Bryan Caplan has been blogging the recent book “Escaping Paternalism” and noted that he wished they had discussed opioids in detail. Jubal Harshaw of the blog GrokInFullness sent him a response, noting a number of posts in which he critiqued “the usual view” that Caplan brought up to contrast with the book. I myself have noted (while reviewing Dreamland) that the scale of deaths due to opioids in recent years has been something of a challenge to a libertarian perspective, which I previously leaned more toward vs consequentialism (I recalled reading Radley Balko railing against the restrictions faced by chronic pain patients), even if I still shy from paternalism. Among the four posts Jubal linked Caplan to, one is this take on Dreamland.

I have a slightly different perspective from Jubal on a certain phenomena: He notes an increase in heroin usage after a crackdown on pill mills, and in my review of Dreamland I noted the rise in heroin overdoses while pill overdoses dropped after Oxycontin switched to a more difficult to abuse formula. This establishes a flow from pill use to heroin use which Jubal was skeptical of, and indicates that public drug policy can be effective, whereas Jubal usually highlights the despair in Quinones’ book about ineffective law enforcement. It’s true that an increase in heroin (and more recently, fentanyl) overdoses isn’t the outcome these policymakers desired, but it has different implications from a scenario where “lol nothing matters“. The late Mark Kleiman, in his own critique of the medical model of addiction (which I think Jubal might appreciate), he noted that swift & certain (even if mild) enforcement worked to deter opiate-addicted doctors with their own special monitoring program, as well as how effective Maoist brutality was in suppressing usage in China. Jubal is looking at things from a normative lens (thus taking into account the benefits that users receive), but reducing things to good or bad can sometimes elide details indicative of the range of possibility.

In my Dreamland post, when noting my continued skepticism of paternalism I linked to Robin Hanson. I find him more persuasive on the topic than Austrians like Mario Rizzo, because as a consequentialist he could be convinced with sufficient evidence. He focuses on issues of information and trust/credibility, asking why people who know better don’t just inform the ignorant rather than restricting them. At the same time, Hanson is known for his skepticism of the benefits of medicine, and not purely because it is government subsidized. Jubal compares an increase in prescriptions to an increase in risky surgeries, assuming it must be a benefit, but per Hanson we could eliminate something like half of all medical treatment on the margin (and recent increases would presumably be on that margin) without any net cost to health.