A bigger killer than car crashes

kw: book reviews, nonfiction, opioids, opiates, addictions, polemics

For most years I remember, the number of people killed in auto accidents in America was about 50,000. Then after about 2000 it got down into the low 40's, and since 2008 has usually been in the mid-to-low 30's. From 2005 until the end of 2018, just over half a million deaths in America have been auto fatalities. Yet, car deaths are on the rise since 2014, with a 10% increase from 2017 to 2018, and I'll get back to that.  But first:

This chart shows data only from 2005 onward, to better focus attention to the crossing trends: In 2009, for the first time, deaths in America from drug overdoses exceeded those from car crashes. Since then, this trend has increased dramatically.

Figures aren't complete for 2018, and they may not have risen as fast as they did the prior year or two. But the fact remains that, from 2005 to 2017, one year less than the sum in the prior paragraph, drug overdose deaths have exceeded 570,000. These two causes together come to about 1.1 million untimely deaths in America in fifteen years.

Ryan Hampton, for one, wants to do something about that, at least the drug overdose part, as he writes in American Fix: Inside the Opioid Addiction Crisis—and How to End it. While I call this book a polemic, in this case I mean that in a very positive way! Nothing short of loud Jeremiads seems able to get through the thick skulls of not just policy makers but the majority of the public.

I must confess that, while Mr. Hampton is a very good writer, it was quite an exercise for me to read through the book. His aim is to pluck heart strings, and he does it masterfully. He is in recovery himself, and pulls no punches about his path from an "innocent" pain prescription, to doctor-shopping (because the "safe" medication he was given wasn't safe after all), to heroin use, and then through several recovery programs to one that has been working for him. Two messages underlie this paragraph:

1. The pharmaceutical companies have tragically underplayed the addictive potential of popular pain-killers. Criminally so.
2. The public and political view of drug abusers is dramatically wrong, and increases their suffering greatly and needlessly.

Americans need to face that fact that drug addiction is a disease. It doesn't resemble other diseases such as cancer or tuberculosis, because the causes are more hidden. They are buried in brain chemistry and the way it is so easily hijacked by certain chemicals. We are also somewhat jaded by hearing numerous radio ads that mention "the disease of addiction", in which it is applied properly no more than half the time. It is not proper to speak of compulsions toward sex, gambling, or chocolate as "addictions", and particularly not proper to treat them as diseases. They are in a different category, even though they do affect the reward circuitry of the brain. Yes, they do so, but not nearly as powerfully.

Let me mention at this point my musing about the 10% rise in traffic deaths last year, and a similar rise a couple of years earlier. How much of it is because the current recreational drug of choice, marijuana, is being legalized?

When I was actively involved in drug rehabilitation programs, some 45-50 years ago, heroin and its relatives was being pushed into the background by psychedelic drugs. LSD was popular, followed by PCP and Meth. Kids I worked with weren't all that likely to OD on LSD. They were more likely to walk out a 4th floor window thinking it was a door to paradise, or fall into a creek and drown, or to have a bad trip or even a flashback and find a way to kill themselves. I was never involved in heroin recovery efforts. And there is a new factor in the OD picture. Heroin is no longer the strongest drug (closely followed by cocaine). Its synthetic cousin Fentanyl is therapeutically effective as a painkiller at doses of around 1-1.5 mg, compared to 2.5-5 mg for morphine; however, its therapeutic range is narrow; 3-4 mg of Fentanyl can kill. There are much worse versions out there, such as Carfentanil. A few mg of that can kill an elephant or rhino.

Thus, I can't really speak intelligently about the author's experiences in recovery. He did not overstate the case. It is grim. If you aren't rich, you can't afford rehab. It's still rare for insurance to cover any part of such programs. The "affordable" rehab programs are so inadequate that they actually set people up for overdose. It works this way. A single heroin dose of 30 mg will usually kill someone who has never used it. The therapeutic dose of morphine (heroin is metabolized into morphine) is single doses in the 2.5-5 mg range, and no more than 30 mg/day. Someone who has abused heroin for a couple of years is using 60-100 mg per "hit", and a total of between 500 mg and one gram daily.

Suppose you are such a user and want to get rehabbed, and you manage to get into a program. It typically ends in four weeks, and you are returned to the street with no more than a "Good luck". If you have at least a little emotional support from peers or parents, you may hold out for a few weeks or months. Then you enter a low spot, emotionally, and go for "just one more hit". But much of the habituation to the drug has been lost. The "nickel bag" you were used to using is now enough to kill you. Many OD deaths are recently rehabbed young people, found with the needle still stuck in, they died so fast.

In a later chapter of the book, the author describes a few programs he found that are working better, because they abandoned old thinking and old ways of treating drug abusers. I think it better to leave it to you at this point. Read this book.

Count yourself lucky if there is absolutely nobody among your family, friends, and acquaintances who has not used a hard drug. We have a lady friend in her late 70's who was successfully weaned from prescription painkillers, just barely! It was costly and pretty hard on her and her husband. Luckily, she had not graduated to heroin!! It is likely that you do know someone, even if you don't know about it yet. So, get this book and read it. Consider Mr. Hampton's call to action in the last chapter. Our voices are needed by those whom society formerly forced into silence.

It grabs you where you live

kw: book reviews, nonfiction, addictions, technology

When I saw the book Irresistible: The Rise of Addictive Technology and the Business of Keeping Us Hooked, by Adam Alter, the verse 1 Corinthians 16:15 came to mind. It speaks of a certain family that "have addicted themselves to the ministry of the saints". At least, that is how the King James Version and two others translate the word εταξαν, a form of τασσω, which in the First Century meant "to set, appoint or ordain", but has lost that meaning in the centuries since. Becoming curious about the English usage of the King James era (early 1600's), I found that "addiction" referred mainly to fascination and devotion. Thus many English versions of the verse use either "set" or "devoted". The term was neither positive nor negative prior to the mid-1800's

Addiction has a much stronger and more focused meaning today. To be addicted is to be in the grip of a compulsion or obsession that harms one, or may eventually kill. Since the early 1900's or a little earlier, "addiction" has referred to a compulsion to use substances such as cocaine. As author Adam Alter tells us, there was quite a struggle in the later Twentieth Century among psychiatrists and psychologists about whether to recognize "behavioral addictions". But the modern phenomena—from binge-watching of TV episodes to online game playing, online gambling, twelve- to 24-hour FaceBook sessions and even "checking in" so compulsively that people walk into fountains, manholes and lampposts—have convinced nearly all that behavioral addiction is real and can be really, really bad.

Note the phrase above, "…or may eventually kill." I do not mean just the shortening of life due to bad health from being a "couch potato" or "FB zombie". Suicides have resulted, not just from being trolled online, but from despair over falling behind the social media rat race.

In a fascinating busman's tour through history, we find that addictive tendencies are with us for very good reasons: our distant ancestors did not become ancestors by ignoring the siren call of pleasurable experiences. In pre-agricultural days, over most of the Earth, eating everything that tasted good kept you alive, and getting all the sex you had opportunity to obtain gave you a chance at having descendants. Also, our ancestors traveled, and the dopamine-fueled thrill of seeing what is over the next ridge motivated many of them to seek new pastures and far horizons. Those who traveled the farthest may have been subject to extra risks, but the chance to populate a new and empty landscape was a benefit not to be ignored.

Our tendencies to fall prey to obsessions, compulsions, and addictions are a direct result of the tens of thousands, even millions of years, that humans lived with scarcity. Now about half the human race lives with relative abundance. What happens then? We overdo it; we overdo it big time.

The author describes many behavioral hooks that turn a potentially enjoyable experience into a compelling one. Unsteady rewards are a big, big factor. Even as Pavlov learned, once a dog has learned to associate receiving food with the ringing of a bell, it will salivate when the bell rings, whether food is given or not. But if food is given roughly every third time, the dog will salivate more and more. Rats given the chance to push a bar to get a food pellet will do so, of course. But if pushing the bar doesn't always yield a pellet, they will push the bar again and again, gathering pellets far beyond their need to eat them. Uncertainty is a big hook.

The most addicting games are those that you win about 1/3 of the time. If you win every time, you get bored. If you win less than 1/10 of the time, you look for a "better" game. This is just one example. Apparently, the most addicting computer game to come along, at least up to the time the book was written, is World of Warcraft. The second-most is probably League of Legends, which my son plays more than he should…though so far it hasn't affected his work enough to cut into his income. I hope that day doesn't come, but for many others it has come already (Cue a stereotypical video of a jobless Millennial who lives in the parents' basement and plays games all day).

So, can we do anything about this? Friends of ours despaired of even slowing down their daughter's FaceBook addiction. Her grades suffered badly. She almost dropped out of college. Nobody knows quite what happened, but she somehow developed a backbone, and a level of resistance, so that her grades improved, she graduated, and now has a responsible job. I don't know how much she may still read her News Feed on FB but I don't see a lot of posts from her. There are other folks—well, I just shake my head. I wonder how they have time to put one or two or three dozen posts in their News Feed every single day. Maybe we just have to let people outgrow it. Pity those who never do.

At the end of Irresistible the author discusses one "thing" (I can't think of another word) that seems to make positive use of the hooks that draw us in: Gamification. This is adding an element of fun into otherwise mundane, boring or unpleasant tasks. In the modern era, technological hooks can be used to trigger our compulsions, just enough, but breaks or "units" are inserted so we won't binge out. The FitBit is a potential gamification of exercise, but it doesn't have any checks, so some people damage their health trying to achieve ever-increasing goals. It needs some work.

But even without FitBit and its kin, overdoing it is a risk. I used to exercise a lot, including certain body-mass strengthening routines, and began keeping records. As it happens, that might have been a mistake. Or, at least, I ought to have obtained a buddy or coach to help me keep track and not ramp up my routines too fast. One day I did too many dips and pulled a muscle in my chest. It took five months to heal (I was about 40; were I younger it might have taken only a month or two). By then, the cycle was broken, and since then I primarily walk. There was no FitBit involved, nor have I ever owned one.

I am also reminded of Zooniverse, with more than 70 somewhat gamified "citizen science" projects. There aren't even any bells and whistles, just accumulating numbers of tiny projects completed, but that is enough that millions of people (myself included) enjoy sorting galaxies, counting penguins, or transcribing hand-written museum labels. Without a few little hooks in the projects, it is actually deadly dull work!

I consider the matter unfinished. We don't yet know how to cope with behavioral addictions. As the author writes, we are in the foothills of addictive technology. But not everyone is equally prone to addiction, whether to substances or behaviors. Perhaps Darwinism will run its course, and a future generation will consist mostly of people who are largely immune to the allure of the Like button.

Faster, for what?

kw: book reviews, nonfiction, technology, addictions

When my son discovered texting, the first month he sent nearly two thousand text messages. That is only about sixty per day; it is a good thing he was in school all day and had four extracurricular activities! I wonder how he'll do if he ever gets a smart phone or Blackberry. But he is really a talker. He got his own phone plan last year, with unlimited talk. He needs it!

It was more than twenty years ago that I first saw this scenario: two colleagues happen to meet in the hallway. One says, "Oh! I was just going to send you a message," immediately runs back to the office and sends the message. Am I right to feel proud that I've never done that, that I still prefer to do business face-to-face? I know in this era I am the unusual one.

In his new book The Tyranny of E-Mail: The Four-Thousand-Year Journey to Your Inbox, John Freeman presents a historical and social sketch followed by a manifesto. While he doesn't make this claim, I suspect there are adults now living who have never sent a snail mail letter, the kind written on paper and sent with an envelope and a stamp.

I am still traditional enough to value paper letters. I have recently finished the basic curation of my parents' letters to each other as an engaged couple during World War II. Hundreds of them; they wrote nearly daily. I also have a couple binders of curated letters from the years prior to World War I, among my grandparents' generation. Though both my grandmothers were great storytellers, there are details in these letters that they never mentioned.

How will our grandchildren learn the homely details of our lives, the lives of the early 21^st Century? Will they screen through thousands of emails? (I don't hyphenate "email" any more). But author Freeman's message is more about the present than about past or future. While he ably presents the development of the mails from clay-tablet times to the present, he is clearly concerned about how we, with our stone-age brains, are adapting to the age of instantaneous communications.

The fact is, we are adapting poorly. The diseases of sedentary living that afflicted our pre-computer ancestors are hitting the X and Y generations (and many Boomers such as myself) with a vengeance. Stress is greater than ever. Many people start and end the day using their Blackberry in bed (whatever happened to a little cuddle from your spouse?). When you get an email from your boss at 4AM, do you feel compelled to answer within the hour?

The manifesto is based on three premises: Speed Matters (and not the way you think); the Physical World Matters; and Context Matters. While he develops these ideas into ten recommendations, three strike me as essential:

(3) Check it Twice a Day. With rare exceptions, our work tasks benefit from block time. Even the most frenetic jobs can usually be done best if the email is checked no more than hourly. While I use Lotus Notes at work, and it is always running, I ignore the Bings and check in only when I have finished the task at hand.

(6) Read the Entire Incoming E-mail Before Replying. I've done it; you've done it: answer the question in the first paragraph without reading further. Huge misunderstandings and even flame wars can result. Read (all), think, think again, then answer.

(10) Schedule Media-free Time Every Day. I am a knowledge worker, so I am faced by a screen all day long. Many days, I decline to turn on any of the computers at home in the evening. Sometimes I'll go the whole weekend without running a computer (which is why I blog less often on weekends). It is also why I haven't bought a Kindle or similar device. I read paper books, nearly every evening. You can be sure that every book I've reviewed in this space (~600 to date) was a paper edition.

Things to do when not emailing:

• Take a walk with a friend, and talk about what you see as you stride along.
• Cook a better meal than usual.
• Engage in a hobby (my main ones are photography and various collections).
• Read a book or magazine.
• Sit and talk.
• Play a card game or board game (non-electronic).
• Learn a musical instrument, or if you know one, play your own music for yourself.

That'll get a body started on a lower-stress life.