[Gatsky]

This is a thorny topic. The trouble is that when a large number of people take a drug, rare but horrific side effects may manifest. How do you factor this in to deciding an appropriate level of regulation? Is it fair that we permit easily accessible experimentation with psychoactive or nootropic substances, when someone downs a few too many, has a psychotic episode and drowns his children? Or has a fatal allergic reaction? Or drives their car off a bridge because they have been awake for 96 hours taking one of these products? That may sound outlandish, but eventually something like this will happen to someone if enough people take it.

So I don't know if you can just couch it in terms of personal freedoms... it seems a bit more complicated than that. I don't know what the answer is, but pretty sure it isn't just 'Let people do whatever they want.' At least with heroin and cocaine people have some idea about the risks, even if they decide to ignore them...

[MichaelGG]

How do we handle alcohol? You tell people that modifying yourself isn't an excuse for committing crimes. And follow up and enforce that. Making it a crime to use chemicals on your own mind is absurd.

With heroin, the biggest risk is the fact it's illegal, thus preventing you from obtaining clean, known-quantity medication. If Tylenol was sold on the streets, with pills ranging from 100mg to 1000mg, we'd have a LOT more liver toxicity cases than we do. It's not like using opiates in a correct manner leads to death on a routine basis.

[Gatsky]

1. Countless lives have been destroyed by alcohol. Busted up families, people killed by drunk drivers, children maimed by fetal alcohol syndrome, abused wives, husbands and children, fried brains, fried livers and across multiple generations... Why would we want to repeat that experience? If alcohol were invented today it would never be in widespread use like it is now. It's become a lifestyle thing because of thousands of years of culture and legacy. It's a prime example of why your approach is a terrible idea.

2. Heroin is a highly addictive substance, that will kill you in sufficient qualities. You don't see that as a problem?? Even if it were cleanly packaged with a black label, people would still take too much and die from it. Cute example with Tylenol, but doesn't cause dependence and withdrawal. Opiates are given to people with pain, where they have a fundamentally different physiological effect.

[MichaelGG]

My comparison to Tylenol is apt. If you bought pills thinking they were ~100mg, but they were 10x that, you would soon find yourself with a broken liver. To be clear Tylenol will kill you in sufficient quantities, amounts you're likely to easily by from a store.

Opiates do not have a "fundamentally different" effect if you're in pain. I think people like saying that about opiates and stimulants so as to excuse people that "need" it.

And yes, personal freedom is worth people choosing to rip apart families.

[Gatsky]

Just to clarify, I'm not advocating criminalisation of nootropics, and I completely agree that the war on drugs is pretty stupid.

The point is about dangerous usage patterns. You are trying to argue that hard drugs are actually not that bad if only they were available with the same safety and dosage rigor applied to approved pharmaceuticals. My point is that it isn't an apt example because nobody gets euphoric or addicted when they take Tylenol. Any drug that causes some physiological disturbance in sufficient quantities is going to be more dangerous if that drug is taken by users in ever increasing quantities.

> Opiates do not have a "fundamentally different" effect if you're in pain. I think people like saying that about opiates and stimulants so as to excuse people that "need" it.

It is different. Say a patient has severe pain from metastatic breast cancer. I can give them a dose of morphine that would stop you from breathing permanently, and they will be fine. Are you saying she didn't really need it, she just likes the rush? I don't understand your point, maybe you can clarify. The rates of opioid addiction in people receiving it for pain are much lower than you would otherwise think from the way people buy oxycodone on the black market.

Personal freedom? What about the personal freedom of the kid who gets bashed by their drunk parent? Or the personal freedom of the cyclist that gets run over by a drink driver? Or the personal freedom of the emergency department nurse that gets her ear bitten off by someone with amphetamine induced violent psychosis?

[MichaelGG]

No, my point is that "hard drugs" like heroin are vastly more dangerous because users cannot use properly whilst the drug remains illegal. It's a manufacturing and usage problem. Opiates are rather tame as far as side effects go, and avoiding overdoses isn't terrifically hard if you have the right stuff. Users don't want to waste precious medicine, nor die. With precision markings, there'd be vastly less problems reaching the right level of usage. Instead, users are admonished to "do a test shot" each time, which, through laziness or practical concerns, gets ignored and someone falls out.

But let me understand you: Are you saying that if someone is in pain, their respiratory system just ignores opiates and they can take large doses even if they're opiate naive? Does this work retroactively, like if you don't have Narcan handy can you just snap someone's leg to save them? (And then, with a broken bone, they'd certainly get medicated - double win!)

Sarcasm aside, do you have a citation for this claim? That opiate tolerance doesn't matter in face of pain? That there's a "fundamental difference" in the effect? I'm truly interested in hearing about that (feel free to contact me via my profile if this thread is too long).

Everything I've read and experienced says otherwise. I've talked with some users that were taking opiates for cancer pain management, or for otherwise long-term pain, and they just as happy to take them as unlicensed users (though perhaps a bit more cautious in admitting so). In personal experience from acute trauma leading to a hospital team applying morphine, I went from screaming in pain to absolute noddy-head bliss. I'm pretty sure that's the exact effect people are seeking.

[Gatsky]

I agree they are vastly more dangerous because they are illegal. But you know, alcohol is legal, and people still binge drink, fall in ditches, have random unprotected sex, get pancreatitis etc... and it isn't even addictive. I'm just trying to say that even if heroin were legal, it would still be unacceptably dangerous, because at the end of the day it's a highly addictive general anaesthetic. Even with 'vastly less' problems, which is your conjecture, there are still significant problems. Anyway, we both clearly think that harm minimisation is a good policy.

Yes, that's right, if someone is in pain, the respiratory depression is less. This is evident to anyone that prescribes opioids regularly or looks after people with chronic and acute pain (as I do). It is also evident that the ever escalating doses and withdrawal symptoms demonstrated by recreational users of heroin for example, are not manifested in people with pain. So that's why I use the word 'fundamental difference', because the coupling between dosage, physiological response and behavior is completely different.

Lots of people don't enjoy taking opioids, they get nausea, nightmares, constipation etc, or it just doesn't work for their pain. I know this because that is what is reported in controlled trials, and because people complain to me about these side effects all the time.

Reference: http://www.ncbi.nlm.nih.gov/pubmed/8867254

More general overview: http://bja.oxfordjournals.org/content/100/6/747.full

(Glad you are truly interested, but in the time it took to write your sarcastic comment, you could have just googled it, and we'd both be better off right now.)