The Massachusetts Department of Public Health reported today on the opioid-related overdose rate in the commonwealth for 2017. The good news is the overdose death rate decreased by 8 percent from 2016 to 2017.
But a closer look at the numbers reveals that overdoses from prescription opioids were found in around 20 percent of “opioid deaths with specific drugs present.” (See figure 4, page 3 of the report.)
A startling 83 percent had fentanyl present in their drug screens, 43 percent had heroin, and 41 percent had cocaine. The report stated that the fentanyl was “most likely illicitly produced and sold, not prescription fentanyl.”
The 20 percent of deaths in which prescription opioids were found in the screen does not break things down any further, but judging by the estimated 68 percent of opioid-related deaths that feature multiple drugs on board (such as benzodiazepines, fentanyl, heroin, cocaine, methamphetamines, alcohol), we can safely assume that the overdose rate due exclusively to prescription painkillers is significantly lower than 20 percent.
Meanwhile, policymakers stay fixated on pressuring doctors to prescribe fewer and lower doses of opioids for their patients in pain, and state attorneys general set their sights on suing opioid manufacturers, completely ignoring the fact that the overdose crisis has primarily been about nonmedical users accessing drugs in the dangerous black market. Prohibition is the real killer.
Speaking last week at a National Opioid Summit in Washington, DC, Attorney General Jeff Sessions reported opioid prescriptions fell another 12 percent during the first eight months of 2018, saying ‘We now have the lowest opioid prescription rates in 18 years.” Some of this was no doubt the result of the chilling effect that prescription surveillance boards have had on the prescribing patterns of physicians. For example, Sessions announced the Trump administration has charged 226 doctors and 221 medical personnel with “opioid-related crimes,” and this has not gone unnoticed by health care practitioners.
Sessions also pledged to meet the goal of a 44 percent overall reduction in the production of opioids permitted by the Drug Enforcement Administration. The DEA, which sets quotas on the production of opioids by US manufacturers, began the process with a 25 percent reduction in 2016 and another 20 percent reduction in 2017. This has led to shortages of injectable opioids in many hospitals, affecting the delivery and quality of care.
Meanwhile, the DEA reported in a Joint Intelligence Report that overdoses in Pennsylvania continued to rise, with 5,456 fatal overdoses in 2017, a 65 percent increase over 2015. Only 20 percent of those overdoses involved prescription opioids, with most deaths involving multiple drugs in combination—usually fentanyl, heroin and cocaine, as well as counterfeit prescription opioids (usually made of illicit fentanyl and heroin pressed into pills). The report stated heroin and fentanyl were found in 97 percent of Pennsylvania’s counties.
Prescription opioids were also responsible for just 20 percent of the fatal overdoses in Massachusetts in 2015, where researchers at Boston University reported last week in the American Journal of Public Health that Opioid Use Disorder among people over age 11 grew to 4.6 percent of the population that year.
The Massachusetts Department of Public Health reports a modest tapering in the fatal overdose rate, from 2,154 in 2016 to 2,069 in 2017, and estimates up to 1,053 have occurred in the first 6 months of 2018. During the first quarter of 2018, 90 percent of those deaths involved fentanyl, 43 percent involved cocaine, 34 percent involved heroin, and 20 percent involved prescription opioids. Fentanyl is responsible for sustaining the death rate in Massachusetts at near-record levels.
What jumps out of these numbers is the fact that efforts to get doctors to curtail their treatment of pain have not meaningfully reduced the overdose rate. They have just caused non-medical users of opioids to migrate over to more dangerous heroin and fentanyl. Fentanyl and heroin—not prescription opioids—are now the principal drugs behind the gruesome mortality statistics.
Addressing the overdose crisis by focusing on doctors treating patients aims at the wrong target. And patients are suffering—often desperately— in the process. The cause has been drug prohibition from the get-go. If policymakers can’t muster the courage to admit and address that fact, then they should at least put the lion's share of reform efforts into mitigating the harmful unintended consequences of prohibition. I wrote about this here.
The Wall Street Journal reported December 14 on a proposal by Massachusetts Governor Charlie Baker to mandate the involuntary 72-hour detention of opioid overdose survivors rescued by first responders. This is another example of feel-good public policy that strains resources and personnel, arguably infringes the civil liberties and due process rights of those detained, and won’t work as intended.
While mandatory rehab has been employed in the criminal justice system for years, the rationale for this has not been evidence-based. A systematic review of over 400 studies on the subject published in the International Journal of Drug Policy in 2016 concluded, “Evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms.”
Furthermore, while the precise length of time needed for successful rehab is uncertain, 3 days is barely enough time to go through acute withdrawal. Even if the 3 days are used to plug the patient into Medication-Assisted Treatment, significant numbers of MAT patients eventually drop out of these programs. Self-motivation and self-regulation play significant roles in successful rehab.
The alarm and frustration of policymakers addressing the overdose crisis is understandable and justifiable. But lashing out with new approaches that are not empirical or data-driven will not fix the problem and may make matters worse.
The Massachusetts legislature is currently debating the state government's budget for the new fiscal year which begins July 1st. This phenomenon---finalizing a spending plan before the beginning of the fiscal year---is something rarely seen in the U.S. Congress any more. Kudos, Bay State, for surpassing the low bar set in Washington, D.C.
But the General Court of Massachusetts is taking one page from the U.S. Congress's tattered playbook. According to WRAL news, it may attach national ID compliance legislation to the budget bill.
That's how Congress passed the ill-conceived REAL ID Act back in 2005. There were no hearings on the national ID issue or the bill that gave us one. Instead, the Republican House leadership attached the national ID law to a must-pass spending bill and rammed it past the Senate to President Bush, leaving states to grapple with implementation challenges and Department of Homeland Security belligerence ever since.
As in many states, the U.S. DHS has been telling Massachusetts legislators that they have to get on board with the national ID law, issuing licenses and ID cards according to federal standards, or see their residents refused at TSA's airport checkpoints.
The threat of federal enforcement in 2016 was broadcast loud and clear last fall. Then in January DHS kicked the deadline a few more years down the road. It's hard to keep track of the number of times DHS has set a REAL ID deadline, then let it slide when elected state officials have declined to obey the instructions of unelected DHS bureaucrats.
Minnesota has had a similar experience. Last winter, its legislature was spooked into creating a special "Legislative Working Group on REAL ID Compliance." But Minnesota just ended its legislative season without passing REAL ID compliance legislation. There are a few people there who recognize the demerits of joining the national ID system, and Minnesota elected officials may have figured out that when DHS bureaucrats say "Jump!" they do not have to ask "How high?"
The General Court has done better than the U.S. Congress on REAL ID by holding hearings before acting. In 2007, then-Massachusetts Attorney General Martha Coakley testified before the Joint Committee on Veterans and Federal Affairs.
"The Real ID Act was pushed through Congress in 2005 without meaningful debate or hearing on its implications for the states," she said. "Not only does the Real ID Act call for sweeping changes in how states issue driver's licenses with limited time to implement the changes, but it does not consider the financial burden placed on the states."
REAL ID still threatens state budgets. If Massachusetts passes REAL ID compliance language in a budget bill, that will be somewhat ironic, because a pledge to REAL ID compliance would give DHS bureaucrats in Washington, D.C. the power to dictate the Bay State's driver licensing policies and practices forevermore. The DHS will tell Massachusetts legislators how to spend Massachusetts taxpayer dollars at the Registry of Motor Vehicles.
Like most states, Massachusetts has yet to grapple with the fact that REAL ID law requires the RMV to share driver data with every other motor vehicle bureau nationwide through a system of databases. The DHS has downplayed that statutory requirement, effectively writing it out of the law until enough states have committed to compliance. But when enough states have signed on, DHS will tell Massachusetts to open up its databases of personal information. Giving nationwide exposure to driver data creates privacy concerns and identity fraud risks greater than the paltry and arguable security benefits of having a national ID.
Will the Massachusetts legislature join the Bush-era Republican Congress in ramming national ID legislation through attached to a spending bill? That's exactly what it should do, said no one ever.
One of the central promises of educational choice is expanding equality of opportunity. When students are assigned to schools based on where they live, access to higher-performing schools depends on a family’s ability to afford a home in a more expensive community. This disparity between higher- and lower-income families persists even in academically high-performing states like Massachusetts.
Though the Bay State consistently ranks among the very top performers on the National Assessment of Educational Progress (NAEP) and is internationally competitive in math and science, these aggregate scores obscure the reality that performance varies considerably across districts, particularly along socio-economic lines.
In wealthier towns and cities like Dover and Weston, where the median household income is $184,646 and $180,815 respectively, students perform well. On the 2013 state assessment (the MCAS), 99 percent of Dover-Sherborn Regional High School students scored ‘proficient’ or ‘advanced’ in math, and 100 percent scored ‘proficient’ or ‘advanced’ in English. Likewise, 97 percent of Weston High School students scored ‘proficient’ or ‘advanced’ in math and 99 percent scored proficient or advanced in English.
By contrast, students from lower-income communities like Chelsea and New Bedford, where the median household income is $43,155 and $37,493 respectively, often do not perform nearly as well. On the most recent MCAS, only 61 percent of Chelsea High School students scored ‘proficient’ or ‘advanced’ in math and 77 percent scored ‘proficient’ or ‘advanced’ in English. So too, only 49 percent of New Bedford High School students scored ‘proficient’ or ‘advanced’ in math, and 76 percent scored ‘proficient’ or ‘advanced’ in English.
This pattern is repeated across the commonwealth – in the 10 poorest cities and towns in Massachusetts, only 40.6 percent of students scored ‘proficient’ or ‘advanced’ on the MCAS score compared to a statewide average of 65.1 percent. In 2013 the percentage of low-income students who scored ‘proficient’ or ‘advanced’ in English or math in all grades was approximately 33 points below the percentage for higher-income students.
One might assume that the differences in performance across income groups reflect disparate funding levels, yet there is scant evidence that increased school resources lead to increased student performance. Indeed, after adjusting for inflation, K-12 spending in the United States has tripled since 1970, but NAEP scores have remained essentially flat.
Wealthier families already have educational choice. They can afford to live in communities with higher-performing schools, like Dover and Weston, or they can send their children to private schools. Since they have the ability to exit, the district schools must be responsive to their children’s needs. By contrast, lower-income families often have only one viable option: the district school to which their children are assigned. They are a captive audience, so their schools become de facto monopolies. And while some low-income families are able to send their children to METCO or charter schools, there are more than 10,000 students on waiting lists for METCO schools and more than 40,000 students on waiting lists for charter schools, demonstrating both the demand for and lack of additional educational options.
Poverty certainly plays a significant role in the varied performance, but high quality studies consistently show that educational choice programs improve academic outcomes for low-income students, often to a greater degree than for higher-income students. While educational choice programs are not a panacea, they are a precondition to ensuring equality of opportunity.
A scholarship tax credit (STC) program tailored to Massachusetts’ needs could expand educational opportunity for thousands of students from low-income families while remaining revenue neutral or even saving the commonwealth money. In a new study, jointly published by Pioneer Institute and Cato Institute, “Giving Kids Credit: Using Scholarship Tax Credits to Increase Educational Opportunity in Massachusetts,” Professor Ken Ardon and I propose a state tax credit worth 90 percent of the amount a corporate or individual taxpayer donates to a qualified scholarship organization. The organization would then use the money to provide scholarships averaging between $4,000 and $4,500 for students whose family income is below 200 percent of the federal poverty line. Families would use the money toward the cost of attending non-public or out-of-district public schools.
Some might question whether scholarships of that size might be useful to low-income families in a state where the average private school tuition is nearly $20,000. However, that figure is skewed by the presence of numerous expensive boarding schools. When reviewing the published private school tuitions in the five poorest of Massachusetts’ 10 largest cities – Springfield, Fall River, New Bedford, Brockton, and Lynn – we found an average tuition of $4,470 for kindergarten, $4,173 for grades 1-5, $4,510 for grades 6-8 and $9,125 for high school. Moreover, those figures do not include all the tuition assistance that private schools already provide to low-income families.
In addition to benefiting low-income students, an STC program produces savings for taxpayers when the amount of money that would have been spent on the scholarship students had they attended a district school exceeds the reduction tax revenue from the tax credits. We estimate that our proposed STC law would save the commonwealth of Massachusetts approximately $41 million in year one and the savings would grow to approximately $222 million by year five.
Few proposals promise to simultaneously expand educational opportunity for low-income students and save money while doing so. Yet this is no pipe dream. There are currently about 200,000 students attending the school of their choice using tax-credit scholarships in more than a dozen states, and the available evidence suggests that these programs are saving money. Though Florida’s STC law is the least likely candidate for savings because it offers a 100 percent tax credit and the most generous scholarships of any state, the Florida legislature’s nonpartisan Office of Program Policy Analysis and Government Accountability estimated that Florida saved $1.44 for every forgone dollar of state tax revenue.
The Constitution of the Commonwealth of Massachusetts declares that the preservation of its citizens rights and liberties depend upon “spreading the opportunities and advantages of education” to all children, no matter their income. An education system that determines a child’s school based on the home her parents can afford fails to achieve the constitution’s vision. True equality of educational opportunity requires breaking the link between education and housing. The proposed scholarship tax credit would move the Commonwealth toward that vision by helping tens of thousands of low-income students attend the school of their choice.
From this weekend's Lawrence (Mass.) Eagle-Tribune:
Millions of dollars originally intended for smoking cessation programs in Massachusetts have been diverted to offset budget deficits, leaving the state struggling to fund quit-smoking hotlines, treatment programs and anti-tobacco advertising, the New England Center for Investigative Reporting has found. ...
“Roughly 99 percent of all the tobacco dollars that come into the state are used for something else,” said Stephen Shestakofsky, recently retired executive director of Tobacco Free Massachusetts, an anti-tobacco advocacy group. He was referring to the nearly $254 million in tobacco-related legal awards given to Massachusetts in 2012. More than $561 million in tobacco taxes was also collected, bringing the state’s total tobacco tally to just over $815 million, the CDC reports.
On the one hand, it's not as if I'd urge the state of Massachusetts to sink vast sums into the paternalist project of hectoring its citizens to quit, especially not at a time when its taxpayers are already having to foot a steep tab for its RomneyCare health insurance experiment. On the other hand, we can now see that it was the purest pretense for attorneys general in states like Massachusetts to have portrayed the Great Tobacco Robbery settlement of some years back as motivated by a supposed need for new "public health" outlays, as opposed to sheer plunder and the interests of the various lawyers involved.
That's worth remembering next time you hear a proposal to extract large sums from the food industry (either through taxation or, as some in the legal profession would like, by suing them for it under some creative theory) with the promise that funds will then be earmarked for anti-obesity efforts. In practice, after voters' attention wanders, funds ordinarily get earmarked for the advancement of the political interests of those in power.
The Massachusetts Uniform Securities Act prohibits general solicitation and advertising by anyone offering unregistered securities, ostensibly for the purpose of furthering state and federal disclosure schemes. Yet this ban on public communications has been applied so broadly that it has undermined those purported disclosure goals. For instance, the ban has prevented individuals who have no interest in investing in any security -- such as journalists, academics, students, and others who are not wealthy or financially sophisticated -- from receiving truthful, non-misleading information about hedge funds.
In Bulldog Investors v. Massachusetts, an investment company maintained an interactive website that provided information about its products. Because Bulldog was not registered in Massachusetts, however, the State filed an administrative action against the firm, demanding it take down its online content.
In response, Bulldog joined a group of other firms and individuals -- including some who have no interest in investing but wish to read the website information -- in a lawsuit claiming that the Massachusetts ban violates their First Amendment rights. The Supreme Judicial Court of Massachusetts upheld the ban, so the plaintiffs have asked the U.S. Supreme Court to take the case.
Cato, along with the Competitive Enterprise Institute and a group of journalists and academics, has now filed an amicus brief supporting that request and arguing that the Massachusetts law is an unconstitutional ban on free speech. We show that the state’s claim that the ban furthers a larger federal regulatory scheme ignores the judgment of many federal officials (from both parties) who have concluded that such bans undermine these goals.
The state’s alleged disclosure interest is just a pretext for coercing companies to register in Massachusetts, and is therefore an unconstitutional attempt at circumventing federal preemption. But even if the ban furthers a legitimate state interest, it is so broad that it is has substantially chilled both truthful, non-misleading commercial speech and noncommercial speech alike.
A law so repugnant to the First Amendment cannot stand.