Spending Money on the Opioid Crisis

Today's Seacoast Sunday headlines a study done of the outcomes of government spending to try to stem the "opioid crisis."
It was a story produced by the Granite State News Collaborative, which meant it provided actual researched news--a rarity for our local "newspaper."

What it showed was that the "opioid crisis" is not a single problem but a web of problems.  
1/ The problem of death from acute opioid overdose.  For the past two years there have been about 470 overdose deaths in New Hampshire annually and as of October this year we stood at 312. This may mean we'll do slightly better this year, and that has been attributed to the wider availability of Narcan on EMT trucks.

Of course, as many of the EMT folks have observed, the same addict tends to be rescued three or four times in a week, and these front line folks ask what is the purpose of rushing out to save a person who is determined to repeat the same behavior, until they do it in a place nobody notices.

2/ The problem of ongoing addiction: While the number of ambulance runs can be counted and recorded easily enough, the number of opioid users is a more difficult thing to quantify because people tend to not raise their hands when asked who is engaging in illegal behavior. 

3/ The problem of assessing efficacy of intervention: for which there is a well established set of techniques, from the scientific point of view, but there is incentive for both government and the "vendors" they pay to claim success where there may be none, like the old "body count" data from Vietnam, which always showed we were winning that war.

Programs to treat addicts basically come down to replacing one addiction--heroin/Fentanyl with another, to methadone or suboxone which are drugs which allow patients to return to normal work and life activities. This is called "medication assisted therapy" or MAT, because calling it "replacement addiction" would not, presumably, be welcomed by the governor or the legislators. 

The National Institute of Drug Abuse posts this on its website:

According to several conservative estimates, every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1. Major savings to the individual and to society also stem from fewer interpersonal conflicts; greater workplace productivity; and fewer drug-related accidents, including overdoses and deaths.

But consider the source:  Would you expect employees of the NIDA to post a statement that says: "Oh, nothing we are doing is helping much" ?


There are about 300 clients for these MAT programs in Littleton, NH, but no figure is give for the state, oddly enough. Given the 24/7 nature of the programs, and the number of hospitals and EMT services which are involved, although most of these not full time, it is entirely possible that more people are, if not making a living, at least profiting from the opioid crisis than are actually being saved by the response.

Last year, at a Rockingham County Democrats meeting, Mad Dog asked Tom Sherman, MD , the New Hampshire state senator,  what evidence he had that the money spent was actually doing anything important to address the problems of drug deaths or drug addiction. At first he said there were statistics to support the benefit but when pressed, he finally admitted he could not bring any to hand and he asked, "But what's the alternative? Just giving up on these people?"

Bubbles 

Of course, there were parents of people who had died from opioid drug overdoses int he audience and they stared hate across the room at Mad Dog, but undeterred, Mad Dog alluded to the graph from the National Institute of Health Institute for Drug Abuse which showed, very clearly, that as long as drug addicts remained in their treatment programs they were apt to stop using drugs, but as soon as they left the programs, they became recidivists. 

This is true for alcoholics, of course and for that matter, for diabetics and hypertension.  The graphs shown above are from the NIDA website and the point is, of course, that as long as the patients remain in treatment, they do well, but as soon as they leave the treatment programs, they relapse, in the case of addicts, to the use of opioids. 

But the question is: Are we prepared to spend as much money on programs for addicts as we are on ongoing therapy for diabetes and hypertension?

You knew it was coming, but Mad Dog simply must refer you to the best single exploration of drug culture ever done: the TV series "The Wire."  Most people simply cannot endure the reality of this fictionalized show and stop watching. But that's the rub: If we, as citizens, are unwilling to actually face reality, but would rather throw money at it like some street beggar just to make it go away, we will never make progress in solving the problem we refuse to actually face.

The Inverse Ratio: Trump's Insight

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Boris Sends Us a Wake Up Call: It's Got to Be Amy

"The old assumptions—that truth matters, that lies shame the liar, that in a democracy the press and the public must have the right to interrogate those who seek those top jobs—have all been swept aside by the Tories’ convictions that in an inattentive, dissatisfied, cacophonous world, victory will go to the most compelling entertainer, the most plausible and shameless deceiver, the leader who can drill home a competitive and seductive incantation. Facts and details will be irrelevant so long as voters feel the politician is on their side…Mr. Johnson is not being exposed or embarrassed by his lies because the flood of them is overwhelming, because Britain’s powerful right wing press is backing him and because he’s dodging any format which could sustain a challenge to him.

Mr. Johnson’s team has seized upon a terrifying truth: that the old media, particularly the broadcasters and the establishment that has decided its rules of operation are no longer the gate keepers to communication. Cunning politicians can skip accountability, and British broadcasting’s rules on impartiality and balance by going straight for the voters’ emotional jugular. In place of public and professional scrutiny there’s Twitter and Facebook, where millions of micro targeted messages are flooding key voters.

These focused, ferocious evasions of democracy’s conventions and protections appear to be working…If the Tories win, they’ll shrug off critics: the demos has spoken."
--Jennie Russell, The New York Times 12/12/19

Mad Dog has been silent lo these many weeks.

He has been busy on Twitter, but after being sent to Twitter Jail yet again--this time for calling Lindsey Graham a political slut--he decided to reassert himself where the politically correct cannot reach him.
Slut? Really?  That's not even on George Carlin's list of the 7 forbidden words.

Twitter is so retro. It's the delusional platform where you may think you are engaging your fellow citizens, changing minds, putting new ideas out there, but nobody much on Twitter is interested in new ideas or having their opinions abridged. Twitter is a safety valve where steam is expelled and it's not even steam; it's more like flatus.

So back to the message in a bottle, the voice in the wilderness, the unheard mind, radiating out into the universe, where some light years from now, some civilization may receive the signal and wonder, "Who, or what, was Mad Dog? And what on planet earth was he talking about?"

Trump's Doppleganger

Yesterday, the Conservative Party swept Boris Johnson into office in a landslide, taking coal mining towns which hadn't voted for the Tories in generations.  The choice was between Boris Johnson and a socialist named Jeremy Corbyn. 

Jennie Russell, writing in the New York Times before the election, under the headline: "Can Boris Johnson Lie His Way Into Office?" was writing about the UK but any American can simply substitute names and recognize what she was talking about.

What this means for our own choices, here in New Hampshire, as we face the primary, now just over a month away is stark:  Much as we may love Bernie or Elizabeth, we have to face reality.

I last heard Bernie in South Church, and that was an entirely appropriate place to hear Bernie, a Unitarian church which is entirely secular, and Bernie was preaching that old time secular religion of power to the people, the rise of the proletariat and he was received with rapturous delight by young and old alike.

And I asked myself, "How could I have ever strayed from Bernie? He is my one true love." But, the fact is, both he and Elizabeth Warren insist that government must exclude private insurance from American healthcare and neither will hear a dissenting voice on this, nor will they explain why an American system could not accommodate both, as systems in Europe, and in England in particular, do.

Having just read "Dr. Zhivago" I could see in our most left candidates the intolerance of opinion, making the perfect the enemy of the good.

So, no, I'll not vote for either socialist. I'll reject Corbyn, Warren and Sanders and vote for the moderate.

But which moderate?  

Biden would be the obvious restoration candidate, but one duty of New Hampshire is to look at these candidates close up and inspect them for cracks and Biden is clearly failing, mentally, if not physically. Why trade a President Archie Bunker for a President Homer Simpson?

Mayor Pete is the most intelligent, articulate of the bunch, but he has that one weight around his neck which will sink him in the Midwest and the South: They will tolerate a Black President, who they can make an exception for, but not a gay President. And Black voters will not vote for him because Blacks go to church, as a rule, and their churches will and do preach against homosexuality. This is not a point you can reason with people about. You can rail at me, say I'm looking at Blacks as if they all think the same. But in politics what counts is characteristics which typify a group, and most Jews tend to revile Nazis and haters and most Blacks will not abide homosexuality.

Corey is a fine man, but for whatever reason, his Mr. Rogers persona has not caught fire with the electorate.  There is something cloying about him, too eager to please. He is the kumbaya candidate and the electorate is not about kumbaya this time around. They are out for blood. 

Which leaves Amy Klobuchar.  

Senator Klobuchar as several things going for her: She grew up in Minnesota, the American heartland. True, she went to Yale where she imbibed deeply from the cup of "the chosen ones" but she returned to Chicago for law school and to her home state for her political career. She's been an effective, law passing machine in the Senate.

Against all that, she is not a household name and unlike Trump, she has not spent decades marketing her brand to fans of the World Wrestling Federation and Fox News.  So, in that sense, she has not paid her dues.  Even JFK did his star making stint on national TV during the Jimmy Hoffa hearings. None of the women in my office have ever heard of her. They watch local news shows in the morning before going to work and none of them have any idea who Boris Johnson is, not to mention Amy.

The big knock against Amy is she is a mean girl, who punches down at her office staff which has the highest turnover on Capitol Hill. Of course, were she a man, this would not be a problem; the turnover of Trump's office staff does not seem to be a problem.

No, Amy's problem is a little different: She was asked at a local house party, "How do you run a campaign of policy against a candidate of charisma?" 

She laughed at that question, and seemed genuinely amused by it. Hadn't been asked that one before. Her response? You could predict it: "Well, I think I have charisma."

An acceptable answer, but a dodge, a place holder. The fact is, she needs work. 

At the last debate, her hair kept obstructing her left eye in a way which was so distracting it was often difficult to listen to what she was saying.

Oh, I know! How sexist! Nobody would ever talk about a man's hair style or his clothes. But this is not about fair. It's about winning.

She is going to have to dance backwards in high heels while her male opponent merely needs to push forward. 

She is clearly very bright. But she also clearly has her demons and she needs to overwhelm that with her rapier wit.

Her capacity for the funny put down is as yet untapped.

She needs to read more Churchill, and other politicians who could destroy an opponent with withering disdain.  She needs to have enough confidence in a coach to become devastating.

One of my sons was a wrestler. He had some strengths, but he had visible weaknesses. He was simply not as physically powerful as the champion opponents. But he found a coach who he trusted and he trained and practiced and the results were remarkable.

Amy needs the same thing.

Things I'd like to hear Amy Say In the Next Debate

Amy Klobuchar needs to save the Republic by gaining the Presidential nomination, given the clear inability of far left candidates to win elections in the 21st century, and given the disabilities and disqualifiers among the other moderate canddiates.
So, in the spirit of helpfulness, Mad Dog proposes she rehearse some of these lines for the next debate:

Pia Guerra

• Donald Trump has never met a fact he hasn't tried to molest.

• You could fill all the Macy's parade balloons with the air from inside  Mr. Trump's head.

• Mr. Trump doesn't hate Black People. He doesn't hate Brown People. He hates poor people, especially poor people from poor countries. He thinks they should have been smart enough to have been been born rich in Queens.

• Mr. Trump thinks poor children from South of the Border are an infestation. And he thinks the KKK is the name of an aerosol disinfectant. 

• Have you ever noticed Mr. Trump can never look you straight in the eye?  It's like holding a mirror up to Count Dracula.

• Mr. Trump thinks the G-7 leaders should all come to one of his resorts for their next meetings. The leaders were reluctant: They wanted to be sure they scheduled for a resort which won't go bankrupt before they have a chance to check out.

• Mr. Trump thinks Sean Hannity is best newsman since Walter Cronkite.

That's like saying The Hulk Hogan is the best hitter since Babe Ruth. 

• Our President has told us he has all the best words.  He must be afraid of spending any of those on us. 

• After Neo Nazis killed a woman protester in Charlottesville, Mr. Trump said some of those Nazis were "very fine people." He was careful, as always to use that great disclaimer "some." Still, he broke new ground. He is the first President to ever actually say that some Nazis are very fine people.

• Half the Republicans on the House Judicial Committee were not patriots in that they placed party loyalty and their own political futures ahead of their country to defend a President who obstructed Congress, and refused to recognize the fact he is not king. So that makes them, in my estimation, moral reprobates. But wait, no, that is to violate the Congressional rule against personal attacks against members of Congress. I rescind that remark. I disavow it. To correct myself: Half of the Republicans on that committee are NOT moral reprobates

• Mr. Trump takes credit for the booming economy, which of course started with Mr. Obama after the Republican crash of 2008. Every day the stock market soars he tweets, claiming credit. That is like a surfer claiming credit for high tide and great surf. Mr. Trump sees the beautiful sunrise over Queens and cries: "See, that's because of me! That's a Trump Sunrise!"  A Trump sunset would be more believable. 

The Gods Will Not Save Us: Maybe the Women Will

Somewhere back in his high school years, my younger son impressed his high school English teacher as they were discussing the Iliad. Asked about Zeus and the reason he had relented in his support for the Greeks in a certain battle, my son said, "I think it was his wife, who favored the Trojans. Zeus was a little scared of her."

The teacher remarked she had not seen that before, and the more she thought about it, the more she saw evidence for it. Zeus, the king of the gods, was intimidated by the queen.

Watching the pathetic spectacle of liberal commentators on Twitter, Mad Dog has been repelled by all those effete Democrats who kept writing about how Trump will be impeached or he will resign, all of them looking for some rescue by a deux ex machina, anything but having to beat Trump in the 2020 election. What cowards. They do not think they can defeat Trump on the field of battle, so they hope the gods of impeachment will intervene.

Mad Dog was equally dismissive of the Million Women March, that massive group hug in various northeast cities, with women in pink knit hats. 

As if  that was going to do any good. Hold up your Teddy bear to the big bad ogre.

But lately, Mad Dog cannot help but notice, it is the women who seem to be donning the armor and going out to do battle.

In our local Rockingham County, we are seeing women carrying the load. 

The men, at our meetings are aged, droning on about past triumphs, reading position papers, talking about how they heroically won elections in bygone years.

It is the women who are actually engaging the enemy.

Last night, at the Rockingham County Democratic meeting, the chairman, told us how Dems had knocked on a thousand doors four times each and "almost" won the special election for the New Hampshire House of Reps. Oh, what a victory! In a "Republican" district we were able to come so close. Lost by only 80 votes!

He mentioned Mary McCarthy, a woman who is busy running a family which extends across oceans and manages with aplomb this familial organization, which would send the typical CEO of a multinational corporation screaming from the room, this woman drove out to the district and dialed numbers from  a phone bank in an attempt to turn the vote.

She did not succeed, but the fact is, it was she who was in the trenches. Yes, there were men participating, but the women are essential.

Liz McConnell

The candidate she was working for was a woman. Mad Dog looked around the room and saw Liz McConnell who had won a seat in deep red Brentwood, and behind him sat Kristi St. Laurent, who is trying to do the same thing in Salem, NH.

Kristi St. Laurent

And these women represent very different sorts of classes within the very white New Hampshire Dems. In some ways they could not be more different: McConnell is the very image of a proper upper class doyen while St. Laurent raises chickens and tools around and rides to the meeting on her motorcycle.  But they share a common set of values which favors the dispossessed over the privileged and which seeks to allow the disadvantaged a better chance to close the income gap.

The Democratic Party may be once have been the party of the unionized worker, or the ethnic group, or the suppressed groups of color, but in this state, it is the party of the offended and motivated woman.

Three years of a corrupt, priapic President and these women are digging the trenches and preparing the assault.

Mad Dog just saw the Trinity Rep production of "Prince of Providence" about the thoroughly corrupt, albeit beloved, mayor of Providence, Rhode Island, Buddy Cianci.
Cianci started out as a prosecutor of the Patriarca family but upon assuming the throne of the Mayor's office, he slid into one corrupt backroom deal after another to placate the unions, the entrenched interests to "get things done" in Providence, which was in 1975 a decaying slum of a city, where people were content with the way things were, even if they were pretty crummy. At least the powers that be were in control, and they didn't care what the town looked like, as long as they got their share of what wealth was available. 

Before the performance, Mad Dog had dined at a family restaurant around the corner from City Hall, where he talked with the owner who told him he knew Cianci well, had in fact been with him when he died and he knew Cianci was corrupt but, like our current President, he told me, "He got things done."

His line was that democracies don't work. Elected leaders are always being bought and sold but the important thing was giving back enough to change some things. Like Trump who came to fame because he said he could complete the Central Park ice skating rink, which had languished for years, unfinished, Trump got it done in 3 months, by firing the union workers. 

Cianci

So it was with Cianci, who was charming, who loved to be seen at every public event, who would show up, the wags said,  for the opening of an envelop.

Now this Cianci booster gave Cianci credit for all the new parks and buildings, most of which were completed long after Cianci was convicted for a felony and removed from office , re elected and then jailed again. This guy gave Cianci all the credit for all the good things that happened to that city as he now gave Trump credit for the low unemployment rate and the booming economy.

And I asked him, you really think that was all Cianci? And he answered, "Yes, and more."
"And you give Trump credit for the economy, for the low unemployment rate?"
"Absolutely!" 

This guy will not be deterred or persuaded. If anyone can see through his hero, Trump,  it will likely be a woman, just as it was women who could see through Cianci. They did not give him a free pass for his transgressions. They did not see a hero where an egomaniac resided.

But the new breed of Democrats do not accept this premise, that in order to change things you have to cheat and commit crimes.

Mindi

There is Mindi Messmer who fights for clean water. She isn't trying to get dirt on her political opponents; she is trying to succeed by the force of her arguments.

And, of course, there is Nancy Pelosi. She may be a septuagenarian, but she has learned some things along the way, and she knows how to throw a punch. 

Maybe Mad Dog is just getting old, but to his weary eyes, the hope is in the women. The men are old, jaded, dulled, limpid, just not able to move forward.

It's the women who are pushing us now.

MAGA: Make American Unions Great Again?

Listening to Mary Kay Henry, the head of the service workers union, this morning brought back a flood of memories. 

Mary Kay Henry

1. Ozzie and Harriet/Leave It to Beaver America:  The 1950's is the touchstone for Donald Trump's white base. Those were the good old days; the nostalgia crowd always talks about the time when a man could go off to the factory with his lunch pail, his wife at home raising the kids and he could take 2 weeks vacation in August, drive his car up to the lake, where he had his boat with its outboard motor and drag the kids water skiing behind. Shangrala. 

This, too, was the 50's 

Of course, the 50's were also a time of whites only water fountains in the South, a time when sex was dirty, forbidden and not to be mentioned, a time when everyone smoked, doctors, too and when the family had only one car because the wife was a home waiting for Daddy to come home and take her shopping, the house was small, women could not get credit cards without their husbands' permission and a lot of bored, lonely housewives became drunks.
Fact is, those halcyon times, especially in the Rust Belt, were created by unions. Before unions, factory workers were impoverished. 

Bill Gates did not build America

2. A surgeon complaining about the hospital "housekeeping" staff, men who cleaned operating rooms between surgeries who cleaned the OR's in 15 minutes, effectively, but whose union contracts said they got 45 minutes to do it, so between every case, there was a 30 minute idle time and multiplied out through the course of 20 operating rooms, through the course of the day, that 30 wasted minutes translated into a $20 million dollar loss for the hospital which could have gone to paying the rest of the staff more, the nurses, the cafeteria workers, all because the housekeeping staff was riddled with "slackers."

3. The news that when Volkswagen said it would be happy to have its factories in Tennessee  unionized, as they were in Germany, both  United States Senators, the governor blocked that idea. Unions were the modern equivalent of freeing the slaves: what would happen if all those low life's got more power?

4. Reading a contract from Hospital Corporation of America, which said:
A. The employee was forbidden from discussing his salary with other employees.
B. If the employee left the employ of HCA he could not work within 20 miles of any other HCA hospital or facility; i.e., leave HCA and you have to leave town.
C. If the employee is a physician, he is not allowed to contact any patient to inform that patient of where he is relocating, or having any contact with former patients. The patients, in essence, "belonged" to HCA, not the doctor. The patients, doubtless, would have been surprised to learn they belong to the corporation. 

Beyond these memories are the realities of today's work environment.
The complexities of the current labor environment are complex:
1. McDonald's store (franchise) owners do not own the land on which their stores are owned, so McDonald's in Chicago can always pull the rug out from under them. McDonald's central does not set wages. The local store owner does, so there is no way to negotiate nation wide wages for McDonald's workers.

2. The gig economy: Uber does not have the same responsibility to Uber drivers the old corporations did. Uber drivers are not "employees" only contractors. So wages, cuts of ride payments, work safety, health insurance or retirement benefits are not in play.

3. The Supreme Court, as much as the President or Congress has been a problem for workers. 

4. The Republicans, who really represent the entrenched corporate executives, are so much better than Democrats, at marketing, at the name game. They want to pass "Right To Work" laws everywhere. Well, who would be against a right to work? 
Of course, what these laws really are are laws against unions. Unions cannot extract dues from workers for whom they negotiate. Kill a union's cash flow and you kill the union. 

Somehow, if we are ever to address income inequality, where the CEO makes $10,000 an hour when the line worker makes $10 an hour, the only foreseeable way would be to get a government in which promotes unions. 

Sackler Family A New Dreyfuss Affair?

Mad Dog has not investigated the role the Sackler family played in marketing Oxycontin as a safe, non addicting opioid, which clearly, as time made clear, it was not.

But there is a reason Mad Dog has not bothered reading the court transcripts or much of the available content in the New York Times or elsewhere: Mad Dog is intimately and extensively familiar with drug marketing.

What is nowhere mentioned in any report about Oxycontin that Mad Dog has seen is the fact that most drugs are approved by the FDA and sent to market with precious little really known about their eventual risks.  Eighteen month studies of eighteen hundred patients is not unusual. 

Every practicing physician knows, or should know, there is a reason why drug companies are required to provide post release approval data on the safety and efficacy of the drugs they market: everyone in the game--apart from the patients--knows how little we know about any drug until 500,000 patients have taken it for at least 10 years.

In the case of DES (diethyl stilbesterol) a hormone used to prevent pregnancy loss, it wasn't until the daughters of the mothers taking it reached age 15 that the high incidence of vaginal carcinoma in the offspring, in the females who were receiving the medication in utero, became evident. 

I remember, twenty years ago, when a physician, a family friend, employed by a drug company, told us over dinner how excited he was about this new drug the company he was working on. It was Oxycontin. He was working with a neurologist I knew well and respected immensely, at the Memorial Sloan Kettering Hospital for Cancer and Allied Diseases, and she was thrilled with this drug. She headed the pain center at MSK and she was happy to have that drug, he said.

I never called her to ask. Pain medicine was not much on my radar then.

But what this memory suggests is that at some point, at least early on, the people working with Oxycontin were true believers. What they knew later is another matter.

Of course, the whole structure of science and medicine is designed to test the hypothesis--and eventually, with enough data and study, the addictive potential of Oxycontin became evident.

Now enter the worlds of journalism, politically viable prosecutors, tort law, money and politics and the Sackler family becomes the prototype of the evil family making billions enslaving an unwitting population on this opioid.

You've got David Simon, (of all people!) tweeting the Sacklers should be brought to a public square and guillotined! 

And this is the guy who brought you "The Wire"! The Wire, that wonderful, detailed exploration of the effects of drug addiction, the "drug fiends" of Baltimore. The Wire, which was unblinking in its portrayal of people Simon knew when he was a reporter for the Baltimore Sun. 

The addicts themselves, blame nobody but themselves. They do not vilify the drug pushers, the touts, the corner boys or the drug lords. They know the problem is within themselves, to some extent, and their struggle is to face up to that. Temptation will always be out there in some form, whether it's heroin, alcohol or Oxycontin or Fentanyl.

Of course, David Simon, wonderful as "The Wire" and "Homicide" and "The Corner" were, is not the man I imagined, as is evident on his Twitter feed. But I expected better with respect to this story.

In the case of most drugs, big pharma is faceless, just corporate headquarters and coroporate boards--there is no one image to focus upon.

But America needs villains, scape goats and the rich, Jewish Sacklers fill that role admirably. We can hate them for their wealth, for their Jewish origins. Oh, they fill the bill.

Nowhere in here is any effort to examine the way Big Pharma advertises to the American public, i.e. "markets" its  drugs, or the profits to TV stations from all that marketing. 

In a corrupt society, there is no such thing as "clean money." The very media networks which are thundering on self righteously about the hideous, predatory Sacklers are themselves raking in millions from the Big Pharma accounts running drug ads on every network from Fox to CNN to CBS.

It's just so much easier to make this into a reality TV show with great villains and not think about it.