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Notes -
Two case studies in government waste:
As you can likely imagine right now a lot of people in medicine are sharing tales and taking sides in the great DOGE debate. Two that popped up on my radar and stuck out to me:
Some problems: -As an emergency room most of their patients have no insurance or Medicare or Medicaid, meaning the facility often get paid less than cost. They only stay open at all because of their state grants.
-Many of the patients are drug addicts or malingering (because of homelessness for example). Every day you’ll hear something like “you’ve been here every day for the last three weeks” or “have you considered stopping using PCP? You always seem to fight with the police when you do” and “here’s your follow-up appointment, will you go? No? Fuck me? Okay thank you have a nice day.”
-Many of the patients who do actually have mental illness are in denial about it, or have some sort of limitation that prevents them from attending aftercare appointments.
-The “best” solution is probably to violate patient rights and involuntarily commit them to make someone else be on the hook for making sure they go to their aftercare.
-In the meantime, the hospital has hired several additional staff to manage some of the administrative complexities associated with this change (for example hammer calling the patients to remind them to come to the appointment). They have also hired night staff whose job is to sit in an office overnight purely to schedule appointments with an outpatient program (otherwise no patient could be discharged overnight because they wouldn’t have an appointment to go to…).
Anyway, he dutifully completed his requirements in a timely fashion (which were all pointless! Ex: what is the motto of the VA???). So, months later his rotation is starting soon. He begins the process of emailing the education team once every 2-4 business days. You have to email them multiple times before they respond. The conversation goes something like this over the course of multiple weeks, “I think I’ve completed my onboarding do I have to do anything else?” “no” “okay is my onboarding done” “no” “okay when can I pick up my ID card” “when your onboarding is done” “I thought my onboarding was done” “yes” “okay what I am waiting on” “nothing.” I have seen the emails; it really looks like this.
At this point his program tells him to CC the chief of medicine at the VA hospital, at which point the person responds with “okay we put in a ticket for this a month ago, your training is complete but your training is marked as incomplete.” A screenshot has been attached that shows the request and an automatic response that says something about high ticket volume and that they will get to it at some point. The chief of medicine replies “….does the trainee need to do anything?” (we are here).
The resident will be able to rotate but will not be able to do any work without computer access.
It’s worth noting that the VA is paying for this resident to be there, despite the fact he will in fact not be able to do anything. At his last VA rotation (yes they go through this for every resident every time) he was six weeks into an eight week rotation before he got access.
Widespread narcan use is surely one of the biggest disasters in the history of modern America.
Imagine if tomorrow, a new medicine called Dementiolab or whatever comes out. It doesn’t prevent or cure Dementia, it doesn’t even slow its progression while someone still has a personality and life to hold on to. But, at the second-to-very-last-stage of the disease, the “giant violent baby” phase, the nightmare phase, Dementiolab prolongs life by 10x, keeping patients alive for many years. American hospitals rush to prescribe this new treatment, after all it literally prolongs the lifespan of dementia patients by a huge amount.
But for insurers, the public purse, families of patients and (I would argue) the patients themselves, it would of course be a disaster. It even further fuels the drug market because when customers don’t die, they come back to buy another day.
Narcan is like this for hard drug addicts. For generations, addicts who got into a really bad way, the kind you can’t really recover from (in 99% of cases), just died. But in Narcan, we invented a Dementiolab, a means to keep people alive in a horrific condition, resurrected again and again to keep suffering, and to keep making everyone else’s life worse.
Humanity, decency, even empathy requires that we stop giving addicts Narcan. If a 7 year old accidentally ingests some fentanyl then sure, otherwise no.
I've mentioned before that Mexico allegedly limits naloxone supply. By "limits" I mean it doesn't allow US advocacy groups to mule across a bunch of drugs to clinics at will. AMLO also said a few things that was skeptical of harm reduction and Narcan's role in the opioid crisis. Not exactly prohibition, but legacy scheduling laws that haven't changed looks like something less than harm reduction.
Narcan is the cheaper, easier solution to overdose treatment. A 20 year old EMT can administer it. Your little sister can administer it. Take Narcan out of the equation and EMS will still respond to overdose calls. They'll pick up junkies, apply whatever alternative medical attention they are able, then go and stick them in the ER.
Napkin math. Around 80,000 opiate overdose deaths in the US as of late. Pick one of the guesstimates, say the NSDUH surveys, on number of opiate users and decide to 2 million opiate addicts is fair enough. At 82,000 deaths a year we get an annual mortality rate of ~4%. To me, this suggests addicts are actually pretty good at not dying from drugs given the drugs are as potent, addictive, and dangerous as ever. If we want to be extra generous with the numbers (decidedly not generous to addicts) then what do you think happens when Narcan is removed as a treatment? My guess would be the annual mortality rate of addicts rises by 2 percentage points for a time. Possibly less. What do we solve with such policy?
You suggest we stop treating overdoses with the best, relatively cheap treatments we have available. Enabling drug use is bad so we should remove tools that enable drug use. Medicine is one such tool, because it enables an addict to live longer to do more drugs. You do not suggest we don't provide medical treatment at all. If we wave the magic wand and blink Narcan out of existence we still the same stressors in the system. EMS arrives, does all the not-Narcan treatments, keeps someone alive if they can, and drives them to the ER. Some greater number of addicts are dead on arrival, but the rest receive the same or possibly greater treatment.
As I've gotten older I find myself more sympathetic to moral hazards. If the cost to widely available, easy to use treatments such as Narcan nasal spray is a 60% increase in opiate deaths (50k in 2015, now 82k) then, yeah you may have a point. The obvious incentives fire up my neurons, too. That said, in writing this post I did not find a study or review that gives Narcan substantial responsibility for the rise opiate use (now plateauing) and deaths. Even if we remain skeptical of harm reduction as an industry, lobbying group, and advocacy movement-- of the motivations of researchers in the field -- Narcan is so widely used there ought to be some. It's an old drug that was subject to innovation in response to increasing opiate use.
Wand waving Narcan does not look like compassion or tough love to me. Withholding the best medicine available doesn't sound decent to me. Tough love is giving someone Narcan, then immediately throwing them in the back of a paddy wagon to some farm in California to get clean and clear wildfire brush as punishment. Zero tolerance prison might work as well, but the cost of addicts taking up space in prison is fairly high. Withholding emergency medical treatment is a half-measure against a population that is filled with friends and family. Psycho Joe on the corner who demands medical attention twice a month is but a slice of the drug addict pie.
Here's one that made the rounds a few years ago: The Effects of Naloxone Access Laws on Opioid Abuse, Mortality, and Crime
Author's website has some additional commentary and appendices. Most interesting is the regional analysis where their estimates are that naloxone access led to a 14% increase in opioid-related mortality in the Midwest in particular (in the West and Northeast: insignificant decrease in mortality; South: insignificant increase). They give two explanations:
Their main policy recommendation is to expand drug treatment programs and find ways to ensure people get help post-overdose. Your paddy-wagon idea might have legs.
Thanks, register as Seen. Felt like they should be some push-back in this direction somewhere.
I can't take a major gander today but will come back. Curious how they control for all the gunk and if they look internationally at all. Estonia was a yuge fentanyl place for a time, but they went at the issue hard as I recall -- law enforcement wise -- and its OD rates got better. Canada, like the US, is bad and I assume has similar maximal harm reduction approaches.
This is interesting and makes sense.
This is what people always say though, hehe. I commiserate with the people tired of hearing it as things progressively get worse. Sounds rather uncontroversial to say that involuntary commitment will save some number of souls. This doesn't have to be attached to naloxone prohibition.
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That's two things. They'll get separated, so they get the Narcan but not the punishment.
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