[sulizilxia]

I've often thought that substance access needs to be completely deregulated, for drugs of abuse as well as other medications. This would increase access and competition among providers, and avoid rent-seeking kinds of economic problems in the health care market. It would also lead to better treatment of substance use problems, and kill cartels by decreasing their monopoly on production and distribution.

In doing so, you could move to a kind of competency-based system akin to what happens with people who have dementia or cognitive impairments. Basically, you're legally entitled to buy whatever meds you want, until you're deemed incompetent to make that decision. Processes could be set up whereby mental health professionals (psychiatrists, psychologists), ethicists, and the judicial system could make determinations that an individual is not competent to make decisions about the substance use purchasing due to addiction.

This might sound kind of draconian, but decisions about competency could be make pretty thorough, requiring a petition, stringent evaluation criteria involving panels and a judicial decision. It would also be dramatically less restrictive than the current system, that basically assumes everyone is incompetent to make drug-related decisions based on the specific drug.

It would also emphasize that the lack of competency is a health-related problem, and not a criminal problem.

[KGIII]

There are loads of problems with that. I agree, in principle, but I'll give you an example of a problem that already is happening.

Not every drug you take is limited to impacting just you. A good example is antibiotics. We are having serious issues with drug-resistant bacteria. Allowing people to just take antibiotics of their own free will is absolutely certain to increase the number of drug-resistant bacteria. This will, with absolute certainty, result in an increase people being killed through no fault of their own.

Could this be prevented? Nope. One might say people could be educated and that they'd make the right choices, but the very idea of that is farcical. The planet is not populated with people who make bright choices and exhibit a propensity for long-term thinking.

I very much believe in allowing autonomy over self, and I've strongly supported these ideals. However, that has to have limits in a functioning society. As much as I'd like to say we should be able to take all the drugs, there is a need to draw some lines. We can move those lines, and I think we should, but eliminating them entirely is absolutely certain to harm innocent people at a level I am unwilling to support.

[xpinguin]

Do you really think, that general populace's misuse of antibiotics could cause the development of resistant bacterial strains en masse?

I might be wrong, and if so, please don't hesitate to provide some factual paper, yet my intuition suggests that in order to obtain solely by selection (under the pressure of a _single_ bioactive substance), a bacterial strain, that is, simultaneously:

- resistant to the aforementioned substance

- stable: resistance is not lost after the generation or so, past the moment when exposure is over

- contagious: strain is resistant to different immune systems (w/o losing its resistance to the substance, of course),

one either needs to perform a directed selection (eg. like that for apple-trees), or to create an environment, where really _huge_ bacterial population could thrive and persist for a long time: like that in hospitals or farms, - where not only frequent turnover of living organisms along with the regular exposure to antibacterial substances do happen, but also some intermediate vessels (medical instruments, ground, water supply, etc.) are available for bacteria to flourish in-between living hosts.

[croatially]

> Do you really think, that general populace's misuse of antibiotics could cause the development of resistant bacterial strains en masse?

Of course not. There's 7 billion people, and just a tiny percentage uses antibiotics.

There's around 60 billion land mammals raised by humans every year, throughout their life most of them use the strongest antibiotics. It speeds up growth, it prevents silly deaths, increases profit.

Diseases, plagues will come from livestock, as they always did, not from humans.

[dbrazel]

In the absence of antibiotics, there is selective pressure to eliminate the genes or mutations that confer resistance. However, there are opposing factors - antibiotic resistance genes are often carried on plasmids, independent genetic elements that can be exchanged between bacteria. Plasmids that contain antibiotic resistance genes frequently also contain heavy metal resistance genes[1]. This allows for co-selection, where the presence of, for example, mercury pollution from coal-fired power plants will maintain antibiotic resistance in antibiotic-free environments[2,3]. Plasmids can act as parasites on their bacterial hosts - many carry pairs of genes that encode both a toxin and a less stable antitoxin. If the plasmid is lost, the bacterium will die[4]. All of these mechanisms can maintain antibiotic resistance without antibiotic exposure.

[1]: http://www.cell.com/trends/microbiology/abstract/S0966-842X(...

[2]: https://link.springer.com/article/10.1007/s00284-012-0194-4

[3]: http://www.tandfonline.com/doi/abs/10.1080/01490450902889072

[4]: http://www.annualreviews.org/doi/abs/10.1146/annurev.micro.5...

[specialist]

I think bad policy leads to bad outcomes. When people are given good information, they make good decisions, on the whole.

As a parent, I was pretty pissed off when I learned that over use of antibiotics harms my child, my society.

As a citizen, I'm pretty pissed off that (one aspect) of the opioid epidemic is because doctors changed pain management protocols, without any followup testing, assessment.

“We started it”: Atul Gawande on doctors’ role in the opioid epidemic

https://www.vox.com/2017/9/8/16270370/atul-gawande-opioid-we...

[specialist]

Deregulated (or decriminalized) doesn't mean unguided, untracked.

Why should antibiotics be treated any differently than psychoactives? And how could empowering individuals, accepting mistakes will be made, be any worse than our (USA) current system? We currently have people self-medicating with supplies from pet stores and veterinarians.

Actually, thinking about it, to your point, poor compliance is because of barriers to care. Making it easier to receive care will improve outcomes.

The most successful efforts replace enforcement (of controlled substances) with treatment, counseling. Imagine if all drugs could be bought at your local pharmacy, where customers can be advised, counseled.

My pharmacist is just a pill pushing bookkeeper. I'll have to ask her if she'd like to use her degree, training, experience for actually helping people, rather than just checking eligibility and collecting copays.

[chicob]

>Could this be prevented? Nope

Pharmaceutical marketing has a role in antibiotics mis-usage, and it can be regulated a lot better. I know people that take AB for the flu, or simply don't take the whole prescription. But at least where I live one cannot get AB without a prescription. Why would a doctor prescribe AB for common viral diseases? Bahamas, that's why.

>We can move those lines, and I think we should, but eliminating them entirely is absolutely certain to harm innocent people at a level I am unwilling to support.

I agree. It's a bit like seat belts or bike helmets: they're mandatory for our own good. Before it was mandatory, people use it if they wanted and took unnecessary risk.

But there's always a fuzzy middle ground...

The general reaction for substance usage goes around 'well it's really up to you, unless you're driving/someone depends on you'.

But as for driving a bike not wearing a helmet, people are a lot less lenient, even if the only person harmed is the self. And this is even before considering welfare, hospital expenditure and such.

Do we need protection from ourselves? Does this just boil down to economic and state welfare efficiency? Less diseases is good because Economy? Or is this a way of maneuvering Economy towards a place where economic interest aligns with principles of human dignity? Sometimes I wonder.

[KGIII]

The comment I was responding to was suggesting that we deregulate all drugs, including prescription drugs without addiction potential. I was mostly addressing that and using antibiotics as a good example.

With antibiotics, it's a bit like vaccinations. Vaccinations are as effective as they are because they provide herd immunity. Not everybody is vaccinated and the vaccinations aren't always effective, but enough people are vaccinated so that it provides protection for everyone, including those who haven't been vaccinated.

Antibiotics are similar, though the effect probably has a different name. Bacteria reproduces very, very quickly and the growth is exponential. We already have a problem where bacteria has evolved to be resistant to our current crop of antibiotics.

It's also important to note that developing safe antibiotics is extremely difficult. I believe I read that there are only two new antibiotics currently in the human testing phase and that no new antibiotics have made it to market in over a decade.

So, we already have a problem with antibiotics being over-prescribed and bacteria evolving to survive the attack. This is a known problem and an increase in people taking antibiotics is going to speed this up. This isn't something that's in doubt, it is absolutely what will happen if humans are given unrestricted access to antibiotics.

We will take more, we will see bacteria evolve, and that is going to result in stringer infections that kill people who may have, as individuals, never once abused antibiotic medications. It's not quite the same as herd protection, but it is fairly close.

I'm pretty much in favor of legalizing drugs. I absolutely believe we should be able to take drugs. I even believe we should be allowed to take drugs that have a good chance at killing us. I firmly believe the right to life should also include the right to die.

What I don't believe in is that the right to life includes the right to harm others. With all rights, there is a risk of harm to others. That is just a fact of a free society. The problem here is that these acts will harm many. Many, many people would be harmed by this.

I absolutely support the right to own a firearm. In no way do I support the right of an individual to own a weapon of mass destruction. I'm okay with someone owning a fully automatic firearm. I'm not okay with someone owning a nuclear weapon.

Does that make sense? I'm trying to explain it as well as I can.

It's not really protection from ourselves, unless you mean collectively. It's protection from others who would cause us harm through ignorance. From an economical viewpoint, healthier people are more productive - to touch on your last thoughts. Fewer diseases is good. Fewer diseased people is even better. Unfettered access is going to increase the number of sick and suffering, and not necessarily through the fault of the afflicted.

[sulizilxia]

The antibiotics example is one type where I admit some kind of regulation (aside from competency) might be in order. I.e., where tragedy of the commons-type scenarios arise.

Still, even in that case, I think you might be better off regulating at the point of sale by pharmacists, kind of akin to pseudoephedrine. I also think situation isn't quite as clear cut as it seems on the surface, in that currently antibiotics are overprescribed anyway, suggesting that our current regulatory regime isn't really working in those cases well either. In any event, my sense of the antibiotics literature is that a, if not the, major contributor to environmental antibiotic resistance is agricultural in nature.

[tim333]

Regarding antibiotics, although I don't have numbers, in most 3rd world countries they are freely available in shops for prices starting at less than $1. I wouldn't mind betting more lives are saved by their free availability where there isn't easy/cheap access to doctors than are lost through drug resistance.

[kwhitefoot]

What do you get for a dollar? A whole course or just one pill? And how much of a person's income is that price, is it really cheap or does it just seem so to those of us who are in rich countries?

[tim333]

Last time I did it it was 30c for a course (8 pills) of Cipro in Cambodia. I assume that's fairly cheap for locals too - you can't buy much of anything for that even in Cambodia.

[JamesBarney]

I still think anti-biotics should be heavily taxed, with exceptions if you have been diagnosed with a bacterial infection

[KGIII]

They currently come with the added price of needing a prescription. Doctors usually charge for this service. I'm not sure that a tax is going to do much to dissuade people.

[JamesBarney]

A large amount of anti-biotics are used livestock. Also I think I'd anti-biotics cost an extra $100 if the doctor is giving you a just in case anti-biotics then I think some people would think twice.

[Fnoord]

Don't worry, many wouldn't think twice. They simply can't afford $100 USD meds.

[craftyguy]

> Not every drug you take is limited to impacting just you. A good example is antibiotics.

Is there anyone addicted to antibiotics? No? Red herring.

[KGIII]

Red herring? It was a direct response to your comment about making all drugs, including prescription drugs, deregulated. It was YOU who mentioned, specifically, drugs of abuse and other medication.

[craftyguy]

That wasn't my comment..

[occultist_throw]

Actually, yes.

It turns out there's some HIV antiretroviral that, instead of being ingested, is smoked proves one hell of a high.

The problem is that in Africa where these drugs are readily available, they are being smoked. The worry is, that HIV will mutate and become immune to those ARV's.

[pizza]

I can only see this ending up like the earlier psychiatric practice of mass-lobotomization did. The same types of alliances of ethicists, the judicial system and mental health professionals collaborated then, too. They really believed that they were doing the humane thing by taking the matter of competency into their own hands and justifying what can only be called torture in the name of therapy.

The existence of any social or institutional mechanism that gives one esteemed category of people the right to deny someone else's rationality is always abused. Not even only abused with small probability, it becomes the norm. Therapeutic authoritarianism produces labels like "drug addict" which only results in widespread persecution of people who don't follow society's preference of correct drug usage; soon people who are the wrong weight might also become deemed 'incompetent to make good-hearted decisions based on the specific drug', or their specific religion, or their "oppositional-defiance disorder" etc..

Could you imagine if we said "people who go to work everyday are helpless because their incompetence prevents them from seeing that they are only doing it because their brain has been rewired to make them depend on their salary for satisfaction" or the seemingly innocuous but even more insidious version, "oh, I did hear that new studies showed that some people are just genetically predisposed to employment.. it's not their choice, it's a disease, you know. Haven't you heard about the long-term epigenetics in the reward center? The brain becomes rewritten!"

The thing called addiction is itself little more than the fear that drugs make a person incapable of choice, their free will. Not surprisingly, in pursuing the desire to correct individual behaviors with state-sanctioned superstition, a decades-long nightmare of rights violations and moral duty to dehumanize 'addicts' in the name of therapy ensued. It's like using thermite to put out a candle. Any transformation of the approach to drug use that forfeits the people it's supposedly benefiting from the regularity of the guaranteed rights granted to all of society is doomed to be the opposite of their freedom..

[smallnamespace]

> The existence of any social or institutional mechanism that gives one esteemed category of people the right to deny someone else's rationality is always abused.

Unless you qualify that statement more, I read it as a blanket indictment of basically any institution with any decision-making power over individuals.

This logic can be equally used to indict:

- courts (because they can throw people in jail and take away their rational decision-making power)

- the military (killing people obvious removes their ability to make decisions)

- taxation (removes the ability to rationally how to allocate a portion of their resources)

- laws (it restricts the freedom of rational individuals to decide right and wrong for themselves)

A heuristic that is so broad that it can be used to paint nearly every social relation in a negative light is not a useful heuristic, because it doesn't let us profitably separate the chaff from the wheat.

The question should not be whether turning addiction into a medical rather than criminal problem would be completely free of abuse. It will not be, because humans and human institutions are imperfect. The question is whether this would be better than the status quo, and it seems like it would be.

What's worse -- no longer having the right to purchase certain drugs, subject to the decisions of a medical bureaucracy, or letting the legal system imprison you for years, like we currently do?

[pizza]

Those things are all perfectly indictable, though - and my indictments do not stem from a failure to attain perfection; but rather, because of the way their real world implementations behave, they are prevented from anything but the complication of society's ability to achieve their noble goals.

I don't intend to say that coercive systems are abusive because they contain an element of coercion by design. Rather, the people they (aim to) abuse (by design) in practice diverge significantly and often hypocritically from the malefactors whose intolerability was so great they caused the hunt in the first place.

I am not simply arguing coercion is empirically unethical, nor that coercion must be perfect, nor that there are no differences between different instances of coercion.

A difficult example where you need to coerce is when someone has Alzheimer's. If your mother has Alzheimer's, you had better provide care for her because the very material (therefore identified because of reliable differentiability of physical matter) brain disease (the opposite of an immaterial, and only socially-identified disease) that prevents her from accessing her existing body of evidence of the world can still be supplanted for her sake, by you as her child, so the kind of capacity of 'self-honesty' that Alzheimer's steals from the elderly can be compensated in a way where you take responsibility to 'donate' her self-identity back to her.

A simpler example is: if you are crossing the street with your young child, and your child darts out into the street in the path of an oncoming car, your duty is nonetheless to forcefully grab them by the arm if possible, because the child wants to survive instead of die by mistake.

I guess that I am trying to say that exactly because each of your examples (courts, law, taxes, mil) fails to meet the exceptional ideal they establish to allow their exception, they just tend towards abuse of privilege (in the sense that the expectation of the injustice from using the privilege is greater than the expectation of the injustice resulting in not using the privilege of coercion).

The thing they have in common is overestimating the frequency of hard successes that their proponents intend. They often inflict more damage to 'false positive' peripheral individuals than they prevent by coercing the 'true positive' individuals they are meant to stop. Therefore they stray very far from their aim. It is the aim that society is improved - but still respects the individual - that necessitates justifying the coercion that transcends the danger of catastrophically legislating coercion.

- courts are currently so beyond their capacity that the norm in >90% of cases (iirc the number correctly, but i am unsure that the statistic is accurate; merely that the percentage is unbelievably high suffices) is to state a lie over one's guilt and accept a plea bargain because the courts are so crowded due to draconian law that they cannot serve as instruments of justice without causing greater, indiscriminate injustice; the pressure for courts to move forward hastily + the laws whose inappropriate scope and severity harm the ability to achieve justice means their combination results in a failure to meet their social obligation to their optimal capacity of ensuring justice for all. You really have to believe there is a benefit to the guilty for living in a society where punishments for crime must be optimally minimal in misallocation. Justice is not the most ruthless form of litigation that results from encouraging self-inflicted punishment a priori for people who become accused. This is more self-referentially crucial to the ideal of justice itself, irrespective of the drug war at all.

- the military often grows because of the work of people who would prefer less of their taxes go to killing and more towards American prosperity. An example of this is Trump's "America First" doctrine having the opposite cost of his more important doctrine of devoting a plurality of funds to national security. The contradiction between the military and taxes is not because the military kills people that Americans don't want nor that taxes don't improve expenditure towards things America wants, but rather because they achieve unity in spite of expression as contradicting ideals:

+ A) our national security is the most important thing we can spend money on, because survival comes before the ability to even benefit from any other expenditure, and

+ B) we only permit taxation in the first place because taxation gives a non-zero-sum benefit for fulfilment of society as a collective beyond each individual only worrying about their own security

My argument is itself a heuristic argument, I would say:

expectation of iatrogenics (harm of the healing) of avoiding iatrogenics of epistemically-flawed institutions < expectation of iatrogenics of epistemically-validated but non-institutionally-remediated concerns < expectation of severe unknown iatrogenics you become exposed to by succumbing to compulsive institutional remediation of lesser, known iatrogenics

If I understand correctly, all you need to do to heuristically estimate which is most harmful in the big picture is to pick a large number K that you use to compare probabilities [0]. The severe outcome for which the probability P(Outcome | Outcome > Harm severity K) is most harmful for those probabilities where P(outcome | outcome > k) is proportional to k*outcome; so large, widespread minor policies can incur massive damage.

[0] Taleb, Silent Risk (forthcoming), Chapter 1

[Broken_Hippo]

I agree that most recreational drugs should be legalized, even if I would never take them. Some would require a few tests to check how much you can safely take, along with education about safe use and so on. This would include a few prescription drugs - such as "study drugs" - that are taken recreationally. Some things might require limits on frequency of purchase to limit side effects. I think this does help for not only addiction, but to help folks not freaking overdose or get a different drug than promised. They should have the same purity and strength standards as something like alcohol or prescription drugs.

A few prescription drugs could easily be considered safe for the public to use, some of which might require a pharmacist's advice. This would include things like birth control pills, 400 or 800mg ibuprofen, erectile dysfunction pills, and things I have never really considered.

But I disagree with most prescription drugs being sold without a doctor's orders. Some drugs are outright dangerous to overuse - antibiotics, for example. Some (most) drugs are really helpful to the right patient, but they need some medical oversight. Lithium, a psychiatric drug, needs to be monitored through blood tests to make sure the dose is within the therapeutic range. Some antifungal pills (as well as a range of other medicines) can cause liver damage. Sleeping pills have their own risks, as do prescription cough syrups. And so on. These aren't things folks are taking in their spare time for the fun of it. I think the actual solution is to make sure folks can afford their doctor's visits and medicines as well as having a comprehensive protections to make sure folks can take care of their health, including paid sick days (more for parents, since they are responsible for other's health as well and can't exactly leave the 7-year-old at home).

[_ph_]

I strongly disagree. Yes, most substances should be decriminalized. But they should not be completely deregulated. Not even alcohol or tobacco are deregulated. And for a good reason, we don't want to give 10year olds free access to alcohol for example.

Many drugs should be taken only under supervision of a medical professional. So the current system of doctors and pharmacies overall is a good system. We might give pharmacists more powers - they tend to be more knowledgeable about pharmaceuticals anyway, but drugs don't belong on supermarket shelves.

[emmab]

> Processes could be set up whereby mental health professionals (psychiatrists, psychologists), ethicists, and the judicial system could make determinations that an individual is not competent to make decisions about the substance use purchasing due to addiction.

These would be abused. People would be told that they're categorically unable to consent for being LGBT.

[sulizilxia]

Without meaning to be dismissive, I doubt that would happen in the US at least at this point in time. And to the extent it did happen, there would be bigger problems to worry about.

Determinations of competency already happen in the US for all sorts of reasons. I'm not saying it's perfect by any means, and that it doesn't get abused, but the abuse of that system pales in comparison to abuses under the current drug enforcement and regulation system.

Personally, I am for complete unrestricted deregulation, but I can see issues around liability for providers, arguments about actual competency to decide, etc., and treating it like other forms of competency decision seems like one mechanism to address that.

Medically speaking it seems like the same situation to me as competency issues due to other forms of neuropsychological incapacitation.

[hutzlibu]

"Processes could be set up whereby mental health professionals (psychiatrists, psychologists), ethicists, and the judicial system could make determinations that an individual is not competent to make decisions"

Isn't that allready pretty much the case?

If a person gets demented, cracy, whatever - then other people around them notice and take action. Hospital, Judge s. There are also other issues than drugs, like driver license, firearms, childcare etc.

Not that it is really easy to determine if a person is sheep-like. Lots of gray area and abuse in that area, so barriers are quite high.

(is a suicidal person for example crazy? I think not necessarily, only in rare exceptions)

But I very much agree, that a normal, mature person should have every right to consume whatever he or she wants. While beeing still fully responsible for all her action s ...

[white-flame]

> This would increase access and competition among providers, and avoid rent-seeking kinds of economic problems in the health care market.

That would also incentivize increasing total substance use to make a profit, just like for-profit prisons create an incentive to increase the incarceration rate to make a profit. Any checks you make against use (like those competency tests) would be undermined by that incentive.

[atmosx]

> I've often thought that substance access needs to be completely deregulated, for drugs of abuse as well as other medications.*.

Now paracetamol (depon) in Greece costs 0.75 EUR. In Greece the market is regulated. In the UK where the market is not regulated and you have pharmacies selling burgers to survive while the same drug costs more than 5 EUR.

How is that possible? :-)

The monopoly you speak of in distribution (pharmacies) happens when you deregulate the market because few big players end up owning what was distributed among thousands.

I agree that more steps need to be taken, but I don't think deregulation has ever worked the way you'd think it did, for the health industry.

Ultimately many decisions stem from your personal belief on the topic:

- Do you think that drugs ought to be social goods and regulated? (social welfare) - Do you think that drugs ought to be public goods and not regulated? (private welfare)

Also note that drug research costs, a lot. Especially if done correctly. It is a fair for some firms to retain the patent for a few years (say 5?).

[DanBC]

You can buy 16 paracetamol for less than 50p.

https://www.mysupermarket.co.uk/tesco-price-comparison/Medic...

[OscarCunningham]

https://www.tesco.com/groceries/en-GB/products/255488740

[atmosx]

This costs 1.5 EUR GR:

http://beautyland25.ecrater.co.uk/p/22341811/depon-maximum-p...

I would not buy or use paracetamol from Tesco. I prefer the one made by Bristol-Mayers, which I know and trust.

[smcl]

What do you mean "pharmacies selling burgers"? I'm rarely the [Citation Needed] guy but come on that's an outlandish claim that needs to be backed up somehow