Drug Addiction: 4 Broad Solutions

A couple of weeks ago I wrote about what addictions entails and the importance of not labeling it as a disease. Now I want to push a train of thought towards possible solutions.

Train Of Thought?

I frequently use the phrase “train of thought” as opposed to the rigid, formulaic solutions that plague our political landscape because the world nowadays is too complicated for that mindset. I try my best not to align with any particular group or political party because they inherently limit themselves in terms of perspective. This cult-like thinking leads itself to naive notions of utopia; there is no final state of understanding. The “train of thought” mentality is wonderfully explicated by The Zeitgeist Movement (TZM) in their book. Here’s a small quote from page 10:

“Therefore, what is left can only be a train of thought with respect to the underlying causal scientific principles. TZM is hence loyal to this train of thought, not figures, institutions or temporal technological advancements.

Solution #1: End The Drug War

This may seem like an obvious solution (it is) to anyone who pays attention to the research, but I think the magnitude of this harmful, so-called ‘war’ needs to be regularly delineated.

In my view, without addressing the drug war, any other proposed solutions will have an infinitesimal impact. This is because the drug war has a litany of problems that encompass nearly every facet of daily life. I’ll list some of the focal points provided in a 2011 United Nations Office on Drugs and Crime report. Keep in mind, I’m only giving a bullet-point summary, so I encourage everyone to read the full report.

1) The drug war wastes billions:

• Globally, $100 billion/year is spent on drug law enforcement
• Specifically, regarding the United States, about $51 billion/year is spent on the war.

2) The drug war undermines security/health, fuels conflict:

• Illicit drug profits fund subversive, paramilitary and terrorist organizations
• This refocuses public spending from health to drug enforcement

3) The drug war actually creates more crime:

• Drugs are the world’s largest illegal trading commodity valued at $330 billion
• The increased financial power justifies more drug enforcement spending which leads to more arrests and violence; it’s a perpetual cycle

A more recent study from the John Hopkins Bloomberg School of Public Health had similar conclusions: not only has the war failed to reduce drug use, but it’s also having a negative impact on HIV rates and overall public health.

So if it doesn’t help with reducing drug use or crime, and actually worsens general public health, why would we continue with this costly method? I see no legitimate justification for continuing the drug war and its draconian punishments.

Solution #1.5: Abolish the Drug Enforcement Agency (DEA)

I put ‘1.5’ because the drug war and the DEA are, of course, inextricably linked. In my view, ending the drug war must be done in conjunction with abolishing the DEA.

Admittedly, I realize that whenever someone advocates for the outright removal of a government agency, they almost always sound hyperbolic. Take, for instance, Rick Perry’s intrepid proposal of wanting to eliminate 3 major government agencies during his 2012 primary campaign. One the agencies, which Mr. Perry momentarily forgot in a debate, was the Department of Energy. This is the agency that is responsible for maintaining our nuclear stockpile; a profoundly vital task, even if you think all nukes should be dismantled. As a result, the Department of Energy has at least one legitimate justification for its existence. I included this little side-tangent because I believe the DEA doesn’t fit this criterion of legitimate justification; their costs heavily outweigh their benefits.

In fact, their lack of legitimate justification can be proven from the onset of the war itself in the early 1970’s/1980’s. Drug-related crime was actually declining during this period; a disconcerting reality highlighted by Michelle Alexander in her book ‘The New Jim Crow.’

More specifically, the DEA have a laundry-list of issues. Stealing $16,000 from a traveler on an Amtrak train, meddling in medical records without probable cause to arrest alleged drug offenders, and paying 18,000 informants $237 million over five years with little oversight and no proof of reliable intelligence, as a result, are just a few examples.

To be fair, these are isolated instances, but they’re symptomatic of larger problems. These problems include being a burden on the taxpayers, committing racial discrimination, using failed supply-side methods (e.g. seizing large quantities of drugs; the efficacy of this approach has yet to be demonstrated) to reduce demand for illicit drugs, and committing many human rights cases of abuse. The Drug Policy Alliance has a short report that explains how and why these problems are perpetrated by the DEA.

Solution #2: Reducing Income Inequality 

At a glance, the link between income inequality and drug use might seem tenuous at best. However, Richard Wilkinson and Kate Pickett in their book The Spirit Level have provided the necessary research to fortify this link.

Wilkinson and Pickett use the 20:20 ratio measure of income inequality from the United Nations Human Development Index for the chart displayed below. The rates of drug use are from a 2007 United Nations World Drug Report. 

 Rates of drug use are lower in more equal countries, but why?

The authors posit that the emotional pain that comes from being in a low position in a social hierarchy as a possible reason. They support this claim by citing a study in Nature Neuroscience; a study which had an interesting conclusion:

“These data demonstrate that alterations in an organism’s environment can produce profound biological changes that have important behavioral associations, including vulnerability to cocaine addiction.”

Another study from Purdue University showed that social isolation or exclusion in this increasingly stratified society can lead to increased rates of depression and feelings of helplessness. This ostracization is also linked to increased intravenous drug use, homelessness, and irregular employment. Granted, the NIH study only looked at 1,879 people from 10 European cities, but the detrimental psychological effects of social exclusion in humans are stable.

These individuals who ruin their lives through drug use and general delinquency are also not entirely culpable for their “choices.” I’ll use the same quote I used in my prior post to reiterate this point of limited responsibility from Dr. Gabor Maté:

“Freedom of choice, understood from the perspective of brain development, is not a universal or fixed attribute but a statistical probability. In other words, given a certain set of life experiences, a human being will have either a lesser or a greater probability of having freedom in the realm of psyche. A warmly nurtured child is much more likely to develop emotional freedom than is an abused and neglected child. As we have seen, the in utero and early childhood experiences of hard-core addicts will likely diminish the possibility of freedom.”

Solution #3: Decriminalize All Drugs

A lot of countries have decriminalized drugs, but I’ll focus on Australia and Portugal because they’re both major, democratic countries analogous to the United States. The degree of decriminalization differs in these countries, but even a modicum of progressive reform yields positive results.

Australia

A report from the University of New South Wales found that a decriminalization program would reduce criminal justice system costs, improve employment outlooks, and have virtually no impact on drug use/crime. I think the fact that decriminalization has almost zero impact on drug use might provoke some cognitive dissonance in some people, so allow me to expand on that realization; from the report:

“Drug use rates don’t change or dramatically increase when the laws are changed to introduce decriminalisation. Research from across the globe has consistently found that decriminalisation is not associated with significant increases in drug use.”

The “research from across the globe” that they’re referring to is from the book Drug Policy and the Public Good. A book that was written by a combination of addiction, public health, and criminology scientists; a summary can be found here.

It’s important to note that in Australia, many people continue to be sent to court for possession of drugs, and they have yet to officially remove criminal penalties by law. However, in six of the countries eight states, De facto reform is provided. This means that citizens caught with illicit drugs are subject to a police referral for education, assessment, and treatment. Non-compliance with this may result in criminal penalties, though.

Portugal

Portugal decriminalized all drugs in 2001. Since then, the results have been overwhelmingly positive, despite some claims to the contrary.

A study published Law & Social Inquiry found that general, lifetime use among adults (15-64) did increase; this seemingly contradicts the above statements about  However, it’s worth pointing out that lifetime use is a very poor (UNODC, p.12) measurement for drug trends. Past-year and past-month, which are better indicators of drug use, have actually decreased.

According to a report from the Transform Drug Policy Foundation, decriminalization of drugs in Portugal led to extraordinary improvements in health, drug-related deaths, and crime:

• Newly diagnosed HIV cases via drug injection went from 1,016 in 2001 to 56 in 2012
• New AIDS cases via drug injection also decreased from 568 in 2001 to 38 in 2012
• Deaths due to drug use fell from 80 in 2001 to 16 in 2012
• Percentage of drug-related offenders in prison declined from 44% in 1999 to 21% in 2012

What the numbers don’t reflect on is the cultural change that stems from this sort of policy. Over time, drugs and drug addicts will be less stigmatized; stigma which is associated with poorer mental health and increased stress on an individual. I’ll let Dr. João Goulão conclude this section.

Solution #4: Legalize, Tax, and Regulate all Drugs

This is going to require lengthy explanation given the scope of the proposed solution. And yes, I am talking about all drugs: marijuana, alcohol, cocaine, heroin, LSD, mushrooms, methamphetamine, and opioids should all be legalized for purchase by any individual aged 21 or over. An important caveat to add, however, is that this shouldn’t be done on a whim by a government or society; incremental changes via education, treatment, regulation and decriminalization need to happen first. People need to be aware of the dangers and prior to having a plethora of powerful drugs immediately available to them.

Some people might be quick to think that this policy would instigate a dramatic spike in addiction rates. Yet, this hypothetical concern rests on the assumption that drugs directly cause addiction or, at the very least, lead to a higher likelihood of addiction. I think these fears are exaggerated because it ignores the majority of people who do not become addicted.

General Trends

I’ve already addressed the “drugs cause addiction” myth in my previous post, but here’s a piece from the section which addresses the big picture:

“According to Dr. Carl Hart in an interview with Democracy Now, 80-90% of people who use drugs don’t become addicted as I’ve defined it above–they handle their daily responsibilities. More specifically, it’s about 10-15 percent for alcohol and 15-20 percent for crack cocaine. This isn’t to say that 10-20% ruin their lives with drugs or spend every waking moment looking for their next hit like a desiccating vampire. They simply fit one or more of the criteria that indicates a potential problem. Even the ostensibly maniacal crack addicts that pervade our TV shows and news will display rationality and opt out of a free, immediate high when economic alternatives are presented.”

Dr. Carl Hart, in an interview with Radio Boston, also explains how most people are misinformed about the frequency of use. The number of individuals who have used heroin in the past 30 days in the United States is about 430,000; for marijuana, it’s about 22 million; for cocaine, it’s about 2 million; and for methamphetamine, it’s about 600,000. So it’s critical to maintain a proper perspective when reading newspapers, especially regarding heroin.

I think part of the reason we, as a society, think the number of people being addicted to harder drugs like heroin and methamphetamine are higher is that we typically only see the worst examples on the news. The users that are going to work, paying their rent or mortgage, and handling their daily responsibilities probably aren’t going to be very vocal about their drug habit, understandably.

Opioids

In my view, opioids should be on the same shelf as Tylenol and Ibuprofen (see the ‘Regulation’ section for more). Instead of jumping through hoops to get a prescription, the onus should be on the individual to make a responsible decision based on the amount of pain he/she is in. And most people, in fact, would make the responsible choice. Don’t believe me? Try pondering a thought experiment that includes alcohol:

• If you’re 21 or over, you can purchase enough alcohol from any gas station or store to kill yourself with relative ease. However, you, like most people, don’t do it; you handle the drug responsibly. Why do you think this is? And why, if alcohol can be managed responsibly, do you believe that this couldn’t apply to other drugs?

Coming back to opioids, their use in treating non-cancer patients with chronic pain, according to a study from the Journal of the Royal Society of Medicine, doesn’t carry a high risk of addiction. The authors of this study have a revealing conclusion:

“The published work on comorbid chronic pain and addiction is dominated by opinion rather than evidence. We suspect that, as happened previously with acute pain and palliative care, fears about addiction from opioid therapy in chronic non-cancer pain have been excessive. This is not to argue that opioids are always the drug of choice for chronic pain—just that excluding them a priori appears based more upon ignorance than on science.”

Education: Addressing Common Concerns

*This section is about challenging the biggest fears about opiates and heroin that our society currently holds. I’m not attempting to downplay the negative health impacts that these drugs can pose, nor am I saying they can’t be addictive. I’m strictly trying to downplay the delirium that is percolating throughout the media about these drugs. As is pointed out by beer commercials: use responsibly.*

When I eluded to education at the beginning of this solution, I wasn’t referring to the ineffective  tactics that masquerade as education by groups such as DARE. In fact, DARE (with their “just say no” slogans) has been linked to increased drug use, according to a report from the Journal of Research in Crime and Delinquency. 

Rather, I’m referring to educating people about what’s in the drugs specifically and how they interact within the human body. We mistakenly avoid talking about this to children with respects to heroin and other hard drugs. “Just saying no” campaigns combined with lugubrious stories about people ruining their lives with addiction isn’t education, it’s scaremongering.

A better example of education would be the fact that popular opioids (Vicodin/Percocet) contain large doses of acetaminophen, ranging from 300-600 milligrams. They also only carry about 5-10 milligrams of the actual opiate. For comparison, a regular dose of Extra Strength Tylenol has about 1,000 milligrams of acetaminophen; ingesting over 4,000 milligrams is considered an overdose. Consequently, acetaminophen poisoning is the number one cause of acute liver failure in the United States. The problem isn’t the opioid, it’s the acetaminophen.

This raises questions about how much, if any, acetaminophen needs to be in a painkiller. Dr. Carl Hart advocates for the complete removal of it in painkillers, as do I. There’s no reason for someone seeking a heroin-like pill to be needlessly exposed to acetaminophen.

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Heroin is another drug that the public desperately needs to educate themselves on to combat the endless hysteria such as the dreaded heroin overdose. Despite feelings to the contrary, it’s actually fairly difficult to overdose on heroin. Don’t take my unqualified word for it, Dr. Stanton Peele, a psychologist who has written numerous books on the subject of addiction, has an article on his website highlighting some of the research surrounding the issue:

“Research at the Jefferson Medical Center in Philadelphia in the 1920s showed that addicts could tolerate up to a ninefold increase in the concentration of their standard, already large, dose. These researchers estimated that a toxic dose of heroin would be at least 500 milligrams for nonusers and 1800 milligrams for addicts . . . the best guess as to what was killing these addicts (aside from general infection, illness, and malnutrition) were the impurities in the drug, such as quinine, which produced adverse reactions in some injectors. A related likelihood which is more evident today is the mixture of drugs, or of drugs and alcohol.”

Another report from the Schaffer Library of Drug Policy corroborates this thesis. They also point out that we often falsely attribute the deaths of well-known heroin users strictly to their use despite other factors. From the report:

“A conscientious search of the United States medical literature throughout recent decades has failed to turn up a single scientific paper reporting that heroin overdose, as established by these or any other reasonable methods of determining overdose, is in fact a cause of death among American heroin addicts. The evidence that addicts have been dying by the hundreds of heroin overdose is simply nonexistent.”

They go on to explain the peculiar history of diagnosing a death:

“At some point in the history of heroin addiction, probably in the early 1940s, the custom arose among coroners and medical examiners of labeling as “heroin overdose” all deaths among heroin addicts the true cause of which could not be determined. These ‘overdose’ determinations rested on only two findings: (1) that the victim was a heroin addict who ‘shot up’ prior to his death; and (2) that there was no evidence of suicide, violence, infection, or other natural cause. No evidence that the victim had taken a large dose was required to warrant a finding of death from overdose. This curious custom continues today. Thus, in common coroner and medical examiner parlance, ‘death from heroin overdose’ is synonymous with ‘death from unknown causes after injecting heroin.’ “

To be fair, this report was published in 1972 and referred specifically to New York City during the 1920’s-1970’s. I’m only including it for some historical background and the fact that most of its research has yet to be disproved.

Contemporary statistics also reveal high proportions of heroin deaths as a result from mixing. One 2013 count has deaths by heroin alone in the United States at around 33%, but this number omitted about 25% of death certificates. Taken state-by-state, the numbers vary greatly. At the high end of the spectrum is New Mexico with 98.9% of heroin deaths involving mixing and Oregon at the low end with 36.9%.

Given what was previously mentioned about the history of medical examination labeling, it’s important to take these numbers with a grain of salt.

Regulation

This is going to be a straightforward solution: treat all of the aforementioned drugs the same way we currently treat alcohol. We tried doing to alcohol what we’re doing to heroin, opiates (to a lesser degree), and psychedelics right now and it was an unmitigated failure. A book published by the National Research Council succinctly summed up 3 lessons from the prohibition era:

1. “Drinking customs in the United States are strongly held and resistant to frontal assault. It is well beyond the will or capacity of government ever to eradicate the customary demand for alcoholic beverages.”
2. “A criminal supply network emerges—if not instantly, then within a few years—if production and sale of alcoholic beverages are outlawed. The prices and extent of this criminal supply depend on the degree of public support for the law and the resources devoted to law enforcement.”
3. “The quantity of alcohol consumption and the rates of problems varying with consumption can, however, be markedly reduced by substantial increases in real price and reductions in the ease of availability.”

The third lesson might sound like a positive if you ignore the increased rates of alcohol poisoning due to bootlegged liquor. A problem which was later fixed with the ending of prohibition and the regulation of alcohol.

There’s no logical reason as to why this couldn’t work with other drugs. Instead of heroin being unknowingly laced with fentanyl or a mix of any other unknown sedatives by the user, the government could regulate the product to ensure purity. As I explained above, this would dramatically reduce heroin-related deaths.

Instead of opioids having copious amounts of acetaminophen, the government could dramatically reduce or outright remove it from the pills. This would lower rates of liver toxicity while giving autonomy back to ordinary citizens to make their own choices. There are more examples I could give, but the train of thought is easy to follow.

If we would adopt one or all of these solutions, I am very confident we could reduce rates of drug-related death, improve public health, and, most importantly, dramatically lower rates of addiction. This isn’t to say that things will be perfect, but continuing what we’re doing now will only intensify the problem.

Drugs and Addiction: A Different Train of Thought

The drug overdose issue seems to be on everyone’s mind nowadays and for a good reason. It has recently been revealed that heroin deaths surpassed gun homicides in 2015. Also, the CDC reported that 19 states saw a “statistically significant” increase in drug overdose deaths from 2014-2015. Not a day goes by where we don’t see a sad story about a fatal drug overdose or someone that has to be rescued from the brink with Naloxone. Innumerable stories can also be found about neglected children being stranded in vehicles during their parents’ overdose.

It’s very easy for someone to have a visceral reaction that’s full of contempt towards these individuals, but I think this comes from a misunderstanding of drugs and the biopsychosocial nature of addiction. Most addictions are attempts to soothe some sort of pain, suffering, or distress. This isn’t to say that we should absolve all culpability from parents who OD with their child present, the State should absolutely take their kids away until proven rehabilitation. However, if our society continues to ignore social roots of addiction, we will keep going down a continuous path of suffering for addicts and the general population as a whole.

From here on out, I’m going to make a lot of references to Dr. Gabor Maté, a Hungarian-born physician who specializes in addiction. More specifically, I’ll be referencing the works in his book ‘In the Realm of Hungry Ghosts’ along with the myriad of sources he provides. I highly recommend this impeccably sourced work which advocates for a compassionate view towards the victims of addiction; any information derived from it will be noted as “(Maté p.’x’)”. Let’s start with the definition of addiction itself.

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What Is Addiction?

An important caveat I’m throwing in before continuing (it’ll probably be fairly obvious) is that I have no scientific credentials in anything regarding neuroscience or addiction. I’m just sharing pieces of research I’ve collected to advocate for a train of thought in regards to drugs that incorporates biological, sociological and psychological factors.

I think many people’s intuition about what addiction entails aligns well with Merriam-Webster’s broad definition: a “persistent compulsive use of a substance known by the user to be harmful.” They also use the words ‘tolerance’ and ‘withdrawal’ in their specific definition about heroin, nicotine, and alcohol. This definition is correct in some ways, but it’s too narrow. Focusing solely on the drug itself and quantities of use distract from other arguably more important factors.

An example of this is Alcoholics Anonymous (AA) with its 12-step program. A cursory glance at this list will show that the primary focus is on the addicted person’s inability to escape the “power” of drugs which, for them, is mostly regarding alcohol. There’s a lot of poetic, religious language involved in the steps which of course can help certain people, but the overall efficacy of the program is pretty bleak with a 5-10% success rate. Although, other research suggests that it’s more beneficial in the long-term than no help at all.

AA aside, addiction, overall, has little to do with the severity of withdrawal, levels of tolerance, or even frequency, it’s actually a measure of social impact (Maté, p. 136). This still is not a complete definition because the social aspect of addiction is only one factor. Maté provides a more detailed list on the same page which includes the following:

1. Compulsive engagement with the behavior, a preoccupation with it.
2. Impaired control over the behavior.
3. Persistence or relapse despite evidence harm
4. Dissatisfaction, irritability, or intense craving when the object–be it a drug, activity, or other goal–is not immediately available.

In my opinion, number four is the most critical to understand. Addiction isn’t confined to drug use. Many social behaviors we regularly engage in such as compulsive shopping, overeating, and workaholism all have adverse effects on our personal health, so why do we continue in them? We continue in them because we are addicted; this is partially promoted by a toxic culture. I’ll quote Dr. Maté in an interview with Stefan Molyneux:

“I define addiction as any behavior that is characterized by craving, temporary relief, temporary pleasure and long-term, negative consequences; and we continue in them, despite the negative consequences. Now, I didn’t say anything about drugs, I said any behavior. So how many of us are familiar with having behaviors that give us temporary relief, but hurt us in the long-term and we continue it? So how different are we from the drug addict?”

Carl Hart, an associate professor of psychology and psychiatry at Columbia University, has similar views on defining addiction. On page 13 of his book ‘High Price,’ he uses the Diagnostic and Statistical Manual of Mental Disorders‘ (DSM) definition of the word which, again, involves the disruption of important life events such as parenting, work, and relationship responsibilities. The DSM also relies more on withdrawal and tolerance as factors in addiction, but I would say the key elements are craving and continuing the behavior despite a conscious awareness of the harmful effects. An individual suffering from Obsessive Compulsive Disorder might experience irritability or withdrawal symptoms if they cannot excessively wash their hands; this doesn’t mean they’re addicted to washing their hands. They don’t crave the behavior, nor are they aware of the harmful effects, they simply must do it. This is a crucial distinction.

Addiction as a Disease

The “addiction is a brain disease” narrative seems like a compassionate view to uphold. Unfortunately, it can actually do more harm than good in a sociological sense by exacerbating social injustice. If drugs themselves are to blame, we must rely on law enforcement to forcefully remove the drug (and drug user) from society. This type of thinking is what has lead to 20 percent of total federal prison inmates being non-violent drug offenders. This is all despite the fact, as Michelle Alexander explains in her book ‘The New Jim Crow,’ that drug-related crime was actually decreasing when the war on drugs was declared in 1971 and 1982; something worth thinking about.

There’s also not much biological evidence to support the claim. This doesn’t mean addiction is a choice per se, but more on choices later. The disease point-of-view places too much emphasis on the role of genes in determining behavior while subsequently giving validity to the theory of an addiction gene. Not only does an addiction gene not exist, it can’t exist (Maté, p. 213). We often view a genetic basis for a particular trait to be immutable and fatalistic, but this is not the case, as a study in the Yale Journal of Biology and Medicine suggests. This isn’t to say the genes don’t play a factor, they do. Yet, they can’t solely explain complex factors such as addiction.

Genes are contingent on the environment; without the proverbial on/off switch of social influences, it’s likely human life couldn’t exist (Maté, p.214). For example, the fundamental act of human contact or social attachment, especially in infancy, is critical for positive development later on in life. Skin-to-skin contact also helps alleviate a mother’s depression while being more receptive to their child’s needs, according to an article in Scientific American. This is called epigenetics, which studies the process of chemical reactions that activate and deactivate parts of the genome due to expression. Epigenetic effects are most influential during early childhood (Maté, p.214), they also place heavy emphasis on maternal care in mediating potentially harmful environmental effects on their child’s neural development.

Regarding the biology of the brain, as revealed by Carl Hart in a Nature article, this idea is also baseless. This is because we cannot currently differentiate between an addicted brain and a non-addicted brain. From the source:

“The notion that drug addiction is a brain disease is catchy but empty: there are virtually no data in humans indicating that addiction is a disease of the brain, in the way that, for instance, Huntington’s or Parkinson’s are diseases of the brain. With these illnesses, one can look at the brains of affected individuals and make accurate predictions about the disease involved and their symptoms.”

 It is true, though, that drugs, especially the powerful ones like methamphetamine and cocaine, profoundly alter brain chemistry when they’re ingested. This is especially noticeable with dopamine levels in the brain. Dopamine is the chemical that’s sometimes attributed to “making us human.” In the context of drug use, it can be described as a neurotransmitter that powers the Ventral Tegmental Area (VTA) and the other related brain circuits (Maté, p. 168). The VTA is basically responsible for holding dopamine and serotonin, these dopamine pathways are major sources of behavior motivation and incentive. So certain activities or brain-altering drugs can have a severe impact on dopamine levels.

Food seeking increases brain dopamine levels by 50 percent; alcohol, nicotine and sexual arousal will yield a 100 percent increase; cocaine will triple them. Still, none of these compare to the effects of crystal meth, which increases dopamine levels by 1,200 percent (Maté, p.154). One of the addicted women in Maté’s book described crystal meth as an “orgasm without sex,” it’s easy to see why. However, with enough time and proper treatment, such as a temporary Methadone prescription, these damages to the brain can be reversed or nearly reversed depending on the severity and length of abuse.

Even taking into account the chemical alterations in the brain while using the drug, I still don’t think it’s grounds for labeling addiction a disease. All experiences, negative or positive, engender chemical changes within the brain. Nonetheless, most of these changes aren’t considered pathological; addiction could better be described as a learning disorder, as is argued in an article in Pacific Standard Magazine. This uses a broader perspective where we’re forced to look at environmental pressures that nudge us towards certain behaviors. Further research into the topic could result in addiction as a certain mental disease, this shouldn’t be ruled out definitively. I’m saying that we use the mental disorder term too ubiquitously considering the limited information we have.

As a final note on this topic, I’ll use a quote from the article:

“In order to use brain scans to prove addiction is a disease, you’d have to show changes that are only seen in addicted people, that occur in all cases of addiction, and that predict relapse and recovery. No one has yet done this.”

Drugs Cause Addiction?

When I listen to an everyday conversation about drug use, it seems like most agree that the best way to avoid drug addiction is to not dabble in them at all. In other words, drugs cause addiction. This perspective seems harmless even though it avoids talking about the overwhelming majority of people who use drugs (including cocaine, heroin and crystal meth) and have no problems. If drugs caused addiction, we should see a statistically significant correlation between use and rates of addiction; reality paints a different picture when a large-scale view is considered.

According to Dr. Carl Hart in an interview with Democracy Now, 80-90% of people who use drugs don’t become addicted as I’ve defined it above–they handle their daily responsibilities. More specifically, it’s about 10-15 percent for alcohol and 15-20 percent for crack cocaine. This isn’t to say that 10-20% ruin their lives with drugs or spend every waking moment looking for their next hit like a desiccating vampire. They simply fit one or more of the criteria that indicates a potential problem. Even the ostensibly maniacal crack addicts that pervade our TV shows and news will display rationality and opt out of a free, immediate high when economic alternatives are presented.

If drugs are inherently addictive, we probably shouldn’t be treating chronic pain, which affects 11.2% of the population, with opioids. However, research shows that when appropriately prescribed for cancer patients, the risk of addiction is very low while improving their quality of life. What about non-cancer treatment?

A 2006 study in the Canadian Medical Association Journal that treated severe, chronic pain with potent opioids (oxycodone and morphine) found that 8.7% self-reported “drug craving” in the morphine trials. Interestingly, however, 4.3% in the placebo group also reported having a “drug craving”; other factors are clearly at play beyond simple drug use. The authors make clear that addiction to opioids cannot be presumed to not exist, though this should certainly put a grain of skepticism into the “opioid crisis” hysteria. In fact, one group of researchers concluded that “doubts or concerns about opioid efficacy, toxicity, tolerance, and abuse or addiction should no longer be used to justify withholding opioids from patients with well-defined rheumatic disease pain.” To conclude this section, let’s talk about Vietnam.

It’s estimated that about half of enlisted men in the Vietnam War had tried some sort of opiate while overseas. Before shipping out, less than 1% had an addiction; after returning, 20% met the criteria for addiction. Once the soldiers returned, however, the remission rate for the afflicted individuals was nearly 95% (Maté, p.142). Overall, average relapse for drug addiction is between 40-60%, so the Vietnam finding was truly remarkable. The U.S. soldiers’ addiction clearly had nothing to do with the use of the substance itself, but the negative social conditions surrounding them. Once they were removed from that environment, need for the drug went away.

To hammer this point home, in 2005, 4.6% (that’s about 1.7 million people!) of Canadians tried crystal meth, yet only 0.5% (180,000) had used in the past year (Maté, p.144). This is more than a 900% reduction in a years time. Clearly, if mere drug use caused addiction, the numbers would be near identical. This also dispels the “try it once, and you’re hooked” scare tactic.

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Choices

This is where I’ll probably separate myself from the people who agree with me that addiction isn’t a mental disease. The debate, at least online, seems to be stuck in a false dichotomy between drug addiction as either a disease or a choice. It’s false because addiction is a biopsychosocial process, as noted above.

Viewing addiction exclusively as a choice is an ill-fated attempt to try and separate individual actions from the environment in which they’re oriented. Our actions aren’t isolated events, they follow a chain of causality. Regarding addiction, this chain of causality starts in childhood. Before getting into that, we have to think conceptually about what making a choice really means to establish a proper frame of reference.

The choice argument implies that we’re all autonomous individuals and any decision we make is of our own free will. As pointed out by Sam Harris in short book ‘Free Will’, this view of our will rests on two assumptions: (1) any behavior we exhibit, we could’ve chosen to behave differently in the past, and (2) that we are cognizant of all our actions and thoughts that motivate said actions. If you think about it, you’ll realize this isn’t true: thoughts spontaneously arise in consciousness.

I don’t want to waste too much time on the philosophical minutia of free will. Although, it’s worth spending a few minutes contemplating this question I’m stealing from one of Sam Harris’ lectures: “If you can’t control your next thought, and you don’t know what it’s going to be until it arises, where is your freedom of will?”

Free will doesn’t have a lot of scientific ground to stand on either. A study from the National Academy of Sciences showed–mainly through the use of Functional Magnetic Resonance Imaging–that human decision to take an immediate action precedes conscious awareness. The supposedly immediate action can be occurring in the brain for several seconds before a person believes that they’ve made a concerted decision to move.

This is an important point to elucidate because opinions on free will have real-world implications for how addicts are treated. If someone has an unwavering belief in free will, then any economic, familial, or moral failing by an individual is unambiguously the result of their bad choices. This is just untrue: trying to place human actions in a vacuum independent of the environment will always be futile.

This isn’t to make an argument for determinism; actions aren’t unconditionally determined by preexisting causes, the current moment is a factor. Rather, I’m saying that the spectrum of choice is much more limited than most hard-line free will proponents like to think. That spectrum is reliant on background causes of which the person isn’t aware.

Addiction and Childhood Trauma

I think it’s clear that the root of addiction starts in childhood. More specifically, events that are known as Adverse Childhood Experiences (ACE’s) are the main reason we’re aware of this. It’s not the sole cause, of course, but the strong association cannot be ignored. Broadly, ACE’s are linked to risky health behaviors, chronic health conditions, and early death. These risks increase as the number of individual ACE’s grow.

About two-thirds of all drug addicts seeking treatment report experiencing some kind of physical, sexual, or emotional abuse during childhood, according to the National Institute on Drug Abuse. Their survey of 1,400 women revealed a correlation with sexual abuse during childhood and drug dependence. Women who experienced any sexual abuse were 3.09 times more likely to become dependent on drugs compared to women who hadn’t been abused, 2.83 times for non-genital, and an astounding 5.70 times more likely for intercourse. Their solemn chart is worth looking at:

 A fact sheet from Boston University shows that about 25% of children under the age of 16 will experience at least one traumatic event which increases the risk of substance abuse in adulthood. Another study from the The National Child Traumatic Stress Network explained that traumatized kids were three times more likely to report current or past substance abuse. Regarding opiates specifically, users are 2.7 times more likely to have a history of childhood abuse than non-users. The link between trauma and an increased propensity for drug abuse is clear, but why?

One possible answer is the self-medication hypothesis. This posits that the abused/traumatized individual will seek particular types of drugs to placate various kinds suffering or unpleasant effects. Interestingly, a victim tends to gravitate towards specific types of drugs to relieve certain conditions. Alcohol, for example, is commonly used as an antidote for depression. Edward J. Khantzian in an article from the Harvard Review of Psychiatry describes it well:

“Although they are not good antidepressants, alcohol and related drugs create the illusion of relief because they temporarily soften rigid defenses and ameliorate states of isolation and emptiness that predispose to depression.”

The Big Picture

Even among large-scale population studies, the results are similar: trauma, neglect, abuse, pain, and suffering are all catalysts for substance abuse. If drug use or addiction is simply a choice, there should be much more variance in the studies and their outcomes. At the very least, there shouldn’t be distinct patterns where factors A, B, and C have a statistically high chance of leading to D. This isn’t to say that everyone who experiences abuse will end up developing a dependence on drugs. Some people escape and make it out okay, at least on the surface. I am saying, though, that the degree to which this professed freedom of choice influences our lives should be challenged.

Allow me to use yet another quote from Gabor Maté on page 308 of his book:

“Freedom of choice, understood from the perspective of brain development, is not a universal or fixed attribute but a statistical probability. In other words, given a certain set of life experiences, a human being will have either a lesser or a greater probability of having freedom in the realm of psyche. A warmly nurtured child is much more likely to develop emotional freedom than is an abused and neglected child. As we have seen, the in utero and early childhood experiences of hard-core addicts will likely diminish the possibility of freedom.”

 The main point in writing this was to try and change common perceptions of drug addicts using data-driven arguments. It’s easy to just state rhetorically that we should treat addicts with compassion and just leave it at that. This isn’t how most people think, though. Moralized language like this doesn’t produce any sort of long-term, tangible change. A more important point to focus on is the “why.”

Why would a parent overdose with their child in the car, don’t they care about their children? Using words like compassion and respect, while helpful in a limited sense, won’t properly answer these type of questions.

I’m not vain enough to expect to change anyone’s mind with a single, lengthy blog post. Although, if you made it this far, I hope to have at least placed a grain of curiosity to make any reader question their visceral reactions to a drug addict and look into the scientific literature of Adverse Childhood Experiences. At the very least, just try and have a conversation with a drug addict. You might be surprised about what you learn.

I’ll publish a post sometime around late May that lays out possible solutions to the addiction problem. I didn’t include them here for the purpose of limiting word count.

A Path Towards True Security

Whether it’s the police, military, TSA, ICE, or CBP, they all operate under the same banner of maintaining safety and security. This cultural meme has been propagated relentlessly with little regard for evidence. Take, for example, a concerning study done on the TSA which revealed that undercover agents were able to smuggle banned weapons and mock explosives through security 95 percent of the time. One could argue for stricter security measures as a solution, but the overall reality is that if someone is sufficiently determined enough to blow up or shoot up an airplane, they will find a way to do it.

These institutions listed above are predicated on aggression, intimidation, and fear to curb crime and maintain safety. However, these methods will never produce any long-term peace or stability because they fail to address the underlying roots of violence: socioeconomic inequality and its adverse effects. This isn’t the sole cause, but there’s an abundance of sociological research linking inequality to increases in violence, imprisonment, and drug use while decreasing mental health, educational performance, and social mobility.

I’m not claiming to have concrete solutions, nor am I suggesting that this would lead to a peaceful utopia. This is just an exercise to elucidate a general train of thought that incorporates a structuralist perspective to pursue a path towards a more peaceful society. First, it’s necessary to break down the process of violence which is the overarching issue when discussing safety or security.

Structural Violence

The word “act” that’s commonly used when describing a gruesome murder or mass shooting is actually a misnomer. The word ‘act’ in the phrase “an act of violence” implies that violence is a direct, behavioral action; this is simply untrue. Treating violence in this manner excludes any historical or socioeconomic factors. The truth is that violence is a multilayered process that can’t be nailed down to a singular cause. Any behavioral outcome, negative or positive, is a result of system assimilation, and trying to separate individual behavior from the environment is futile.

The realization of structural violence was first introduced to me by Dr. Paul Farmer who has done astounding work and provides a workable definition of the term:

“Structural violence is one way of describing social arrangements that put individuals and populations in harm’s way… The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people … neither culture nor pure individual will is at fault; rather, historically given (and often economically driven) processes and forces conspire to constrain individual agency. Structural violence is visited upon all those whose social status denies them access to the fruits of scientific and social progress.”

An important detail that I would personally add to this definition is that structural violence operates under a scientific reality where most basic human needs can be met. In other words, they’re almost entirely preventable if our social system were tweaked to promote better public health. A good illustration of preventable suffering is the absurd prevalence of food waste in the United States.

In 2015, 42.2 million Americans lived in food insecure households which are defined as households having inadequate physical, social or economic access to nutritious food.  Meanwhile, around 30-40% of the U.S. food supply is thrown away according to the USDA; this amounts to $160 billion worth of food. This problem is preventable partly because the arbitrary expiration dates, bulk packaging, and outright deliberate throwing away of food motivated by risible market logic is unnecessary. We already produce more than enough food for the entire population; the real issue here is poverty and degradation, not scarcity.

As an aside, we can easily grow enough food to feed the 7.2 billion people in the world by utilizing vertical farms. It’d take about 144,000 thirty-story structures to accomplish while only using 0.006% of the Earth’s land (we currently use 11%) and 95% less water than conventional methods. Simply ending hunger and food insecurity will have a profound boost in public health, especially for children. This would lower hospitalizations, chronic health conditions, behavioral problems and pregnancy complications just to name a few.

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More personal, 1-on-1 violence has structuralist roots as well; Dr. James Gilligan, former director of the Center for the Study of Violence at Harvard Medical School, is an excellent source for this subject. His 1997 book ‘Violence: Reflections on a National Epidemic’ is a brilliant piece of writing where he describes his experiences as a prison psychiatrist.

Right from the onset, he seems to detest anyone using moralized language when describing the cause of violence. For example, using religious notions of “good and evil” when depicting a murderer is distracting and unhelpful. I think Dr. Gilligan summarized it well on p.92-93 of his book:

“I am suggesting that the only way to explain the causes of violence, so that we can learn how to prevent it, is to approach violence as a problem in public health and preventive medicine, and to think of violence as a symptom of life-threatening (and often lethal) pathology, which, like all forms of illness, has an etiology or cause, a pathogen. To think of violence as evil–if we confuse that value judgement about violence with an explanation of it– can only confuse us into thinking that we have an explanation when we do not.”

It is evident, at least in the context of the United States, that we are nowhere close to addressing the current problem of violence in a systemic way. Once someone is arrested for a violent act (and non-violent acts in regards to drug arrests) in the U.S., an inflexible “justice” system takes charge that’s incapable of minimizing recidivism when compared to other countries. This punitive mindset treats prisoners as a group incapable of rehabilitation. Meanwhile, in Norway, a study revealed that rehabilitation and job-training programs in the countries prison system was essential to reducing the pattern of criminal behavior in an individual. When you change the social environment from negative to positive, *most* will respond by improving their lives accordingly. Who would’ve guessed?!

Violence Is Natural?

As a final point of emphasis, I want briefly address the belief that violence is intrinsic to our species. Many people believe that humans have natural propensities for violent acts and cut-throat competition. If this is true, then there would be little point in trying to reduce violence since it’s ostensibly instinctive. Fortunately, the evidence suggests a different story. You shouldn’t separate an individual’s actions from the social environment in which they’re oriented. Dr. Gilligan highlights the dangers with this kind of thinking on p.212 of his book:

“If the assumption is that violence is an inextricable part of our inborn ‘human nature’, then clearly the only way to keep the problem under control is to emphasize just that: control, meaning the control of some people (whose violence is ‘bad’) by other people (whose violence is ‘good’).”

This dichotomy of “good vs. bad” with uses of violence is exactly how the police, military, TSA, ICE, and CBP vindicate their methods. Their perpetuation of violence is seen as a positive because they’re eradicating something they deem as dangerous: this could be called a cyclical circle of violence. Ideally, we should view every arrest by these institutions as a failure of the system; “the system” that I’m referring to here is the Prison Industrial Complex (PIC). The PIC is an overarching term used to describe confluence between government and private industry that use invasive, punitive techniques as solutions to social and economic problems. The reality is that our environment heavily shapes our behavior; thus we should all feel a sense of mutual responsibility.

Violence, for most of us, isn’t intertwined with our biology. We actually have a propensity for compassion (partially motivated by the lovely hormone oxytocin), and that reality is moderately exemplified by Rhesus monkeys. A 1964 study at Northwestern University led by psychiatrist Jules Masserman reported that Rhesus monkeys would literally starve themselves after they found out that pulling a chain that gave them food also gave a shock to a companion (The Compassionate Instinct, p.18).

Overall, most violent “acts” are multi-faceted and cannot be pinned down to any single cause. Ignoring negative social pressures (i.e. poverty, inequality) that push individuals towards certain destructive behaviors is a truncated point-of-view and will always lead to unhelpful individualized associations of violence which help sustain the cyclical circle of violence. 

Greater Equality Promotes Peace

Allow me to lay out the truth succinctly: socioeconomic equality produces a safer, healthier, stronger and more sustainable society. This assertion isn’t just a feel-good bromide, it’s supported by mountains of evidence which is unraveled by Richard Wilkinson and Kate Pickett in their book ‘The Spirit Level.’ Their research shows how unequal societies generally produce greater violence while also diminishing public health through various forms. The rest of this post will be showcasing the important charts in the book with subsequent explanations and corroborating evidence.

Poverty vs. Inequality

It’s important to explain the difference between poverty and inequality. Health and social problems cannot be wholly attributed to levels of income; the degree of inequality makes a profound difference.

All of the charts I will share that display international comparisons are using the 20:20 ratio measure of income inequality from the United Nations Human Development Index. All of the state comparisons are using the Gini Index. The statistics are all gathered from the World Bank, World Health Organization, the United Nations and the Organization for Economic Cooperation and Development–all of which are reputable sources.

Overall, public health is better in more equal countries. A statistical scatter like this cannot be explained away by chance or coincidence. Let’s see how this compares to overall income.

 The correlation here is tenuous and doesn’t exhibit a consistent trend like the previous chart on inequality. This is because wealth isn’t necessarily linked to improved living conditions. How do U.S. states compare?

While it’s a little less obvious than the country comparison, the trend within the states is still the same. Now let’s look at incomes per state.

A Brief Digression on Costa Rica

So why is poverty only weakly related (in rich countries) to health and social problems? It’s hard to pin down to a simple answer, but let’s take Costa Rica as an example. This is a deviation from the The Spirit Levels’ methods because Costa Rica doesn’t file under a “rich country” with a GDP of only $79 billion. However, I think the results when compared to the United States are worth taking into consideration.

It might come as a shock to many that the poorest Costa Ricans have a longer, healthier life than the poorest Americans. This conclusion is from Luis Rosero-Bixbya from the Universidad de Costa Rica and William H. Dow from the University of California, Berkeley. The findings were published in the Proceedings of the National Academy of Sciences of the United States of America.  Why is this?

It can’t be from income inequality seeing as Costa Rica has a Gini Index of 0.52 compared to the U.S. at 0.40. However, the inequality in health care within the U.S. is much higher. Costa Rica has lifetime universal health insurance and a strong social safety net for their residents under 65. Their healthcare system still struggles to help people with specialized care needs, and their inability to mitigate hypertension looks unfavorable when compared to the U.S. Regardless, the overall reality remains the same: poor Americans under 65 would be better off living in Costa Rica.

Structural Violence in Healthcare

I would argue that the first thing to consider when trying to reduce violence of all kind is healthcare. Without a stable, equitable system, the poorest individuals will become further saddled into debt which results in a downward spiral of desperation for the people. Desperation from this already debt-fueled economy leads to higher diastolic blood pressure, increases in depression and worse general health. This connection desperately needs to be acknowledged and contemplated by everyone, especially the representatives in Congress. America, for ideological reasons, chooses not to adopt a universal system that covers everyone even though it’d be more efficient. Our current system (assuming the AHCA is passed) will exacerbate income inequality and push a higher cost burden onto low-income citizens. The American healthcare system is a form of violence when taking this structural perspective.

Going back to The Spirit Level, the American system listed above that punishes the most desperate populations leads itself to a host of other adverse health effects. Let’s start with mental illness.

The countries here line up almost perfectly with the only outlier being Italy. The authors say that anxiety disorders, impulse-control disorders, and severe illness are all strongly correlated with inequality while mood disorders are weakly correlated (p.68). So why is mental illness higher in more unequal societies?

Some might attribute it to cultural affluenza where people’s only perception of social prestige is the amount of money one earns; this can lead to vulnerability to emotional distress. Economist Robert H. Frank coined the term ‘luxury fever’ which he describes as “luxury consumption in Western industrialized countries has been rising at an astronomical rate even though recent psychological research shows that there is a scant correlation between this consumption and levels of stated life satisfaction.” This behavior is more widely observed in unequal countries.

Drug Use

The use of drugs isn’t inherently a negative thing, but the higher use of more potent drugs like cocaine and amphetamines have profound impacts brain activity. These create severe imbalances in dopamine and serotonin; low dopamine and serotonin levels have been linked to depression and various other mental disorders (TSL, p.71).

We also have to look at this from a societal point-of-view as well. As mentioned prior, vast numbers of people are in federal prison for non-violent drug offenses. So not only does America have a high rate of drug use partially caused by inequality, but we also throw them in prison and, once released, deny them opportunities to get ahead mostly via discrimination. The cycle continues.

This post is becoming pretty verbose, and anyone making it this far can see the main idea that I’m delineating. There are many more categories: obesity, educational performance, teenage births, social mobility and social relations just to name a few. I encourage everyone to read the book for themselves, but overall, all of these are worse in more unequal countries. I wanted to start with health and social problems first because together they compound the problem of overall violence. Let’s look at one final category before I conclude and bring this all together: homicides.

These rates are from the United Nations Surveys on Crime Trends and the Operations of Criminal Justice Systems.  The trend is similar in U.S. states.

What are the reasons for this? Some propose that this may begin in childhood, to quote James Gilligan once again in talking about the violent men in prisons he worked with:

“They had been subjected to a degree of child abuse that was off the scale of anything I had previously thought of describing with that term. Many had been beaten nearly to death, raped repeatedly or prostituted, or neglected to a life-threatening degree by parents too disabled to care for their child. And of those who had not experienced these extremes of physical abuse or neglect, my colleagues and I found that they had experienced a degree of emotional abuse that had been just as damaging . . . in which they served as the scapegoat for whatever feelings of shame and humiliation their parents had suffered and then attempted to rid themselves of by transferring them onto their child, by subjecting him to systemic and chronic shaming and humiliation, taunting and ridicule.” (TSL, p.138)

One again, this violent behavior is structural through numerous factors over many years. But even this cannot explain fully why unequal societies have such high rates of homicides. All we know is that the overall trend is there and reversing inequality will certainly help.

Reducing Inequality

Now that a basic framework of the problems and a possible solution is established, what next? Pursuing a more egalitarian society is becoming increasingly necessary at this point in time. One small, obvious solution that mostly involves government intervention is ending low wages (which cost taxpayers about $152 billion/year) via raising the minimum wage to a living wage.

This isn’t a blanket $15/hr proposal that politicians incessantly rave about, but a calculated cost-of-living analysis that quantifies the number necessary on a county-by-county basis; MIT’s calculator is an excellent resource here. People who make the argument that you can’t quantify a living wage because you can’t account for the price of goods are partially correct. However, they drastically underestimate our ability to measure these sorts of factors nowadays.

For example, Purdue University has an online calculator where you punch in your businesses zip code and the proposed minimum wage hike, it will then give a report on what that particular number means for managers of fast-food restaurants. Overall, they found that a blanket $15/hr minimum wage increase would result in a 4.3% increase in the price of food at these ‘limited-service’ restaurants. As nice as this sounds, a living wage doesn’t address enough because meeting the bare minimum for living standards still produces anxiety among those populations. Other solutions involve incorporating a more progressive tax system while ending tax loopholes which would certainly help, but it’s a band-aid.

We need to focus less on the moral and ideological objections to policy and more on the mere fact of getting it done. For instance, a Universal Basic Income would be much more effective than trying to manipulate wages. I’ll quote a passage from one of my previous posts regarding a UBI.

A precursory step towards technical efficiency would be embracing and implementing the idea of a Universal Basic Income (UBI) which has a simple definition: a guaranteed income to every citizen with no work requirement or any other sort of test. I view UBI as more of a future inevitability rather than a pie-in-the-sky social or moral justice theory. This is because of the nearing technological unemployment phenomenon that will slowly engulf the menial, mechanical jobs. A 2013 study by Oxford researches concluded that around 45% of American jobs are under threat of automation in the next 20 years. Although data is sparse on UBI, we do have a few examples of it being implemented. Medicine Hat, a small city in Canada with a population of 60,000 (2011 census), decided to give the residents a UBI. They managed to house 885 of the cities 1,000 homeless people. This housing also saved an estimated $65,000/person in annual care costs according to Human Services in Alberta, Canada. This is because simply providing free housing/free money lessens the health impact these homeless people endure, thus alleviating some of the financial burden on the healthcare system. The simple reality is that just giving people money and a house with little questions asked is cheaper than leaving them on the streets.

This is the train of thought we need to pursue as a society if we’re ever going to lessen income inequality and mitigate violence. If these issues of inequality are addressed, the need for forceful institutions like the police will be drastically less needed and, ideally, eliminated. However, if we keep walking down the path we’re currently on, our public health problems will only get worse and may eventually lead to a major social collapse.

 

 

Regarding Healthcare

The most fundamental point that I can make regarding healthcare and healthcare systems is that they require significant state oversight to maintain their functions. One can talk about “red tape” and the costs of regulations, as the CATO institute has, but it misses the overall point: the push to rid the U.S. healthcare system of government involvement creates perverse incentives, makes it less efficient and pushes a higher cost burden onto the consumer. Some industries shouldn’t be utilized through the private sector, historically this references the Commons and natural monopolies.

For the next 4-8 years, the U.S. is going to be subject to an administration that seems to reduce healthcare policy discussion to rhetorical buzz phrases: “Government takeover of healthcare”, “sell across state lines” and “promoting competition” are a few that are chaotically thrown around.

To be fair, Trump does have actual policy proposals for reform, but it’s a very truncated view and has been estimated by the Commonwealth Fund to increase out-of-pocket spending by  $2,500 on average. Regardless, the political hoopla over keeping or reforming/replacing the Affordable Care Act (ACA) doesn’t take enough into consideration;  a pro vs. con list isn’t going to get the U.S. system very far.

Instead, a comparative policy analysis that factors in as many variables as possible is what seems to be missing in the political landscape. This is where T.R. Reid’s book ‘The Healing of America: A Global Quest for Better, Cheaper, and Fairer Healthcare’ comes in. Mr. Reid’s book combines statistical information with personal experience because he actually went and visited hospitals in Germany, Japan, England, Canada, France and India to inquiry about his shoulder which was so severely damaged that it required a total shoulder arthroplasty; a procedure with an average cost of around $10,000.

A Few Problems With U.S. Healthcare

It’s important to identify a few essential problems with the healthcare system that’s currently in place so the realization for a change is understood:

• Between 1995-2007, the uninsured rate (non-elderly) was around 16% (KFF)
• 45,000 people die every year from lack of access to health insurance (Harvard, 2009).
• Compared to 19 other industrialized nations, the U.S. comes in last when it comes to Preventable Mortality–deaths that might have been prevented with effective and timely care (Commonwealth Fund, 2008).
• Despite being less efficient, the U.S. still spends 17.1% of their GDP on healthcare, vastly higher compared with other nations like France (11.6%), Canada (10.7%), or the UK (8.8%) (Commonwealth Fund, 2015)
• Most for-profit insurance companies in the U.S. have administrative costs between 15-20%. Comparatively, it’s 3% for the Medicare system and 5% for Britain’s National Healthcare Service. (T.R. Reid, pg. 38)

Overall, there are 4 different models that encompass the countries with an established healthcare infrastructure, all of which I’ll garner from Mr. Reid’s book. For a more succinct online reference, look here.

The Bismarck Model

Named after Otto von Bismarck, a Prussian chancellor in the late 1800’s who was mainly focused on building a unified, powerful German state. He despised the spread of socialism in Europe and worked to introduce health insurance and pensions.

This model is currently used in Germany, Japan, Belgium and Switzerland. These countries are similar to the U.S. in the sense that they utilize the private sector for financing healthcare plans. However, unlike the U.S., the industry basically functions as a non-profit charity. Even though hospitals and insurance companies are private entities, there are tight medical regulations which serve as cost-control mechanisms.

The Beveridge Model

Named after William Beveridge, a British economist and social reformer in the early 1900’s who galvanized the National Health Service. The NHS launched in 1948 and provides free healthcare that’s funded purely from taxation to about 64 million residents in the UK.

This model is used in Britain, Spain, Italy and most of Scandinavia. There are no medical bills and healthcare is treated as a social utility analogous to a public library. Most hospitals and clinics are owned by the government where the staff are government employees. There are some private doctors and insurance plans, but polls have shown that only about 13% of (mostly upper-class) citizens in the UK belong to these plans. The exorbitant prices of these Private Medical Insurance plans are the main self-reported deterrent for individuals not subscribing to them.

The National Health Insurance Model

This is a blend of the Beveridge and Bismarck model: the payer is a government-run insurance program where every citizen contributes, but the providers are private. It’s mainly used in Canada with Australia, South Korea and Taiwan adopting some of the tenets.

With no need for marketing, profits, or offices of people who contribute to high administrative costs by denying claims, this system tends to be much cheaper than America’s for-profit system (T.R. Reid, pg. 19).

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By mentioning Canada, I feel obligated to write a quick rant about the waiting times argument because it’s often brought up as the holy grail of counterpoints.

First of all, it’s worth mentioning that the ostensible influx of Canadians migrating to the U.S. for healthcare is an exaggerated myth; from the source:

“This study was undertaken to quantify the nature and extent of use by Canadians of medical services provided in the United States. It is frequently claimed, by critics of single-payer public health insurance on both sides of the border, that such use is large and that it reflects Canadian patients’ dissatisfaction with their inadequate health care system. All of the evidence we have, however, indicates that the anecdotal reports of Medicare refugees from Canada are not the tip of a southbound iceberg but a small number of scattered cubes. The cross-border flow of care-seeking patients appears to be very small.”

Secondly, the dreaded wait times are mostly for non-elective procedures; anyone that requires urgent care can get it (T.R. Reid, pg. 130). The wait times are also partially attributed to choice; Canadians voluntarily choose not to spend more on their healthcare system which would result in decreased wait times. Canada spends about 10.4% (2012) of their GDP on healthcare, up from 8.9% in 2002 so there’s legitimate cause for concern.

Lastly,  Americans are more frequently observed as heading north for cheaper drugs or treatment compared to their Canadian counterparts (T.R. Reid, pg. 130).

The Out-Of-Pocket-Model 

To put it bluntly, this is a system where the wealthy receive medical care and everyone else stays sick or dies. This is mostly seen in rural regions of India, Africa, South America and China where millions will go their whole lives without ever seeing a doctor. As a result, these are regions where people are forced to rely on unsubstantiated alternative medicine for their main method of treatment.

Out-of-pocket spending accounts for 91% of health spending in Cambodia, 85% in India, 73% in Egypt, 17% in the United States and 3% in Britain (T.R. Reid, pg. 19-20).

So which system does the United States use? Well, it’s complicated. From page 20 of T.R. Reid’s book:

• For most working people under 65, they use the Bismarck Model.
• For Native Americans, military personnel, and veterans, they use the Beveridge Model.
• For individuals over 65, they use the National Health Insurance Model.
• For the 45 million uninsured Americans, they’re Cambodia.

With these 4 systems in mind, which one should the U.S. adopt? Should we keep the system we have now where a myriad of for-profit insurance companies contribute to an inefficient, bureaucratic system? Yes, that’s a loaded question fallacy, but it doesn’t make it untrue.

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My personal, opinionated solution is to adopt a “health care for all” single-payer system. Physicians for a National Healthcare Program have a detailed FAQ on their website that addresses a lot of the common objections to this model.

I think this country would benefit immensely from a healthcare system that has been proposed by Vermont Senator Bernie Sanders.

Although a 2015 Center for Medicare and Medicaid Services report highlighted that healthcare spending is about $3.2 trillion/year, Bernie’s plan posits that it can reduce this spending by $6 trillion over the next 10 years. Admittedly, it’s not very clear on his website on how these savings will be accomplished. However, his recently published book ‘Our Revolution: A Future to Believe In’ paints a more lucid picture.

From page 324-325 of the book:

“Private insurers’ overhead currently averages 12 percent, as compared with only 2.1 percent for fee-for-service Medicare. The complexity of reimbursement systems also forces physicians and hospitals to waste substantial resources on documentation, billing, and collections. As a result, U.S. healthcare administration costs are about double those in Canada, where the single-payer system pays hospitals global budgets and positions via simplified fee schedules. Reducing U.S. administrative costs to Canadian levels would save over $400 billion annually.”

 I think the $400 billion number by solely adopting Canada’s system is overestimated, the closest number I found was in a 2014 Commonwealth Fund study which concluded that reducing our administrative costs–costs that also have no link to higher quality of care– to Canadian levels (2011) would result in $158 billion annual savings. The PNHP FAQ sourced above corroborates this by stating the U.S. would save $150 billion a year.

Reducing administrative costs to the Medicare level of 2.1%, however, would certainly get the U.S. to the $400 billion number. The New England Journal of Medicine did a study that found replacing our for-profit, multi-payer system to a national health program would save $320 billion in administrative costs.

These savings are combined with the following revenue-raising taxes:

• 6.2% income-based health premium paid by employers ($630 billion/year).
• 2.2% income-based health premium paid by households ($210 billion/year). Also, any household making under $28,800/year wouldn’t pay this tax and households making $50,000/year would only pay $466/year under this plan.
• A progressive income tax ($110 billion/year) which includes the following:

1. 37% on incomes between $250,000-$500,000
2. 43% on incomes between $500,000-$2 million
3. 48% on incomes between $2-$10 million (this only affects 113,000 households, or 0.08% of the taxpaying population)
4. 52% on incomes above $10 million (this only affects 13,000 households, or 0.01% of the taxpaying population)

Also thrown into the mix is taxing capital gains, limiting tax deductions for the rich, and an estate tax which combines to $128 billion/year in revenue raised. Add all of this together combined with the savings listed above and you have a grand total of $1.398 trillion which pays for the $1.38 trillion cost of implementing this system.

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With all the dry economics out-of-the-way, I think the moral imperative of our system lacking healthcare equity is the heart of the issue . Alleviating the burden of healthcare costs for the poor, working class people who need it the most is an accomplishment that we should ultimately strive for. Currently, medical bills are the number one cause of bankruptcy in the United States. This unnecessary stress on our nations poorest people, which leads to higher vulnerability to diseases later in life, is something that our policy makers are exacerbating as a matter of choice.  That is simply immoral and a systemic failure.

Poor Americans live in areas with worse air quality which can lead to a litany of problems like  lower birth weights, kidney problems and even an increased propensity for heart attacks and strokes. All of this leads to an estimated 470,000 deaths per year and perhaps even millions when different factors are included, from the study:

“Using simulated concentrations for 2000 and 1850 and concentration–response functions (CRFs), we estimate that, at present, 470 000 (95% confidence interval, 140 000 to 900 000) premature respiratory deaths are associated globally and annually with anthropogenic ozone, and 2.1 (1.3 to 3.0) million deaths with anthropogenic PM_2.5-related cardiopulmonary diseases (93%) and lung cancer (7%).”

Until we get a strangle hold on man-made pollution, these problems will continue to persist and intensify.

A Change Of Culture

Americans today are seeming to become increasingly hostile towards the mere mention of any sort of tax increases regardless of context. We seem to view the government as a school yard bully who takes our lunch money; this is true in some areas. For example, The Army Corps of Engineers spending $74.5 million on an unused airport and $29 million on a harbor with no roads connecting to an Alaskan town of 75 full-time residents.

Healthcare isn’t one of these areas. As I’ve explained above, in the context of healthcare, the for-profit, private system is actually less efficient, less equitable, more bureaucratic and wasteful than the government. As a nation, we’ll simply have to do the hard work and look at the profound long-term benefits of a meager tax increase for a single-payer system. If we don’t, the U.S. will continue to fall further and further behind other developed nations in all categories of health.