Why We Have an Opioid Epidemic

WARNING: Before we go any further, I am going to lay my cards on the table, and state my biases. I have suffered from age 12 for 48 years with 2 intractable pain conditions, for which I have been prescribed opioids on both an acute and chronic basis for 38 of those years. At age 12, I suffered my first classic migraine. From age 12 to age 18, I was treated in the ER roughly 6 times each year with Demerol as a rescue medication for acute migraine headaches. Over the next 6 years, as an undergraduate and during my first two years of medical school, I was prescribed oral oxycodone (Percodan) to self manage my migraines, 12 tablets every 6 months. The sleep deprivation of clinical rounds caused my migraine frequency to peak, and when the faculty of my medical school was unable to treat my frequent migraine headaches, I was forced to leave medical school after the third year. I was opioid free between 1985 and 1996, but after many workups, my headache specialist started me on 30 mg OxiContin per day. This controlled my migraines from 1996 through 2008. In 2008 my car was struck by another car and hit a tree at 45 mph. I suffered 15 broken bones, including 3 fractured vertebrae. I was discharged from the hospital 22 days later on 600 Milligram Morphine Equivalents (MMEs). That dose was titrated down to about 120 over two years, and I was maintained on that 120 MME dosage through 2018. This year my current pain management physician titrated me to 85 MME, due to the current CDC Guideline. I will discuss further my beliefs surrounding opioids; however, I wanted to provide a disclosure.

No one doubts that the number of drug overdose death rate has increased dramatically since 1999. And because some number of those deaths involve opioids, whether or not the opioid was the causative agent, the increase has been labeled the opioid epidemic.

Drug overdose deaths (DOD) have steadily increased from 1999 through 2017. In 1999, there were 6.1 DOD per 100,000 standard population; in 2016 that rate had risen to 19.8 per 100,000. The rates for all age groups above 15 years of age increased over that time frame. For some age groups, the increase was much larger than others (See figures 1 and 2).

The Centers for Disease Control and Prevention (CDC) has been one of the lead agencies in describing, defining, and combating the opioid epidemic. Why? Two factors (at least): their name (Disease Prevention) and their constitution i.e. a collection of epidemiologists. The CDC uses epidemiological methods to describe and characterize outbreaks of sickness. I remember receiving the CDC Morbidity and Mortality Weekly Report (MMWR) from my first week of medical school in 1980. Do they treat patients? Rarely, but they do crunch numbers and characterize epidemics.

We know that people are dying due to drug overdoses that include opioids because the CDC has produced report after report with thousands of statistics on these opioid overdoses. And not just the CDC. The White House Office of National Drug Control Policy (ONDCP) and the Drug Enforcement Agency also release statistics about the number of deaths due to opioids, and the number of prescriptions for opioid medications that are being written. One little problem: The statistics don't always agree. In fact, the agencies can't even agree on the trends. And this is a big problem, because if we can't determine how many people are dying, what drugs they are dying of, and where they got their drugs, how can we fix the problem?

As an example, on December 8, 2016, the Obama White House's ONDCP stated that 17,536 Americans dies in 2015 from overdoses involving prescription opioids, a 4% increase over the previous year. However, on December 16, 2016, the CDC stated in that weeks MMWR that the number of drug overdoses due to prescription opioids was actually 12,700 in 2015. When the Pain News Network, (PNN) a pain management advocacy newsletter, contacted the CDC for comments on the disparity, they were given a third statistic: 15,281, for 2015. The PNN column also noted that the CDC failed to mention that the DEA had reported that the prescribing and abuse of opioid pain medication (as opposed to illicit opioids) is falling, and that less than 1% of prescription opioids are diverted.

Part of the reason is the methodology involved: the CDC's epidemiologists consult death reports for cause of death. And death reports, by the CDC's own grading system, are not of uniform or even high quality. The CDC states that only 28 states provide "high quality reporting" on overdose deaths. Also, death certificates do not necessarily reflect the cause of death, merely conditions that exist as death. As an example, a patient that dies of cancer who received morphine from their oncologist would constitute an "opioid involved death". Another problem with the statistics involves heroin: heroin is rapidly metabolized to morphine, and therefore some illicit drug deaths may be reported as prescription drug deaths, or double counted as both prescription and heroin deaths.

The CDC developed voluntary guidelines for prescribing opioids for chronic pain. These guidelines were intended to be for family practitioners, the class of physicians who treat the vast majority of chronic pain patients in the US, and who receive little training in the use of opioids for chronic pain. In addition, these guidelines were intended for new chronic pain patients, and weren't supposed to be applied to already established patients. But due to the public outcry over the opioid epidemic, the CDC guidelines have been adopted by some state legislatures and/or state licensing boards, causing those guidelines to become hard and fast rules for all chronic pain patients.

So, we know we have an opioid epidemic, although we don't know how bad it is, because we don't even know how good the statistics are. Some say that the epidemic occurred because of opioids being prescribed for pain. Others point to big pharma, saying that the drug companies pushed the opioids on people. Others point to irresponsible doctors, and others at pill mills.

All of these play some little role. But there is a bigger role, one that isn't talked about much. And we will never control and "solve" the opioid crisis if we don't talk about the cause.

Pain is a human condition. Every person is exposed to pain, from an early age. We touch as stove and learn to avoid heat in response to the pain of a burn. We skin a knee and learn to run a bit more carefully to avoid the pain of falling down. A woman experience childbirth and learns that a new child comes after the pain of labor. But for some of us, either the painful condition is never cured, or the pain doesn't go away after the trauma is supposedly healed. These are what constitutes chronic pain. How prevalent is chronic pain? Unfortunately, just like the statistics for the opioid crisis, there is lack of agreement.

The CDC issued a report that estimated that in 2016 20.4% of Americans (66 million) suffered chronic pain most or every day for 6 months, and 8.0% (26 million) suffered high-impact chronic pain, where high-impact chronic pain was pain most or every day that prevented functioning in work or family surroundings for 6 months of 2016. By comparison, in 2011 the National Institutes of Medicine issued its report Relieving Pain In America which found that more than 100 million Americans suffered from chronic pain every year.

It is unfortunate that chronic pain does not receive the attention it deserves. Why is that? There are class, cultural, economic and personal reasons for that. And these in turn shed light on why we have an opioid epidemic.

Let's start with class: If you are upper middle or upper class, odds are you don't have a job that will lead to your becoming crippled with chronic pain. Oh, you may suffer some back pain from sitting at a desk too long. But crippled? Hardly. But if you are lower or lower middle class? Much more likely. And crippled means hurting.

I am including a block from an article by Lauren Hough, published in Huff Post, who worked for 10 years as a cable tech:

We weren’t allowed to discuss pay. But we weren’t allowed to smoke pot and most of us did. We weren’t allowed to work on opiates either. We were all working hurt. I can’t handle opiates. But if I’d wanted them, there were plenty of guys stealing them from customer’s bathrooms. I could’ve bought what I needed after any team meeting.

That’s the thing they don’t tell you about opiate addiction. People are in pain because unless you went to college, the only way you’ll earn a decent living is by breaking your body or risking your life — plumbers, electricians, steamfitters, welders, mechanics, cable guys, linemen, fishermen, garbagemen, the options are endless.

They’re all considered jobs for men because they require a certain amount of strength. The bigger the risk, the bigger the paycheck. But you don’t get to take it easy when your back hurts from carrying a 90-pound ladder that becomes a sail in the wind. You don’t get to sit at a desk when your knees or ankles start to give out after crawling through attics, under desks, through crawl spaces. When your elbow still hurts from the time you disconnected a cable line and your body became the neutral line on the electrical feeder and 220 volts ran through your body to the ground. When your hands become useless claws 30 feet in the air on a telephone pole and you leave your skin frozen to the metal tap. So you take a couple pills to get through the day, the week, the year. If painkillers show up on your drug test, you have that prescription from the last time you fell off a roof. Because that’s the other thing about these jobs, they all require drug tests when you get hurt. Smoke pot one night, whether for fun or because you hurt too much to sleep, the company doesn’t have to pay for your injury when your van slides down an icy off-ramp three weeks later. I chose pot to numb my head and body every night. But it was the bigger risk.

I probably should’ve stolen pills. It would have made up for the fact I was making less than every tech I asked. They don’t like you talking about your pay for a reason. Some had been there longer. Most hadn’t. I was the only female tech because really, why the fuck was I even doing that job? Because I didn’t go to college. I joined the Air Force.

Why do you think that there are more opioid overdoses in the Mid-West and Appalachia? Florida, Massachusetts, New Hampshire and Maine: where are fisherman located? What about coal miners: Kentucky, West Virginia, Ohio.

Let's talk economics. Which classes are less likely to have good medical insurance? Let's go back to the great recession. What states had the most foreclosures? Take a look and compare:

It sure isn't a perfect match. But I could probably show correlation, at least for a large number of states. Yet the CDC would have you believe that the opioid epidemic is because of physicians prescribing too many opioids, or big pharma pushing too many. I'm sorry, but the reasons are much more nuanced.

My belief is we don't treat chronic pain patients well enough. There are many alternative treatments for pain than just opioids. Pain experts such as Dr. Lynn Webster, in his book The Painful Truth, talk about these. I have been fortunate to have received many of these, including injections, topical NSAIDs and lidocaine, psychiatric therapy, physical therapy, and opioids. Very few chronic pain patients have medical insurance that pays for the range of therapies needed for a balanced approach to chronic pain. And there are far too few pain management physicians for the number of chronic pain patients that exist. And it is getting worse, because the mis-guided approach of American regulatory bodies are driving both pain management physicians and other practitioners out of the pain management practice.

As I mentioned in my warning at the beginning, I studied medicine for three years, until my first chronic pain condition forced me to leave medicine. At that time, around 1980-1983, the use of opioids was very limited, even to cancer and terminal patients. In 1989, Texas passed the Texas Intractable Pain Act. This act provided a safe harbor for physicians to treat pain from a condition that had no cure, provided they documented the condition and their determination that the condition could not be cured or alleviated by existing medical means. Prior to the act, physicians were being disciplined by the Texas Medical Board because giving an opioid to a patient on a continuing basis made them "habitual users". By 1996, the Intractable Pin Act was modified to allow physicians to prescribe opioids to pain patients that had been abusers, so long as the prescription was to alleviate their pain that the prescriber had a duty to monitor and document.

In Texas, the Intractable Pain Act (Chapter 107, Texas Occupational Code) has been subsumed by the pain management rules codified at Chapter 170.3, Title 22, Texas Administrative Code. Chapter 170 describes those "guidelines" that the physician must meet to legally treat chronic pain in the state of Texas. Rule 170.3 states:

A physician's treatment of a patient's pain will be evaluated by considering whether it meets the generally accepted standard of care and whether the following minimum requirements have been met:

1. Evaluation of the patient.
2. Treatment plan for chronic pain. The physician is responsible for a written treatment plan that is documented in the medical records. The medical record must include:
3. Informed consent. It is the physician's responsibility to discuss the risks and benefits of the use of controlled substances for the treatment of chronic pain with the patient, persons designated by the patient, or with the patient's surrogate or guardian if the patient is without medical decision-making capacity. This discussion must be documented by either a written signed document maintained in the records or a contemporaneous notation included in the medical records. Discussion of risks and benefits must include an explanation of the:
4. Agreement for treatment of chronic pain. A proper patient-physician relationship for treatment of chronic pain requires the physician to establish and inform the patient of the physician's expectations that are necessary for patient compliance. If the treatment plan includes extended drug therapy, the physician must use a written pain management agreement between the physician and the patient outlining patient responsibilities, including the following provisions:
5. Periodic review of the treatment of chronic pain.
6. Consultation and Referral. The physician must refer a patient with chronic pain for further evaluation and treatment as necessary. Patients who are at-risk for abuse or addiction require special attention. Patients with chronic pain and histories of substance abuse or with co-morbid psychiatric disorders require even more care. A consult with or referral to an expert in the management of such patients must be considered in their treatment.
7. Medical records. The medical records shall document the physician's rationale for the treatment plan and the prescription of drugs for the chief complaint of chronic pain and show that the physician has followed these rules. Specifically the records must include:

Wow! That seems like a lot. But it is not... I will flesh out the lower levels in a moment. But look, there's nothing here about 90 MMEs maximum a day, or a maximum of 7 days of opioid medication, or other of the guidelines from the CDC. What these seven items constitute are basic standards of care we would want any physician to give us before they treat us with any treatment.

We want our physician to evaluate our symptoms. We want the doctor to tell us how they will treat our problem, and document it. We want them to explain the treatment, in sufficient detail so that we understand and can make an informed decision. We want to give out agreement, or not be treated at all. We want the doctor to periodically evaluate whether the treatment is helping, and not just keep giving us the same treatment if it isn't. We expect the treatment plan to be updated if necessary. If the treatment isn't working, and the primary physician needs help, we expect to be referred or have the physician consult with a doctor that can. And we expect all of this to be properly documented.

That is a minimum standard of care I was taught as a first year medical student. Every first year medical student is taught this. It's a no-brainer.

Rule 170.3 fleshes these items out in detail:

1. Evaluation of the patient.
   1. A physician is responsible for obtaining a medical history and a physical examination that includes a problem-focused exam specific to the chief presenting complaint of the patient.
   2. The medical record shall document the medical history and physical examination. In the case of chronic pain, the medical record must document:
      1. the nature and intensity of the pain;
      2. current and past treatments for pain;
      3. underlying or coexisting diseases and conditions;
      4. the effect of the pain on physical and psychological function;
      5. any history and potential for substance abuse or diversion; and
      6. the presence of one or more recognized medical indications for the use of a dangerous or scheduled drug.
   3. Prior to prescribing dangerous drugs or controlled substances for the treatment of chronic pain, a physician must consider reviewing prescription data and history related to the patient, if any, contained in the Prescription Drug Monitoring Program described by §§481.075, 481.076, and 481.0761 of the Texas Health and Safety Code and consider obtaining at a minimum a baseline toxicology drug screen to determine the presence of drugs in a patient, if any. If a physician determines that such steps are not necessary prior to prescribing dangerous drugs or controlled substances to the patient, the physician must document in the medical record his or her rationale for not completing such steps.
2. Treatment plan for chronic pain. The physician is responsible for a written treatment plan that is documented in the medical records. The medical record must include:
   1. How the medication relates to the chief presenting complaint of chronic pain;
   2. dosage and frequency of any drugs prescribed;
   3. further testing and diagnostic evaluations to be ordered, if medically indicated;
   4. other treatments that are planned or considered;
   5. periodic reviews planned; and
   6. objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function.
3. Informed consent. It is the physician's responsibility to discuss the risks and benefits of the use of controlled substances for the treatment of chronic pain with the patient, persons designated by the patient, or with the patient's surrogate or guardian if the patient is without medical decision-making capacity. This discussion must be documented by either a written signed document maintained in the records or a contemporaneous notation included in the medical records. Discussion of risks and benefits must include an explanation of the:
   1. diagnosis;
   2. treatment plan;
   3. anticipated therapeutic results, including the realistic expectations for sustained pain relief and improved functioning and possibilities for lack of pain relief;
   4. therapies in addition to or instead of drug therapy, including physical therapy or psychological techniques;
   5. potential side effects and how to manage them;
   6. adverse effects, including the potential for dependence, addiction, tolerance, and withdrawal; and
   7. potential for impairment of judgment and motor skills.
4. Agreement for treatment of chronic pain. A proper patient-physician relationship for treatment of chronic pain requires the physician to establish and inform the patient of the physician's expectations that are necessary for patient compliance. If the treatment plan includes extended drug therapy, the physician must use a written pain management agreement between the physician and the patient outlining patient responsibilities, including the following provisions:
   1. the physician may require laboratory tests for drug levels upon request;
   2. the physician may limit the number and frequency of prescription refills;
   3. only the primary pain management physician or another physician covering for the primary pain management physician in compliance with Chapter 177, Subchapter E of this title (relating to Physician Call Coverage Medical Services), may prescribe dangerous and scheduled drugs for the treatment of chronic pain. For any prescriptions issued for medications to treat acute or chronic pain by a person other than the primary pain management physician or covering physician, the terms of the agreement must require that at or before the patient's next date of service, the patient notify the primary pain management physician or covering physician about the prescription(s) issued. The terms of the agreement must require that such notice include at a minimum the name and contact information for the person who issued the prescription, the date of the prescription, and the name and quantity of the drug prescribed;
   4. only one pharmacy designated by the patient will be used for prescriptions for the treatment of chronic pain, with an exception for those circumstances for which the patient has no control or responsibility, that prevent the patient from obtaining prescribed medications at the designated pharmacy under the agreement. For such circumstances, the agreement's terms must require that at or before the patient's next date of service, the patient notify the primary pain management physician or covering physician of the circumstances and identify the pharmacy that dispensed the medication; and
   5. reasons for which drug therapy may be discontinued (e.g. violation of agreement).
5. Periodic review of the treatment of chronic pain.
   1. The physician must see the patient for periodic review at reasonable intervals in view of the individual circumstances of the patient.
   2. Periodic review must assess progress toward reaching treatment objectives, taking into consideration the history of medication usage, as well as any new information about the etiology of the pain.
   3. Each periodic visit shall be documented in the medical records.
   4. Contemporaneous to the periodic reviews, the physician must note in the medical records any adjustment in the treatment plan based on the individual medical needs of the patient.
   5. A physician must base any continuation or modification of the use of dangerous and scheduled drugs for pain management on an evaluation of progress toward treatment objectives.
      1. Progress or the lack of progress in relieving pain must be documented in the patient's record.
      2. Satisfactory response to treatment may be indicated by the patient's decreased pain, increased level of function, and/or improved quality of life.
      3. Objective evidence of improved or diminished function must be monitored. Information from family members or other caregivers, if offered or provided, must be considered in determining the patient's response to treatment.
      4. If the patient's progress is unsatisfactory, the physician must reassess the current treatment plan and consider the use of other therapeutic modalities.
      5. The physician must periodically review the patient's compliance with the prescribed treatment plan and reevaluate for any potential for substance abuse or diversion. In such a review, the physician must consider reviewing prescription data and history related to the patient, if any, contained in the Prescription Drug Monitoring Program described by §§481.075, 481.076, and 481.0761 of the Texas Health and Safety Code and consider obtaining at a minimum a toxicology drug screen to determine the presence of drugs in a patient, if any. If a physician determines that such steps are not necessary, the physician must document in the medical record his or her rationale for not completing such steps.
6. Consultation and Referral. The physician must refer a patient with chronic pain for further evaluation and treatment as necessary. Patients who are at-risk for abuse or addiction require special attention. Patients with chronic pain and histories of substance abuse or with co-morbid psychiatric disorders require even more care. A consult with or referral to an expert in the management of such patients must be considered in their treatment.
7. Medical records. The medical records shall document the physician's rationale for the treatment plan and the prescription of drugs for the chief complaint of chronic pain and show that the physician has followed these rules. Specifically the records must include:
   1. the medical history and the physical examination;
   2. diagnostic, therapeutic and laboratory results;
   3. evaluations and consultations;
   4. treatment objectives;
   5. discussion of risks and benefits;
   6. informed consent;
   7. treatments;
   8. medications (including date, type, dosage and quantity prescribed);
   9. instructions and agreements; and
   10. periodic reviews.

All of these things strike me as reasonable and necessary to treat a patient with dangerous drugs. Again, nowhere is there a list of MMEs or days of opioids prescribed. These kinds of arbitrary, one size fits all regulations are bad, and they get in the way of the physician crafting a pain management program that is tailored for the patient.

In fact, the CDC guidelines, or any regulation based on a maximum amount of morphine equivalents is bad medicine, for a variety of reasons that I will cover in a future post.

Laissez faire capitalism vs. The Tragedy of the Commons

As I write this there is a battle going on in the US. It's a philosophical battle over economics, and the results will be millions for the winners, and ruin for the losers. The battle is to justify and continue the 30+ years of deregulation versus the efforts to halt deregulation and begin to reregulate and control the many aspects of our economy and lives that have changed over the past 30 years. Like any battle that results in a huge payoff, it is being fought in the media, on the campaign trail, in the White House and Congress and the Courts, in boardrooms and in PR planning sessions. It is even being fought over the kitchen table.

Here in mid-July, 2019, it manifests in our President characterizing the Democratic party and every Democratic politician as a socialist.¹ In turn, the President points with pride to a large number of regulations the executive has undone.² His position is that these regulations stifle economic growth and prevent businesses, large and small, from operating efficiently. His opponents claim that these regulations are needed to prevent harm, to keep big corporations from taking advantage of their customers.

The President and his advisors promise that the classic theories of the marketplace will provide the greatest economic gain for all. As long as the government stays out of the way the laws of supply and demand will take care of any problems that arise. A single company such as Boeing establishing a monopoly? That simply provides an opportunity for new companies to be formed to compete with Boeing to make new and novel airliners. Your local hospital is charging outlandish prices (for operations, ER visits, aspirin even!). Get together with your friends and start your own. Tired of the local cable company ripping you off. That's a great opportunity to start your own cable outlet!

Unfortunately, the promises of trickle-down economics, deregulation, and laissez-faire capitalism that we have heard since 1980 have not panned out for the middle and lower classes.³ Only the upper class, in fact, the top 1%, have received real returns on the economic changes that were introduced by Ronald Reagan and accelerated by George H. W. Bush, Bill Clinton, George W. Bush, and even Barrack Obama. Every President since and including Ronald Regan have, to a greater or lesser extent, bought into and continued the push for deregulation. The result has been the unraveling of the regulated market place that was established under Franklin Delano Roosevelt during the Great Depression and extended under Harry Truman, Dwight D. Eisenhower, John F. Kennedy. Lyndon B. Johnson and even Richard M. Nixon. The decade of the 1970s and the Presidencies of Gerald Ford and Jimmy Carter marked the transition period from the regulated market place of the New Deal era to the deregulation movement that undid many of the New Deal reforms that grew out of the Great Depression crisis.

In fact, it was in 1971 that future Supreme Court justice Lewis Powell wrote a confidential memo for the US Chamber of Commerce entitled "Attack on the American Free Enterprise System". The memo was, in part, a reaction to Ralph Nader's consumer movement, which he saw as undermining American's faith in Enterprise and the first step down the slippery slope of Socialism. Powell viewed the press as biased agents of socialism, based on his work as an attorney for Phillip Morris and the refusal of the media to publish the pseudoscience that the tobacco industry was promoting to cover up the dangers of smoking to health. Powell urged business to become more active in molding society's thinking about business, politics, government, and law. Powell helped to harness the heirs of wealthy industrialists to invest in the formation of think tanks that would promote Powell's idea of a pro-business, anti-socialist, minimalist government-regulated America as it existed at the turn of the century, prior to the Great Depression and the rise of FDR's New Deal.

The Powell memorandum became the blueprint for the rise of the American Conservative movement and the formation of right-wing think tanks and lobbying organizations such as the Heritage Foundation and the American Legislative Exchange Council (ALEC). David Harvey, a professor at CUNY, traces the formation of the neoliberalism directly to Powell's memo.

Powell's 33-page memo to the Chamber of Commerce was dated August 23, 1971. On October 21, 1971, Richard M. Nixon nominated Lewis Powell to the Supreme Court.

There are many ways to look at the harm that has been done by the deregulation movement and the removal of the safeguards that were put in place as part of the New Deal. One simple lesson falls under the title of the Tragedy of the Commons. Businesses attempt to unload costs that they would otherwise have to pay on to the community or to other parties. An example of this is failing to treat a waste stream and dumping it into a local stream. Without regulations that force businesses to pay for this pollution, the real cost of producing the product is not factored into the price and the cost of the pollution becomes an externality born by the local community. President Trump's deregulation of the coal industry through the reduction and/or elimination of environmental regulations is an attempt to allow coal companies to compete with natural gas prices by allowing them to pollute, and forcing local and state governments to subsidize the coal industry.

An example of Government involvement to prevent this kind of exploitation is occurring today in Thailand. In 2000, the movie "The Beach" brought fortune and fame to Maya Bay on the west coast of Thailand. For years thousands and thousands of tourists fought to travel by small boat to the beach and relax beneath the high cliffs. But in 2018 the Thai Government closed the beach until 2021. The popularity of the beach had caused 90% of the coral to die, and many of the mangrove trees were also dying, along with the fish that lived in the tree's root system. Trash, sunscreen, boat anchors and urine had all contributed to the death of the coral and associated wildlife.

Maya Beach had become a classic case of the Tragedy of the Commons. This occurs when people are paying the full price of a shared resource. The phrase "tragedy of the commons" was created to describe the use of common, shared grazing land in English villages. It was in each villager's interests to graze as many cattle as possible on the shared lands; however, this would lead to overgrazing of the common, shared land.

In the case of Maya beach, any boat owner could take tourists to Maya beach, as long as each tourist paid a fee (about $12). It was in the boat owner's interest to take as many tourists as possible to the beach. Any boat owner that would stop carrying tourists, to allow the beach time to heal, would simply be allowing his competitor to carry more tourists in his place. The tourists were like the cattle in the English village commons, but instead of eating the grass, they were peeing on the coral.

At one point, more than 10,000 tourists per day were visiting Maya beach.

Possible solutions include higher fees, stringent rules on tourist behavior, and a quota to restrict the number of tourists allowed to visit the beach per day. A classic example of where government regulation is critical, and where laissez-faire capitalism and deregulation have harmed, not helped, the situation.

---

^{1. "Fact-Checking Trump’s Claims That Democrats Are Radical Socialists", New York Times, July 20, 2019. ↩ 2. "Tracking deregulation in the Trump era." Brookings Institute, July 17, 2019. ↩ 3. "U.S. Census Bureau, Real Median Household Income in the United States [MEHOINUSA672N]", July 24, 2019. Retrieved from FRED, Federal Reserve Bank of St. Louis ↩}

As If We Don't Have Enough Things to Worry About...

Today, Thursday December 27, 2018, CNN was running news, video and interviews about Russia's new Avangard Hypervelocity "system", repeating Vladimir Putin's boasts that the new Yu-74 Avangard hypervelocity glider, designed to be MIRV'ed atop Russia's R36M2 (NATO SS-18 Satan) and/or RS-28 Sarmat (NATO SS-X-30) ICBMs. CNN was quick to interview several security experts who warned that 1. Yes, Putin was right that we had no defenses for it, and 2. Yes, we needed to spend a bunch of money to defeat it and/or field the technology ourselves.

I am not a security expert (at least not in CNN's employ and not formally trained or experienced). But I have read a few (or many, as my wife would say) books in the subject area. Before jumping to the subject at hand, I would like to point out that, in general, we are living in one of, if not the, safest periods in history, and, here in the U.S. at least, one of the safest countries in the world. Unfortunately, scaring people is one good way of getting them to cough up money to save themselves, and I am afraid that this is one particular area this is a prime example. As for my claim about this being the safest times to live, just several points:

1. Air travel: Only one person died traveling in a U.S. certified airliner since 2009, and that was the woman who was partially sucked out of the window of the Southwest Airlines flight in 2017 after a turbine fan blade failure. Compare that with the period when jet airliners were first rolled out: there were no years between 1958 and 1970 were there were no deaths due to crashes. The safety rate of commercial airline travel in the U.S. has improved dramatically. And U.S. practices have been exported around the world. Take a look at the chart following; commercial air travel fatalities peaked in 1972 and has been falling ever since. The rate of fatalities jumped up in the early 1960's and 1970's as first, the introduction of jets after 1958 and then second, jumbo jets in 1968 allowed more and more people to travel at ever cheaper prices. These peaks stimulated better engineering, usability improvements in the cockpit, pilot/copilot team training, automation, navigation, flame retardent materials, and many other safety improvements.

2. Terrorism: The words of our president to the contrary, we have little to fear from terrorism. Like dying in an airline crash, the thought of dying due to a terrorist attack scares us because we have no control over the situation. When we decide to get in our cars and drive to grandma's house for Christmas, we do so after deciding that the risk of being injured or killed while on the road is low. When a skydiver takes that leap from the plane, they believe that parachutes work, most of the time, and that they will enjoy all of the experience, including the landing. But terrorism is one of those things that we can't make a risk evaluation ourselves (so we are told) and need to leave that up to the "experts". Those experts have convinced us that the expenditures we make in our tax dollars are needed (and continue to be needed) to keep us safe. And how safe are we?

In 2017, the British Royal Statistical Society (RSS) chose the International Statistic of 2017 to the number 69. That is the number of people that are killed in the United States (annually) due to lawnmowers. By contrast, the number of Americans killed (on average) to immigrant Jihadist terrorists is 2. Terrorist attacks fall into the category of events that are episodic and volatile. The blog article cited above discusses whether it is "fair" or good science to make decisions using statistics about such volatile events. When you look at the chart of causes of death in 2016, terrorism is next to the bottom. When you look at the number of deaths due to terrorism for the years between 1970 and 2017, 1995 and 2001 contribute heavily, being outliers. Nevertheless, I would argue the point that in America, we have little to worry about Jihadi terrorists sneaking across our southern border and attacking us as we shop for groceries. (And I live in South-central Texas, less than 4 hours from Laredo, our nearest border crossing).

Getting back to today's news reports about Russia's Avangarde hypervelocity "system", actually a hypervelocity vehicle. We call the warheads on top of an ICBM vehicles, as in MIRV: Multiple, Independent targetable, Rentry, Vehicles. Towards the end of the 1960's the Soviet Union was working to develop and deploy an Anti- Ballistic Missile (ABM) defense system to protect Moscow, primarily from our Minuteman land-based missiles. The U.S. developed the Minuteman III missile, armed with 3 170 Kt W62 warheads each, replacing the Minuteman II, which was armed with a single 1.2Mt W56 warhead. Each of the Minuteman III's MIRV warheads could be targeted independently. In addition, the Minuteman III's warheads were much more accurate; this allowed the reduction of the warhead yield from 1.2Mt to 170 Kt. Being able to use a warhead just 1/6th the size of the previous model is a big improvement, especially if you are in the same neighborhood of a megaton size hydrogen bomb.

As a side note, much of the Chinese nuclear weapons spying has reportedly been to gain MIRV technology. While the US/USSR arms race was one of numbers, the Chinese have, until recently, relied on a relatively small number of big warheads. The U.S. phased out the Titan II ICBM in 1987, leaving only the Minuteman III missiles with 170Kt warheads. The W53 warhead yield, as carried by the Titan II missile, was classified, but the B53 bomb, which uses the same physics package, was known to have a yield of 9 Mt. Such as large bomb has two purposes: 1. a "bunker buster" to destroy deeply buried hardened (military) targets; and 2. City killing. China was thought to have obtained, by spying, the designs of the Titan II missile and to have reverse engineered and deployed about 100 similar missiles with similar yield warheads to act in what as known as a counter-value role, i.e. holding non-military targets such as cities in hostage. It has been reported that they sought to develop MIRV technology to target U.S. missile silos and aircraft carriers, which require larger numbers of more precise warheads.

Hypervelocity vehicles are those that travel at speeds faster than Mach 8, or about 6,700 miles per hour/11,000 kilometers per hour/10,000 ft/s. US and Russian ICBM warheads reenter the atmosphere at about Mach 20-22. They enter the atmosphere at an altitude of about 100 kilometers. They slow about 3-5 Mach numbers over their 20-25 seconds (~125 kilometers traveled) of reentry. Traveling their terminal 100 kilometers in ~25 seconds, they average about Mach 18.

Both the R36M2 and RS-28 boosters have the throw weight to boost ~24 MIRV warheads. Current strategic missile agreements between the US and Russia allow for a single warhead per missile. The deployed R36M2 and Minuteman III missiles have only a single (by agreement) warhead. The excess throw weight is presumed to be used for warhead decoys. The RS-28 booster has been developed with the intent of up to 24 MIRV'ed Avangard hypervelocity vehicles which would be able to maneuver during the short ~25 second period in the atmosphere, in order to defeat U.S. ABM defenses. However, this despite the fact that the 44 currently deployed ABM interceptors at Ft. Greely (AK) and Vandenburg AFB (CA) were designed more with North Korea in mind that Russia (or China, for that matter). Russia should be able to launch a single R36M2 with a single warhead and its 40 decoys to soak up 41 of the 44 deployed ground based interceptors, leaving only 3 left to handle the remaining 699 ICBM/SLBMs left, as allowed by the NEW START agreement. But Russia has been worried by the U.S. ABM systems; the RS-28 is not only designed for the Avangard vehicle, it is also said to have a shorter first stage burn time to limit the time period during which a launch would be detected by U.S. satellites. (The question is: Is this aim realistic? The U.S. has had geosynchronous satellites staring at the known Soviet/Russian missile fields for many decades now.)

CNN interviewed several security experts who agreed that the deployment (not merely the announcement) of hypervelocity vehicles atop ICBMs would be serious, and would require the U.S. to invest considerable new monies in research to deploy a similar system. This is despite the fact that Russia claims that Avangard is a response to the U.S. Prompt Global Strike (PGS), a system that would allow the attack of any target in the world within one hour. Considering that the ICBMs of the U.S. and the USSR/Russia require ~30 minutes to travel across the Arctic Circle, it would require an ICBM to launch a hypervelocity missile to target the other side of the globe. The U.S. doesn't seem likely to target Canada or Mexico.

But once a country is thinking of using an ICBM to launch a warhead of any type, such a system begins to appear destabilizing. The cold war was reasonably stable because the threat of nuclear missiles and warheads were of such risk that their use was considered very rarely. We should remember the introduction of nuclear missiles into Cuba was one of the one or two times where the Cold War very nearly became hot.

Recently, the U.S. and Russia have been talking past each other about another agreement, the Intermediate-range Nuclear Forces Treaty (INF). The INF was signed by Presidents Reagan and Gorbachev and resulted in the withdrawal and scrapping of the Pershing II and SS-20 IRBMs in Europe. The Soviet Union deployed the SS-20, and then was extremely frightened by the U.S. plans to deploy Pershing II missiles in Europe. The flight times of the SS-20 and Pershing IIs was less than 15 minutes. The Pershing II missiles were designed to replace the Pershing Ia missiles. The Ia had a W50 400Kt warhead, much larger than needed for a "tactical" missile. The Pershing II missiles featured a W85 5 - 80 Kt variable yield warhead; they were much more accurate than the Ia missiles to allow the use of lower yield warheads. One feature that has been forgotten about the Pershing II missiles: the Reentry Vehicle (RV) was maneuverable and used radar to scan for the target, which controlled pitch-up and pitch-down maneuvers to maneuver the RV to the target. With a RV speed of at least Mach 8, the Pershing II RV was a hypervelocity vehicle.

President Trump has talked of pulling out of the INF agreement, over the stationing of Russian 9K720 Ikander (NATO SS-26 Stone) Short range ICDMs in Crimea and/or Kaliningrad. The U.S. has retired all of its Lance missiles, and has no corresponding short range missile.

Perhaps it is time that we start rebuilding those soft assets that Generals Kelly and Mattis and Secretary Tillerson talked about, such as diplomats, instead of hardware and hypervelocity vehicles. We want to continue making this time the safest of all.

Not long after finishing this, I read an interesting quote:

Our grandfathers stormed the beaches of Normandy to protect our freedoms. And now, because we are afraid and not willing to accept personal risk, we're giving up those same freedoms that they fought and dies for. We're giving away our freedoms because we're scared.

Cyberstorm Matthew Mather, 2013.

I fully agree. The next time someone tells you that you need to be scared of immigrants crossing our borders, or terrorists sneaking across the borders, or Russian hypervelocity vehicles making our defenses totally useless, ask yourself who benefits from your fears. Take a look into the real risks involved. Or as CNN says, ask yourself if the banana is really a banana. Maybe it's really an apple.

The U.S. Must Move Away From a "One Size Fits All" Policy...

I started to title this post "The Federal Government Must Move Away From a 'One Size Fits All' Policy..." but changed it at the last moment to widen it in scope. Please read on.

Drones are taking off (pardon the pun) around the world, yet in the U.S. they are being stifled by regulatory oversite by the FAA. In Africa drones are being used for critical life saving needs, such as vaccine and medication delivery, where the infrastructure delivery does not exist. Never mind Amazon delivery, suppose you need rabies vaccine or snake antivenom in a region where it is not cost effective, or where hospitals don't exist, to stock it? Such needs are driving the innovation of new drone platforms and systems.

Yet here in U.S. where you would expect innovation to be highest, the FAA is stifling development by assuming a risk model that is not appropriate for drones. Such is the conclusion by the National Academies of Sciences, Engineering and Medicine. A new Congressionally mandated report concluded that the FAA is using a near-zero risk model, designed for passenger aircraft, to evaluate the safety of drones.

“FAA needs to accelerate its move away from the ‘one size fits all’ philosophy for UAS operations,” said George Ligler, proprietor of GTL Associates and chair of the committee. “The FAA’s current methods for safety and risk management certainly ensure safety within the manned aircraft sector, but UASs present new and unique challenges and opportunities, which make it important for the agency to take a broader view on risk analysis.”

The FAA has brought near perfect safety to the U.S. aircraft industry. This past April, a passenger on a Southwest Airlines flight was killed after the left engine failed. It was 2012 when last a passenger fatality occurred. This safety/risk model has been exported to the world, with a resulting reduction in accidents and deaths, and an incredible rise in safety:

No one would want this safety model to be loosened for passenger aircraft. But applying the same risk model to small drones is inappropriate, and it is stifling the development of drone business in the U.S. where our technology should lead. And what about cost effectiveness? We need infrastructure investments to repair our aging bridges and roads, but if drone delivery could reduce the requirements for ground traffic, would we need to invest as much in the continuing expansion of roads to accomodate delivery vehicles?

This brings to mind another example where the U.S. has implemented a "One Size Fits All" policy: the current opioid epidemic. Deaths due to overdose more than tripled between 1999 and 2016, according to the CDC. The reasons for this, we are told, include the increase in the rate of prescription of opioids for pain, and the increased availability of prescription opioids produced by pharmaceutical companies.

In response, the CDC created guidelines for the prescription of opioids by general practitioners for chronic pain. A CDC report analyzed the incidence of chronic pain in the U.S. and concluded that in 2016 approximately 20% (~50M) of Americans experienced chronic pain, and ~8% (20M) had high-impact chronic pain. Pain is the most frequent cause for patients to contact a physician. The cost of chronic pain in the U.S. was thought to be as high as $635B in 2012.

The issue is even more complicated: The CDC admits that its statistics are poor, because reporting agencies may lump overdose deaths from street drugs, such as heroin and street fentanyl, with those of prescription overdoses. Worse, non-opioid street drugs like cocaine and methamphetamine are being cut with fentanyl, confusing the statistics.

Even that simple model of physicians prescribing too many pain pills is not simple. The number of physicians sanctioned for over-prescribing is low, yet it has caused a real problem of care for physicians caring for chronic pain patients. Many chronic pain patients are having difficulties finding a physician for treatment.

The CDC guidelines for prescribing for chronic pain were written for general practice physicians treating chronic pain. General practice physicians do not receive specialized training for treating pain, nor for prescribing for chronic pain. But many state legislatures and state medical boards have adopted the CDC guidelines as hard and fast rules for all physicians, including pain management physicians who are specifically trained (and in practice) to treat pain, primarily chronic pain, since acute and postoperative pain are generally treated in the ER and hospital, respectively.

The result: chronic pain patients being under or not treated at all. This has lead to a rise in chronic pain patient suicide.

No one wants the opioid crisis to get worse. Yet it is clear (to this author) that there are too many "One Size Fits All" policies being applied in an attempt to "cure" the opioid crisis. Yet the essence of physician practice is the individual treatment of each patient, crafting a treatment plan that is specific to their condition and needs. Like the drone policy, we need better in the U.S. if we are to lead in not only technology but patient care.

Tax Cuts...Again? (Part II)

It has been a week since the Trump Administration announced its framework for tax simplification and rate cuts. A week in the Time of Trump seem like a month to a year in the past. The past week has seen the continuation of the feud with the NFL, the devastation of Puerto Rico, the feud between Trump and his supporters and the mayor of San Juan, and now the Las Vegas massacre. Still, parties on the Hill are working on this tax cut, so it seems very important to look between the covers at some numbers.

In my previous post I pointed out that these tax cuts serve to disproportionately benefit the wealthiest 1% of the country. Gary Cohn refused to answer the question of wether the tax cuts would benefit the wealthy, saying only that he thought everyone was concerned with what they would be getting. How true! And no one is able to determine if the tax cuts will benefit Trump (he says they won't) because he still hasn't released his tax returns. So let's look at some numbers and charts.

First question: Do we need more or less taxes? Looking at a chart of the Debt to GDP ratio says we do. The ratio of debt to GDP is rising to the levels that haven't been seen since WW II - debt above 100% of GDP.

Notice though that revenues have remained pretty much in the same band, between 15% and 20% of GDP (brown points). Here's a chart of Receipts as a percentage of GDP:

Outlays have tended to remain between 15% and 25% of GDP:

The difference between Outlays and Receipts is our Surplus or Deficit:

WW II was a global fight for Democracy, funded by war bonds and deficit spending. That "Greatest Generation" didn't want to pass on debt to their children and hiked marginal tax rates to payoff all that debt. And despite those high marginal rates businesses and individuals thrived and grew. Today, we argue that high tax rates are a disincentive to businesses and individuals, but history doesn't agree. And history also doesn't support the idea that tax cuts lead to economic growth.

Here's a chart of the marginal rates:

By 1988, Regan had cut the marginal rate to 28%. If you refer back to the first chart of Debt to GDP, that was the year that the debt had fallen to its lowest level after WW II. The Regan tax cuts and subsequent Bush tax cuts sent the debt levels back up again.

We can't afford any more tax cuts. Our infrastructure, our bridges and highways and water systems and electrical grid, is old and needs replacement. The effects of climate change are going to cost money as more and more superstorms hit our shores. These are new outlays, added to our existing debt. It is time to say no to Trump's tax cuts and have the rich pay their fair share by increasing marginal rates.

Tax Cuts...Again?

The Trump Administration is proposing another Republican tax cut. And those tax cuts, like the Regan and Bush tax cuts before them, are slated to disproportionately aid the wealthy. Not withstanding Gary Cohn's lie that the wealthy won't benefit from the Trump Tax Plan () the Trump tax cuts appear to give:

• 50% of the net tax cuts to the top 1% of households, those that earn over $700,000 annually
• 30% of the net tax cuts to the top 0.1% of households, those that earn over $3.8 million annually

(based on an analysis from the Center on Budget and Policy Priorities).

The plan has some special benefits for special households:

• Pass-through income would get a special 25% rate. Pass through income is income from partnerships, S corporations, and sole proprietorships that business owners claim as their personal income. This includes hedge funds, real estate developers and law firms exempt from corporate tax rates and taxes on dividends. 79% of the benefits of this tax cut would flow to filers with income over $1 million.The 400 households with the top income would each receive a cut of $5.5 million.
• Only the wealthiest 0.2% of estates pay the estate tax. The first $5.9 million ($11 million for a couple) is already exempt from taxation. 
• Most economists conclude that cutting the corporate tax rate from 35% to 20% would mainly benefit stockholders, who would receive stock buy-backs and dividends, rather than workers receiving wage increases or consumers receiving lower prices.
• The Alternative Minimum Tax (AMT) was designed to ensure that the wealthiest individuals that benefitted from inordinate deductions would have to pay a minimum amount of taxes. Ending the AMT (rather than updating its provisions) will allow the wealthy to game the system and avoid taxes.

In total, the Center on Budget and Policy Priorities estimate that the top 1% of households would receive 50% of the tax cuts or about $150,000 each, while the top 0.1% of households would receive 30% of the tax cuts or about $800,000 per year.

Perhaps Gary Cohn thinks that you need to be above the top 0.1% to be wealthy, i.e. make more than $3.8 million per year? What would you expect from a former Goldman Sachs exec? 

It IS Time to Talk About Climate Change

The Director of the EPA, Scott Pruitt, doesn't think that it is time to talk about climate change. With the effects of two devastating hurricanes being felt in Texas and Florida, Pruitt says that it is inappropriate to talk of climate change:

“What we need to focus on is access to clean water, addressing these areas of superfund activities that may cause an attack on water, these issues of access to fuel,” he said. “Those are things so important to citizens of Florida right now, and to discuss the cause and effect of these storms, there’s the… place (and time) to do that, it’s not now.”

While I absolutely agree that the items Pruitt enumerated in the Washington Post article need attention at the moment, there is absolutely no reason not to focus on climate change at this moment also. Americans have shown a remarkable propensity to question science, and it is leaders such as Pruitt who foster this regrettable tendency with their actions, actions which probably stem less from a disbelief in science but rather from a vested interest in reaping monetary benefits from the results of questioning what is truly unquestionable.

In the 1960's NASA was at the forefront of America's exploration of space. While a large portion of NASA was made up of administrators and engineers that designed and managed the spacecraft that astronauts rode into space, they were working based on the theories and discoveries made by the scientists. When President John Kennedy charged America with reaching the moon in a decade, America didn't question the advances NASA scientists and engineers where making. This was probably due to the decades of American scientific achievements that had been made to win World War II, develop new drugs and vaccines, and all the other achievements that made the late 40's and '50s a period of plenty for the growing American middle class.

But today, when NASA presents the evidence and scientific consensus (97% of actively publishing climate scientists agree on the causes of global warming), major administration officials, including the President and the Director of the EPA refuse to acknowledge what is known scientifically: Global Warming is man-made, is an existential danger to man's existence, and that we must change the way we live if we are to save our way of life.

I suspect that Scott Pruitt understands man-made climate change. He simply stands to gain too much from his associations with fossil fuel developers. Al Gore's new movie 'An Inconvenient Sequel: Truth to Power' covers the dramatic fall in the price of renewable-based energy generation, which now is comparable to the price of fossil fuel generation. It seems a no-brainer: if you can generate electricity for the same price using a resource like wind or solar that costs the same as oil or natural gas, but doesn't contribute to global warming, why wouldn't you choose the renewable energy? The answer, of course, depends on whether you own fossil fuels or renewables. And therein, I believe, is the real reason Scott Pruitt doesn't want to talk about climate change.