Monday, October 16, 2017

Addicted to Bad Statistics - a Growing Epidemic

OK, references keep popping up to this CDC study on the dangers of patients receiving prescriptions for opiate pain-relievers becoming chronic opiate users. Specifically, they make reference to a finding that patients receiving a 1-day prescription for opiates only have a 2.6% chance of still being on opiates 1 year later while those given an initial 30-day prescription have a 45% chance of being on opiates 1 year later... So, I look up the study to see the data and conclusions for myself. Apparently not enough people sit through classes on research traps and simple mistakes.

This is the most telling point which should jump out at anyone interested in citing the research to make recommendations on opioid prescriptions or policy:

The findings in this report are subject to at least five limitations... Second, the extent to which chronic opioid use was intentional ... is not known. ... Third, information on pain intensity or duration were not available, and the etiology of pain, which might influence the duration of opioid use, was not considered in the analysis. [ (emphasis mine)]

They also note that longer-term prescriptions were much less common than short-term prescriptions. So... the obvious conclusion would be that doctors tend to write prescriptions for longer-terms for patients expected to need the pain relief for a longer period of time and... not surprisingly, they do. The study also notes that those receiving longer-term prescriptions tend to (among other things) be older and have a previous pain diagnosis. (duh!)

In other words, doctors are already likely exercising judgement by providing short term prescriptions to most people and only giving 30-day prescriptions to a much smaller number of people with longer-term conditions. But the researchers did not have data available to exclude this possibility ---and to their credit, say so. The warning in the study, however, is completely ignored by everyone citing it even though the data is useless for the purposes they are trying to make of it.

Garbage in; Garbage out

The capital-P Problem is that the purpose they are generally trying to make of it is this: recommending that doctors stop providing 30-day prescriptions to people with chronic conditions because of the higher danger of long-term use! This is usually linked to a claim that 80% of heroin users get their start with prescription opioids (another bad statistic I'll save for another day) and that reducing opioid prescriptions will therefore reduce future heroin use.

Question: what will long-term pain sufferers likely turn to when they cannot get legal prescriptions from their doctor to treat their valid medical conditions? In all likelihood, they will turn to black market sources, with no quality control, which has a higher chance of leading to addiction and overdose as well as feeding our larger issues with drug smuggling.

Is there a very large recent increase in drug overdoses? Yes. Is this a problem? Yes. Does stupid misuse of incomplete data help point to a solution? No.

And the solutions we persistently fail to consider...

You cannot willy nilly stop prescribing opiates to people with long-term pain unless and until you can offer other solutions. To do so is inhuman. Unfortunately, for many people who suffer long-term pain (including myself until recently), other solutions are few and non-existent. Opiates are more effective for short-term pain and lousy for long-term pain--- this is well-known. Using opiates to control long-term pain simply sucks less than being in pain for months on end with no other alternative.

Ironically, better alternatives for long-term pain are either difficult to get FDA-approval in the US or are flat illegal. Marijuana, for instance, shows long-term efficacy for chronic pain for some classes of patients and is much less dangerous than opium-based medications, but it is currently defined in law as having no valid medical use. Nor am I making a pro-marijuana case here, but rather the case that it is disingenuous to say people should stop using opiates while we are actively foreclosing alternatives.

Thursday, October 5, 2017

Las Vegas Shooter Scoped Other Events, Reflections On Living With Violence

Yes, another update on Las Vegas, but this is rather interesting: the Clarke County Sheriff there has stated to the press that Paddock probably did have help (they are looking for a particular woman seen in the hotel, not his girlfriend) and information has been released that he has booked other hotels overlooking other major events: this was a *long* time in planning. He started buying weapons in 1982, so it is hard to tell when the purpose of his purchases may have changed.

[Las Vegas shooter booked hotel overlooking Lollapalooza, seen with mystery woman]

If this guy fits profiles of other mass murderers (and note that so far he does not), then he will have reached out to other people (small number) over that time to pull them into his plan. Normally, they will make suggestions that they can pass off as a joke if rebuffed, and therefore the subject does not necessarily connect the comment until after (I, myself, experienced this with a shooter). As people come forward, they may provide more insight into the situation, especially if authorities locate actual co-conspirators. This process may, however, take years to gather information and to actually piece it together.

Another part of the picture that is starting to emerge: given the time and resources ($100s of thousands, aircraft, etc.) available to this plot, very little had a chance of preventing it. The only realistic chance of stopping it would have been if his preparation had been discovered more or less by accident, if a co-conspirator chickened and came forward, or if someone he approached a) understood what he was asking, b) went to authorities, and c) was believed. Nothing short of that would have likely prevented the incident or necessarily reduced the scope of the damage he was able to cause.

Believe me, that is not a comfortable thing to realize--- it is not something we like to admit--- but it is likely the truth. I had a discussion with my wife this morning and with the father of a victim at my school a few years back that I am doing better at handling this kind of thing than I used to be because I no longer feel helpless: I am doing things that make a difference. As Mr. Gibson put it, I have found “a way to make lemonade”. The people that find a way to do that--- or found a way to do that during the attack--- the heroes of that night--- will have a much better time coping and moving forward. We have to find a practical way to do that as a country, and that is actually one of the reasons for the misguided push for gun control and other measures which likely would not make a difference. I know from experience that they are wrong, but I understand the impulse.

The things which *would* make a difference are not quick fixes, they take time, thought, and facing uncomfortable reality. Maybe we will eventually get to that point. The other thing that helps is simply *faith*: I believe we live in a fallen world, that evil exists, it always has, and though we continue to strive against it, it will to the End. At some point, we have to realize that life is deadly, that it is unfair, and move on with what we have. I truly believe there IS an ultimate purpose, and that helps me deal with the horror of where I have been.

Sunday, August 13, 2017

Monuments To Lasting Peace

There is a deep irony in the efforts to remove monuments like those to Robert E. Lee in the name of "healing from the Civil War". To a great extent, the efforts of people like Lee after the Civil War are why we have a country to heal in the first place. Lee, Confederate General Longstreet, Union General Sherman (among others) worked tirelessly to end the Civil War and knit the country back together.

Lee took efforts at Appomattox to endure that he was not surrendering merely the forces under his command but signing an overall armistice. He made particular efforts to stop groups of Confederates who wished to wage a guerrilla campaign after the stacking of arms. The entire process was conducted with such dignity and honor that Union General Chamberlain ordered his soldiers to salute their defeated foe--- a salute which was returned by the Confederates in the first step of becoming a single nation again. Rarely in history does any civil war end in that kind of mutual respect.

After the surrender, Lincoln, Lee, Longstreet, and Sherman, along with Grant and Breckenridge (the last Confederate Secretary of War), worked to get people to come together to build a new peace without endless reprisals. They managed to hold the fragile peace together through and after Lincoln's assassination. Lee himself died five years after the surrender. Longstreet and Sherman--- perhaps one of history's unlikeliest combinations--- became good friends, working to keep Lee and Lincoln's vision of a new nation going through the upheavals of reconstruction and economic collapse. Longstreet and Sherman, with Lee's support, lead efforts to get land, education, and economic self-sufficiency to freedmen (much of which was later undone by others).

This is all, of course, a simplification, just one piece of a very complex period, of complex people, but the point is, there is more to war than who won and who gets blamed in the victor's history books. Victory is imposed on the battlefield, but establishing lasting peace takes something more. By attacking the memory of people like Lee, Longstreet, etc., we are attacking the precarious peace that they gave us. The "we won, now shut up and go away" attitude is exactly what people--- better people than us, apparently--- fought to prevent. We were shown the right way to end a war: all we have to do is keep walking in that direction.

Further Reading

There are many books and many primary sources on the fighting of the Civil War. Finding good accounts on the establishment of peace afterwards is surprisingly hard and woven into many other sources. As Union General J. L. Chamberlain noted, once the fighting ended, so did the official record of the Civil War. Here are a few sources which may be a good start:

  • William C. Davis, "An Honorable Defeat: the Last Days of the Confederate Government" Harcourt. New York. 1946
  • Joshua L. Chamberlain, "The Passing of the Armies; An Account of the Final Campaign of the Army of the Potomac, Based Upon Personal Reminiscences of the Fifth Army Corps" J.P. Putnam and Sons. New York. 1915. (Chamberlain was responsible for organizing the surrender ceremony and receiving the stacking of arms on behalf of the V Corps, U.S. Volunteers. He also notes his fears for the loss of the peace after Lincoln's assassination. A more compact record of just the surrender is here:
  • Eric Foyner, "A Brief History of Reconstruction" Harper and Row. New York. 1990 (Woven in and out of this larger work are accounts of people who tried to keep Reconstruction on track and meet their obligations to former slaves, including, at various points,  Lee, Longstreet, and Sherman. If you have not read about the tortured history of Reconstruction and its dramatic failures, this is not a bad place to start.
  • The personal memoirs of Ulysses S. Grant, now in the public domain, also contain personal recollections bearing on these issues, including his fears of a collapse of the peace--- or of large-scale retribution against the South--- after Lincoln's assassination.
  • Information on the Fifth Avenue Presbyterian Church monument to Stonewall Jackson commissioned by Rev L. L. Downing, the son of a slave Jackson taught to read. The stained-glass window behind the pulpit is beautiful, and worth seeing. If you do not understand the inscription, they are the last words Thomas J. Jackson spoke in the presence of his wife and surgeon on his death bed after the Battle of 2nd Chancellorsville.

Other commentary