is a lot of dough for McConnell to throw around as he ramps up the pressure.

538 had a really interesting discussions that rated how likely each supposedly opposition Republican Senator is to actually come around.  The key may be Rand Paul staying true to his libertarian principles.  I think they quite rightly point out that Ted Cruz is a completely non-credible opportunist.

And, back to the title of the post, nice NYT article on what McConnell tried and how it has not thus far worked:

WASHINGTON — Senator Mitch McConnell of Kentucky, the majority leader, has long enjoyed a reputation as a master tactician. But when it comes to repealing the Affordable Care Act, he seems to have miscalculated in the first round of play.

He assumed that his conservative and moderate colleagues would come together to make good on their seven-year promise to repeal the health care law, and quickly.

But when he assembled a group of senators to cobble together a health care bill last month, he seemed to go out of his way to exclude some of the most knowledgeable members and moderate voices on health care, like Senators Bill Cassidy of Louisiana, a doctor, and Susan Collins of Maine, an insurance expert and one of the few women in the Senate Republican conference. Views outside of Mr. McConnell’s on health care did not receive extensive consideration. [emphasis mine]

When Republicans from states that had expanded their Medicaid programs quickly found themselves at odds with more conservative members who wanted a large rollback of Medicaid, Mr. McConnell did little to allay those worries. Conservatives generally wanted to rein in costs while moderate members wanted to increase spending, particularly in states where health care costs are high and opioid addiction is escalating.

Perhaps this was, indeed, a tactical mistake by McConnell operating under the belief that “moderates always cave.”  I’m still not sure that’s not true.  At least you can now say, “moderates don’t always cave… right away.”

That said, I think the fact that the vote has been delayed till after the recess is potentially a big, big deal.  There’s a reason McConnell wanted to rush this– to make it that much harder for his caucus to face opposition back in their states.  Now they are going to and, hopefully, that opposition will be metaphorically loud and well-organized.  Drum:

In any case, the summer recess will now be an opportunity for Republican senators to find out just how dangerous a Yes vote really is. The progressive community needs to make sure they find out. And don’t forget to recruit your moderate conservative friends too. They probably have more influence with your local GOP senator than you do.

Americans love same-sex marriage

Again, the pace of change on this issue is pretty amazing.  Here’s the latest Pew survey.  Just 6 years ago support and oppose was basically tied:

And Americans of all ages have been changing:

Notice that even younger Republicans generally support:

And lastly, even the younger Evangelicals are changing fast on the issue:

Pretty clear why the right needs Trans people to be cultural villains now.

 

Smoking is for poor people

It really is kind of amazing how much American society has bifurcated on smoking.  It is more than ever a class marker of being poorer and less educated.  As I hate smoking and being around it, I will confess to being glad that my particular social stratum has moved away most dramatically.  Here’s a chart from Wonkblog:

 

This explains why I can literally think of only a single friend/acquaintance who is an active smoker.

The CDC with some nice charts, too:

Current Use of Cigarettes, Cigars, and Smokeless Tobacco Among Adults Living Below Poverty Level Compared With Those Living At Or Above Poverty Level

Current Use of Cigarettes, Cigars, and Smokeless Tobacco Among Adults With Less Than High School Education Compared With Adults With College Degree

 

Republican health care– the short version

Two great charts from Drum:

Any questions?

The political culture war

If you didn’t have a chance to read Lee Drutman’s terrific piece on the 2016 election, consider this interview with him in TNR an excellent TLDR.  Here’s the conclusion:

The fault lines that Trump exposed in 2016 aren’t going anywhere. Even with Democrats confident that the unpopularity of American Health Care Act will propel them to victories in 2018 and 2020, Trump seems to be set on hitting immigration and identity over and over again.

Hitting immigration and identity is what brought him to the White House. If that’s the most salient issue for voters, they will stay supporters no matter what he does because he’s picked the right enemies and he’s signalled that he’s on their side. If the focus is on whether he’s still hanging on to his promises of delivering government entitlements, he loses. If the question is over American identity, he has a chance of retaining support.

If you think about it, the takeaway—which is a broad takeaway on American politics—generally on economic issues, on welfare issues, the country’s overwhelmingly liberal. On cultural issues, the American population is conservative, particularly in rural areas that tend to be overrepresented in our system of government.

Trump was able to pitch himself to voters as a marriage of social conservatism and economic liberalism, arguing that he would maintain (and possibly even expand) the welfare state. He’s clearly going back on many of the promises he made on the campaign trail and he won’t be able to run as a unicorn in 2020. Could that cost him his presidency?

Well, it may. That may be the case, but it may also be the case that as long as Trump maintains the right enemies, then he seems like he’s still the lesser of two evils to many voters. Republicans may succeed by making Democrats look like the party of globalist multiculturalism undermining American Christian greatness. That could still be enough to win.

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