Category: reason

Two recent studies show how the attempt to curtail drug abuse by discouraging and restricting opioid prescriptions has hurt bona fide patients by depriving them of the medication they need to ease their pain. The harm inflicted on these innocent bystanders, which would not be morally justified even if the opioid crackdown did what it was supposed to do, is all the more appalling because limiting legal access to these drugs seems to have accelerated the upward trend in opioid-related deaths by driving nonmedical users toward black-market substitutes.

Jon Furuno, an associate professor of pharmacy practice at the Oregon State University College of Pharmacy, looked at prescribing patterns among 2,648 terminal patients who were transferred from an academic medical center to hospice care from January 2010 through December 2018. During that period, regulators and legislators responded to the “opioid crisis” by directly and indirectly limiting analgesic prescriptions, often in ham-handed ways. While that was happening, the study found, the share of hospice-bound patients who had opioid prescriptions when they were discharged fell from 91.2 percent to 79.3 percent—a 13 percent drop.

Furuno and his co-authors, who reported their results this month in the Journal of Pain and Symptom Management, controlled for age, sex, diagnosis, and the location of hospice care, so changes in those factors do not account for the decline in opioid prescriptions. Furthermore, “prescribing of non-opioid analgesic  medications increased over the same time period,” meaning that pain was more likely to be treated with less effective but still potentially dangerous drugs.

The average age of these patients was 66. Nearly three-fifths had cancer diagnoses, and all of them were expected to die soon, meaning that treatment should have been focused on making them as comfortable as possible in their remaining time.

“Even among patients prescribed opioids during the last 24 hours of their inpatient hospital stay, opioid prescribing upon discharge decreased,” Furuno noted in a press release. “It seems unlikely that patients would merit an opioid prescription on their last day in the hospital but not on their first day in hospice care, and it’s well documented that interruptions in the continuity of pain treatment on transition to hospice are associated with poor patient outcomes.”

Furuno noted that “pain is a common end-of-life symptom, and it’s often debilitating.” He added that more than 60 percent of terminal cancer patients report “very distressing pain.”

In this context, it is especially striking that Furuno and his colleagues cite “patient and caregiver concerns regarding addiction” as one obstacle to adequate pain treatment. The risk of addiction is exaggerated and overemphasized even when physicians are treating chronic pain in patients who may have years or decades to live. When patients on the verge of death are suffering severe pain that could be relieved by opioids, “concerns regarding addiction” seem like a cruel joke.

Furuno et al. also mention “policies and practices aimed at limiting opioid use in response to the opioid epidemic,” which are based on similar fears and reinforce them. In particular, Furuno cites the opioid prescribing guidelines that the Centers for Disease Control and Prevention (CDC) issued in 2016.

Those recommendations, which were widely interpreted as setting firm and binding limits, led to large, sudden, and indiscriminate dose reductions, along with outright cessation of treatment and patient abandonment. The suffering caused by that response has been highlighted by the American Medical Association, the Food and Drug Administration (FDA), and the CDC itself. The authors of the guidelines blamed clinicians who “misimplemented” their advice.

“There are some concerns…that indiscriminate adoption or misapplication of these initiatives may be having unintended consequences,” Furuno said. “The CDC Prescribing Guideline and the other initiatives weren’t meant to negatively affect patients at the end of their lives, but few studies have really looked at whether that’s happening. Our results quantify a decrease in opioids among patients who are often in pain and for whom the main goal is comfort and quality of life.”

A Journal of General Internal Medicine study published in February further illustrates how indiscriminate efforts to drive down medical use of opioids have undermined patient care. Researchers at Harvard and the University of Minnesota examined prescribing records for a 20 percent sample of Medicare patients treated from 2012 to 2017. They identified nearly 260,000 patients who were on long-term opioid therapy (LTOT) during that period and found that LTOT was discontinued in 17,617 of those cases.

“Adjusted rates of LTOT discontinuation increased from 5.7% of users in 2012 to 8.5% in 2017, a 49% relative increase,” the researchers reported. In a large majority of cases, LTOT “stopped abruptly,” and sudden cessation became more common during the study period, accounting for 81.2 percent of discontinuations by the end, up from 70.1 percent at the beginning. Two years ago, the FDA warned that such abrupt tapering may lead to “serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.”

Study co-author Michael Barnett, a physician and an assistant professor of health policy and management at Harvard’s T.H. Chan School of Public Health, was dismayed by the frequency of such “off the cliff” dose reductions. “The vast majority of long-term opioid users whose therapy was discontinued had an extremely rapid, abrupt taper that was far outside of guideline recommendations,” he told MedPage Today. “It would have been concerning to find that, say, one in four long-term opioid users had abrupt cessation of their therapy, but we found that it was most, even among those with very high daily doses of opioids.”

Barnett concluded that “we need more education and support for patients on long-term opioid therapy to taper in a clinically rational way.” But the speed of tapering is not the only concern raised by these findings.

Drug warriors may assume that all of these LTOT discontinuations would have been medically appropriate if only they had been carried out more gradually—in other words, that all of these patients were better off without the opioids they had long used to relieve their pain. But it seems unrealistic to suppose that doctors, operating under extraordinary government pressure, never sacrificed the interests of their patients to avoid unwelcome scrutiny. The increased risk of suicide among patients suddenly deprived of pain medication suggests otherwise.

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Food and Drug Administration (FDA) bureaucrats imposed a “safety pause” on administering Johnson & Johnson’s one-shot COVID-19 vaccine on April 12. The agency recommended that inoculations of the vaccine come to a stop after six women out of nearly 7 million people who received the shot reported experiencing dangerous blood clots. At the time, various public health experts insisted that this safety-first response was taken in order to “maintain public trust” and could “actually build confidence in people” in the vaccine.

Other commentators pointed out that this highly risk-averse regulatory action would backfire and would instead make Americans more worried about the safety of the vaccine.

Last Friday, after 10 days, the FDA lifted its pause. The agency concluded that “the available data show that the vaccine’s known and potential benefits outweigh its known and potential risks in individuals 18 years of age and older.”

So did the pause bolster the confidence of Americans in the vaccine as predicted? Not quite. “Fewer than 1 in 4 Americans not yet immunized against the coronavirus say they would be willing to get the vaccine made by Johnson & Johnson, according to a Washington Post-ABC News poll that finds broad mistrust of the shot’s safety after federal health officials paused its use,” reports the The Washington Post.

“If I hear the phrase ‘abundance of caution’ one more time, I’m going to jump out of my window,” Paul A. Offit, a vaccine expert at Children’s Hospital of Philadelphia, told the Post. “In the name of transparency, in the name of openness, we scare people.”

Scaring people away from being inoculated with a very safe and effective vaccine means that more will die from, become hospitalized by, and suffer the miseries of the COVID-19 infections that would otherwise have been prevented.

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It’s official: Democratic California Gov. Gavin Newsom is on his way to facing a recall election.

On Monday, Secretary of State Shirley N. Weber announced that supporters have gathered more than enough valid signatures—1.6 million of them—to force a vote over whether Newsom will complete his term in office.

The state’s last such recall election occurred in 2003, when Gov. Gray Davis—also a Democrat—was booted out of office by voters. Davis became increasingly unpopular due to his mishandling of an electricity crisis, which saw rolling blackouts during the summer heat.

Under Newsom, California has actually seen a return of summer rolling blackouts, but that’s not the only justification for the current recall push. A number of voters are particularly upset about Newsom’s reaction to the COVID-19 pandemic, which has included unilaterally shutting down the state and tying reopening measures to hotly contested “equity metrics” and other politicized policies that seemed to have little to do with protecting public health.

Recall supporters still face an uphill battle. Yes, Newsom’s overall popularity has taken a hit in the pandemic, but more than half of all voters still approve of his performance, according to a March poll by the Public Policy Institute of California. If the recall had been held at the time of the poll, only 40 percent would have voted him out. If the state continues to reopen, Newsom’s support might not just hold steady but even start to increase.

Recall supporters also have another problem. Polling shows that Republicans heavily support the recall effort while Democrats heavily oppose it. Since Democrats overwhelmingly outnumber Republicans in the state, the math would seem to speak for itself.

On the other hand, summer is approaching and that might mean more rolling blackouts and related troubles, which might draw attention to Newsom’s recently announced plan to completely ban fracking and phase out oil production within the state by 2025. Newsom’s ambitious environmental agenda might end up hurting him at the polls if hundreds of thousands of people have to endure power outages during the hottest parts of the year.

So far, three Republican candidates have announced their intent to run as potential replacements should Newsom be recalled. They are businessman John Cox (who ran against Newsom in 2018 and lost by more than 20 percentage points); former San Diego Mayor Kevin Faulkner; and former Olympian turned reality television star and transgender activist Caitlyn Jenner.

More candidates will surely come forward and, yes, it’s going to be a circus. Remember that when Davis was recalled, 135 candidates ran to replace him. Only four of them broke the 1 percent barrier. Three of those candidates officially ran as Libertarians, collecting a combined total of 5,887 votes out of more than 9.4 million votes cast.

Californians who signed the recall petitions have 30 days to ask the secretary of state to remove their names. If enough signatures remain after that, the state’s Department of Finance then gets 30 days to calculate the election cost, then another 30 days to review those figures, and then it’s up to the state’s lieutenant governor to set the date for the actual recall election, which will fall somewhere between 60 and 80 days from the final certification of signatures. If all of that goes as planned, the recall election will likely take place sometime in September, October, or November.

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The Centers for Disease Control and Prevention (CDC) updated its public health guidance on Tuesday, finally conceding that people who are fully vaccinated do not need to wear masks while outdoors.

“There are many situations where fully vaccinated people do not need to wear masks,” said CDC Director Rochelle Walensky, citing mounting evidence that the disease does not spread easily outdoors. “If you are fully vaccinated and want to attend a small outdoor gathering with people who are vaccinated or unvaccinated, the science shows, if you are vaccinated, you can do so safely unmasked.”

Her remarks prompted a few reporters to ask why anyone has to wear a mask outdoors if COVID-19 is not easily spread under such circumstances, and whether vaccinated people wearing masks indoors was more about sending the right message than actually keeping people safe. In both of those cases, Walensky urged people to stick to the restrictions until more of the population is vaccinated and case rates have declined further.

Federal health officials are still being too cautious, as is their custom. Yet it’s an encouraging sign that the CDC has made this concession, since it means that the intellectual defenders of universal masking (such as Joy Reid and Keith Olbermann) are no longer following either the most up-to-date science or the official guidelines. They have no leg to stand on.

Indeed, Walensky explicitly said that government mask mandates should be changed to comply with the CDC’s new position, which is that vaccinated people do not need masks outdoors. It’s not much, but it’s something.

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You wouldn’t be able to tell from federal policy, but most Americans have a favorable view of immigrants, and a majority believes that improving opportunities for immigrants to come here legally would be better than beefing up border security and cracking down on illegal immigrants.

Those are two of the major findings from a new survey of Americans’ views on immigration policy conducted by the Cato Institute, a libertarian think tank. The survey, which polled 2,600 adults and was released Tuesday, shows that 72 percent of Americans believe immigrants come to the U.S. to “find jobs and improve their lives” while only 27 percent believe that immigrants are primarily attracted by the promise of taxpayer-funded welfare programs. Similarly, 53 percent of immigrants and the children of immigrants say their families came to the U.S. for economic opportunity, while just 8 percent say they sought to tap into government aid.

When it comes to setting policies, 55 percent of Americans say they favor providing a “pathway to citizenship” for undocumented immigrants and 56 percent say that simplifying the process for legal immigration is the best way to reduce illegal immigration. Only 24 percent say they would like to deport undocumented immigrants rather than allowing them to become full citizens or permanent residents.

Overall, the Cato immigration survey shows that Americans’ views on immigration are more nuanced and complex than what is usually captured by media and politics. Partisanship is a factor—self-identified Democrats, for example, are far more likely to view immigration favorably—but the survey suggests that both Republican and Democratic administrations may be overestimating the extent to which Americans support harsh treatment of illegal immigrants, as well as underestimating the support for streamlining legal immigration.

Anti-immigrant rhetoric has become more prominent on the political right in recent years, and restrictions on both legal and illegal immigration were hallmarks of former President Donald Trump’s administration (though former President Barack Obama actually deported more people). President Joe Biden has condemned Trump’s approach, but so far has done very little to reverse those policies. Last week, for example, the Biden administration said it would not increase the annual cap on refugees allowed into the United States—which Trump had cut dramatically—before abruptly changing course after a public backlash. The Biden administration has also continued construction on Trump’s much-ballyhooed border wall, and it has not put an end to policies that separate refugee families when they are apprehended while crossing the border.

Sen. Bob Menendez (D–N.J.) and Rep. Linda Sanchez (D–Calif.) have introduced bills in Congress outlining an eight-year process for undocumented immigrants to become U.S. citizens. Their proposals have the backing of the Biden administration but face an uncertain future in Congress.

The biggest obstacle for the Biden administration’s immigration reform agenda might not be public or political opposition, but the president’s competing policy goals. As David Bier, an immigration policy analyst for the Cato Institute, wrote for Reason earlier this year: “Presidents Obama and Trump both campaigned promising immigration changes. Both had the advantage of a friendly Congress. But neither wanted immigration reforms to upset prospects for their other major priorities…[Biden is] also beholden to a complex interwoven system of partisan priorities that could cause him to turn his back on immigration—or enthusiastically embrace it—later in his presidency, depending on what else is going on.”

For now, that means federal immigration policy is likely to remain out of step with the views of most Americans. And while the loudest voices demanding the biggest walls are likely to continue to exercise undue influence within immigration politics, it’s useful to keep in mind that they represent a distinct minority of the country.

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