Comment author: Denkenberger 15 August 2017 11:25:01PM *  0 points [-]

Thanks - very interesting. Could an EA pay for drug medical studies in Portugal? It seems like there are millions of people working on marijuana legalization, and many critics of the war on drugs. I know you are looking more holistically, but overall it doesn't seem that neglected.

For those who think something else is more important, I would be very grateful if you could produce some (very rough) estimates of how many times more cost effective money to their preferred cause is than DPR.

Some people would say ~10^40 times (computer consciousnesses and spreading intergalactically). Of course there are many reasons why this vision may not pan out, but it does seem like we should have a non-negligible probability that we are alone in the galaxy (or even the visible universe) and that we can and have the will to colonize the stars if we don't destroy ourselves. These qualifiers might only take a few orders of magnitude off. Then even if you do not believe in the tractability of AI, there are many other concrete interventions that could reduce existential risk, like asteroid defense and alternate foods. So basically I do not believe the prior of cost effectiveness of global poverty interventions should be strong, so I don't think we should adjust these expected value calculations downward nearly as much as some proposed models have done.

Also, if one does not value the far future, there are other claims of cost effectiveness better than global poverty.

Comment author: Lee_Sharkey 16 August 2017 08:30:07PM 1 point [-]

Hey Denkenberger, thanks for your comment. I too tend to weight the future heavily and I think there are some reasons to believe that DPR could have nontrivial benefits with this set of preferences. This was in fact why, as Michael mentions above:

"FWIW, I think the mental health impact of DPR is about 80% of it's value, but when I asked Lee the same question (before telling him my view) I think he said it was about 30% (we were potentially using different moral philosophies)." because I think DPR's effects on the far future could be the source of most of its expected value.

DPR sits at the juncture between international development & economic growth, global & mental health, national & international crime, terrorism, conflict & security, and human rights. I think we should expect solving the world drug problem to improve some or all of these issues, as Michael argued in the series.

I think it could be easy to overlook the expected benefits of significant reductions in funding and motivation for crime, corruption, terrorism, and conflict for fostering a stable, trusting global system. My weak conjecture is that such reductions would bring an array of global benefits composed of reduced out-group fear (on community and international levels), stronger institutions, and richer societies.

DPR might thus offer a step in the right direction towards solving issues of global coordination, which in turn may increase our expectations for solving the coordination problem for AI and, thence, the long-term future. I admit this is a fairly hand-wavy notion and that the causal chains are undesirably long and uncertain, relying on unpredictable assumptions (such as the timing of an intelligence takeoff compared with the length of time it would take to observe the international social benefits, for a start). My confidence intervals are therefore commensurately wide, but still I struggle to think of ways in which it could be net negative for global coordination. So almost all of my probability weight is positive. Multiplied by humanity's cosmic endowment, I weigh this relatively heavily. Of course, there may be other, more certain activities that we can do to improve the EV of humanity's future, and I think there are, but I don't think DPR is obviously a waste of time if that's what we care about.

Comment author: MichaelPlant 16 August 2017 10:26:33AM *  2 points [-]

Thanks for the comment, although I largely feel you're accusing me/us of things I'm not guilty of. (note: Lee wrote the pain section but we both did editing, so I'm unsure whether to use 'I' or 'we' here)

What I see this series of post as doing is suggesting DPR to the EA world as a cause worth taking seriously. I don't insist on particular policy suggestions. I haven't made my mind up and others are free to draw their own conclusions.

One issue we highlight is the lack of pain medication in part A of the world, whilst noting there is too much in part B, but that we wont talk about B. That doesn't seem unreasonable to do in an essay limited in scope, unless it's obvious changing the situation in A would obviously lead to it becoming like B. It's not obvious (although we can argue about it) so we left it out. Indeed, given the use of psychedelics to treat addiciton (see footnote 27), you might think that part of DPR is important because you worry about the opiate crisis.

Further, as I claim in part 1, there are multiple arguments for different types of DPR. So it's not sufficient to claim one part would backfire to say we shouldn't be interested in any of it. There are lots of ways we could do DPR, and you could change everything else whilst leaving opiates unchanged. By analogy, seems that I'm saying something like "X will reduce crimes apart from murders" and you're replying "but you should think about stopping murders" which strikes me as irrelevant.

Here's the quote where I mentioned this in part 3:

Perhaps we should legalise all those drugs up to and including cannabis on the graph of harms I used earlier, but no further. This would mean legalising everything apart from amphetamines, cocaine and heroin (and presumably keeping tobacco and alcohol legal too) [note: graph now added; must have been lost in transmission]

I'm slightly unsure how to response to your point about original analysis, which feels unhelpfully personal. In section 2.1 above I say why drugs have been made illegal, but I didn't want to get stuck into that because I took the real objective to be explaining why DPR might do good. I also suggest a range of policies (in part 3) and how they each solve different parts of the problems. I'm not claiming to be the first to write about DPR. What I thought was missing was an analysis that brings all the different arguments together, as I also discuss in part 3, and, further, brings it to the attention to EA. If you already know lots about DPR the argumentative pay-off only comes in part 4 where I explain why this might be more cost-effective that causes EAs already support. If I'd just written part 4 you (or others) would be justified in complaining I hadn't made the case!

Finally, FWIW, I think the largest ammount of value from DPR would come from tackling mental health with new methods, and that doesn't have the obvious backfire worries. I'm not really sure how to think about the heroin epidemic, nor do I see it as necessary for me to provide an answer. If you happen to have a solution to the opiate crisis and can give me a cost-effectiveness model, then I can build that in to what I do have. I'm not expecting you to have a solution, nor I think I need one to be able to deal with other parts of the topic.

Comment author: Lee_Sharkey 16 August 2017 05:46:19PM 1 point [-]

(note: Lee wrote the pain section but we both did editing, so I'm unsure whether to use 'I' or 'we' here)

I align myself Michael's comment.

Comment author: Lee_Sharkey 16 February 2017 09:29:23AM 4 points [-]

Really enjoying the Oxford Prioritisation Project!

One of my favourite comments from the Anonymous EA comments was the wish that EAs would post "little 5-hour research overviews of the best causes within almost-random cause areas and preliminary bad suggested donation targets." (http://effective-altruism.com/ea/16g/anonymous_comments/)

I expect average OPP posts take over 5 hours, and 5 hours might be an underestimate of the amount of time it would take for a useful overview without prior subject knowledge. But both that comment and the OPP seem to be of the same spirit, and it's great to see all this information shared through an EA lens.

Comment author: ThomasSittler 15 February 2017 03:43:20PM *  1 point [-]

I am aware that the formatting is poor, but the EA forum text editor is hard to deal with. Tips on how to improve would be appreciated.

Right now the best way to read Daniel's post is probably the Google Doc:

https://docs.google.com/document/d/13wsMAugRacu52EPZo6-7NJh4QuYayKyIbjChwU0KsVU/edit#

Comment author: Lee_Sharkey 16 February 2017 09:11:18AM 0 points [-]

I'd second that - it's not the most wieldy text editor. Not sure how easy it would be to remedy. Going into the HTML gets you what you want in the end, but it's undue effort.

Comment author: tomstocker 06 February 2017 09:36:52PM 3 points [-]

I'm really happy to see this article - I mentioned it to givewell a while ago but they weren't interested. For me this hits what I see as the moral priority more than a lot of the other projects and options on the go.

Simple, complex and neuropathic pains respond differently to different anaelgasics. Opioids v effective for simple pain over the short term, e.g. surgeries, broken bones etc. Neuropathic and complex pain don't have good equivalents for pain relief and patients are stuck with cannabinoids, anti-epileptics and anti-depressants (or, ketamine, ironically, if it wasn't so restricted in the developed world for its noted impact on organ function).

Not a reason not to back access to opioids in the developing world.

Least well explored part IMO is the impact of pain control on the nature of medicine and doctor-patient interaction etc. because the west may have fallen into a trap that it may be a shame to hasten in the developing world.

Comment author: Lee_Sharkey 07 February 2017 09:27:23AM *  2 points [-]

Hi Tom,

Great to hear that it's been suggested. By the looks of it, it may be an area better suited to an Open Philanthropy Project-style approach, being primarily a question of policy and having a sparser evidence base and impact definition difficulties. I styled my analysis around OPP's approach (with some obvious shortcomings on my part).

I could have done better in the analysis to distinguish between the various types of pain. As you say, they are not trivial distinctions, especially when it comes to treatment with opioids.

I'd be interested to hear your take on the impact of pain control on the nature of medicine and the doctor-patient dynamic. What trends are you concerned about hastening exactly?

Comment author: egastfriend 07 February 2017 02:48:54AM *  3 points [-]

Great analysis! Very fair and balanced.

As you point out, increasing the prescriptions of opioids in the US lead to an enormous disaster -- drug overdoses now kill more Americans each year than car crashes. The regulatory environment in the US isn't great, but it's decades ahead of what most developing countries have. The fact that the US still hasn't figured out a sensible policy to managing prescription opioids makes me very skeptical that developing countries could pull it off safely.

E.g., look at these two articles. This one points out that there are already deceptive marketing practices around opioids happening in China: https://www.bloomberg.com/news/articles/2016-12-18/china-s-oxycontin-boom-is-a-goldmine-for-this-drugmaker And this one looks at the aggressive expansion of painkillers into developing countries: http://www.scmp.com/news/world/article/2057240/big-push-opioid-epidemic-killing-oxycontins-us-market-so-makers-target

Rather than trying to expand access, the better strategy may be to advise developing countries on drug control policies to be able to better monitor opioid misuse and handle the inevitable increased availability of drugs.

Note: I'm working on a tech startup that helps people who overuse substances.

Comment author: Lee_Sharkey 07 February 2017 09:08:36AM *  2 points [-]

Thanks for those links. It's troubling to hear about some of the promotional techniques described, though I can't say it's surprising.

While US regulations have been developed decades before their equivalents in many developing countries, it's not necessarily a mark of quality. In the article I refer to less desirable idiosyncrasies of the US health system (i.e. aspects of the consumer-based model; pain as a fifth vital sign), which have exacerbated the crisis there and will not necessarily exist in some developing countries. Yet, while I hesitate to paint all developing countries with the same skeptical brush when it comes to developing adequate regulations, I agree with you more than I disagree. I say that a small amount of adverse outcomes are almost inevitable, and it's really difficult to judge where the positives outweigh the negatives.

I still think expanding access should be part of the strategy. The approach promoted by WHO, UNODC, INCB, is to aim for a 'balanced in policies on controlled substances'. The trouble is that countries are all too keen to control the downsides of using narcotic drugs at the expense of the upsides. So I think that what you're suggesting may already be the approach being taken, but the emphasis needs to compensate for states' existing imbalance.

And what you're doing sounds interesting! Feel free to post links

Comment author: Austen_Forrester 03 February 2017 06:01:15PM 1 point [-]

I'm a little confused as to why you are trying to promote a cause that you think is low priority and financially inefficient. Anyhow, I don't find your anti-corporate stance convincing. Lack of corporate involvement (ie. to distribute analgesics) is the missing link preventing some countries from having functional palliative care in some countries according to Dr. Foley. It's important to work with all stakeholders for progress in any space. The affordable anti-retroviral movement made progress by working with pharma. The risks of working with industry in the public's interest can be minimized with appropriate controls.

Access to properly regulated mobile phone, internet, and financial services have greatly helped the poor and require corporate involvement. Unfortunately, they are underutilized because SJW's like to maintain their purity and reject corporate involvement. I hope your palliative care movement doesn't suffer from the same self-defeating ideology.

Comment author: Lee_Sharkey 04 February 2017 04:19:53PM *  2 points [-]

Hi Austen,

Just to clarify, I'm not trying to promote or demote the cause. I'm aware that the cause is of interest to some EAs, and as someone in a good position to inform them, I thought something like this would help them make their own judgement :) I'm just sharing info and trying to be impartial.

Sorry if I my comments gave the impression that I thought it was low priority and financially inefficient. To reiterate I've withheld strong judgement on its priority, and I said I haven't looked into its financial efficiency compared with other interventions. Because its importance/effectiveness depends heavily on ethical value preferences, both of these question are hard for me to take strong stances on.

My apologies for seeming contrary here, but I'm not taking an anti-corporate stance either. I made those points because the way you had originally put it made it seem like you believed that access to pain relief was unique in that corporate influence didn't carry much risk compared with other causes. Unfortunately, it isn't so. Of course pharma involvement is essential, yet the history of this very cause illustrates the risks. I'd agree with you that lack of corporate involvement is the missing link in some aspects of increasing access, but we should both be specific about the sectors we're talking about to avoid appearing broadly pro-corporate or anti-corporate, which we both agree is unhelpful.

I haven't got a wide enough grasp of the palliative care movement to say if it suffers from an anti-corporate agenda. 'Global health' in general tends to be pretty anti-pharma, and it's hard to argue that the short-term externalities of the existing capitalistic model of drug development and production favours the 'Global health' agenda over the agenda of 'health in the developed world'. So Global health's culture of being anti-pharma is at least understandable, even if it relies on discounting the potentially-positive long-term externalities of the capitalistic model. It's hard to say if access to pain relief/palliative care is more antagonistic to pharma than the rest of Global health. If it is suspicious of opioid manufacturers being involved in other aspects of the movement such as policy, then, without being too SJW, I actually think they actually have good reason to be so, given the history.

Comment author: Austen_Forrester 02 February 2017 11:17:13PM 2 points [-]

One good thing about this space is that, unlike so much other policy work, access to pain relief doesn't have corporations interfering by paying off government, etc. If anything, corporations would stand to gain by increasing access to pharmaceuticals. So much other policy advocacy is stifled by corporate interference, so palliative care has a huge advantage in that regard. Would it be possible for advocates to work with pharma corporations to lobby for increased access? I know that sometimes governments have good regulations in place but can't find corporations willing to supply/distribute the country with the meds, which I find baffling.

Do you think that an effective strategy for pain relief would be to first convince a Ministry of Health of the importance of palliative care? Rather than putting drugs as the forefront of advocacy, perhaps getting government to agree to the principle of palliative care and pain control first would be more productive because once they agree to that, it is a given that narcotics are necessary.

Increasing pain relief is a notable cause in so many ways. It is a major issue in moderate income countries such as in former Soviet nations. Africa may be the worst, but pain relief restriction is by no means limited to the poorest regions of the world. Just shows that the best altruistic opportunities aren't always in the poorest countries. I would think that the more developed countries would be a priority target for advocacy because they would actually have functional health care systems that would permit implementation of increased palliative care.

From what I've studied so far, I don't see how you can say that increased analgesic access is low-medium in neglectedness and tractability. Dr. Kathleen Foley says that University of Wisconsin's fellows only spend 15% of their time on this and usually make progress in their respective countries. If true, that demonstrates that this issue is severely neglected and tractable with long-term pay-offs, at least in some countries.

Is it possible for existing major global health initiatives to lead this cause? PEPFAR is well-funded and pain relief is part of AIDS treatment. I know you mentioned them, but perhaps they haven't put an appropriate portion of their funding towards this area for political reasons.

Comment author: Lee_Sharkey 03 February 2017 01:20:09AM *  2 points [-]

Hi Austen,

Thanks for all your interest!

I would have to disagree on your point about corporate influence. Pharma has been implicated heavily in the current opioid epidemic in the States and elsewhere. See the John Oliver expose for a light introduction (link above). In this area, if anything, there is even more reason to be wary of pharma influence because the product is so addictive when misused. Pharma does do some positive work - I'm aware of a BMS-funded training hospice in Romania (Casa Sperantei). I've only heard good things about it.

You've hit on an accepted strategy for promoting pain relief access/palliative care. One only knows one has succeeded in making a MoH care about the area when it does something about it, such as developing a policy. The 'public health approach' to increasing access to pain relief/palliative care, supported by WHO, recognizes policy as the foundation on which other progress can be built. Without it, success in other areas of the approach (namely medicine availability, education, and implementation) is much less likely. Kathy Foley and colleagues introduce the public health approach here http://www.jpsmjournal.com/article/S0885-3924(07)00122-4/pdf

Regarding tractability:

The issue is likely to be more tractable in some countries than in others, and so it's hard for me to give anything but a range.

I'm adding retrospective justification for my choice of low-moderate tractability here, but compare this cause to similar ones assessed by 80k. The scores given to them according to their scoring matrix are: Smoking in the Developing World - 3/6; Health in poor countries - 5/6; Land Use Reform - 3/6;

(Where 3 is "Some possible ways to make progress, with significant controversy; Significant uncertainty about how to approach, solution at least a decade off; many relevant people don’t care, or some supportive but significant opposition from status quo.")

Judging by the rest of the scoring matrix I think a range of 2 - 3.5 in most countries is appropriate, which roughly correlates to low-moderate in my book.

So I think I would stand by my choice of low-moderate. I probably a proclivity for pessimism so perhaps I'm not being generous enough about its solvability here. The problem may be highly tractable in some countries but I feel that to recognise it in the range would misrepresent the issue. As for Wisconsin, I would hesitate to proclaim its effectiveness before more specific analysis. So even if they only spend 15% of their time on it, that may not mean much in terms of tractability or neglectedness. It does seem promising though.

Other funding: There are reasons other than politics that PEPFAR may not have chose to fund palliative care measures. Preventive measures may just be way more cost effective in the long run. I haven't looked closely into it.

An area where palliative care is of growing interest is in multidrug resistant TB.

Comment author: Elizabeth 02 February 2017 09:34:19PM *  4 points [-]

I'm super happy to see people taking this seriously. Why the emphasis on opioids? My understanding is they're bad for chronic pain because you acclimate so quickly, and they usually don't affect pain that is purely neurological. Cannibidiol works better for many people, is overwhelmingly safer (http://www.nytimes.com/roomfordebate/2016/04/26/is-marijuana-a-gateway-drug/overdoses-fell-with-medical-marijuana-legalization), and can be grown at home. Kratom has a reputation for being good, although I know less about it.

Comment author: Lee_Sharkey 02 February 2017 10:40:58PM 6 points [-]

Hi Elizabeth,

I focus on opioid medications for the same reasons that I don't focus on cannabinoids:

  • There isn't strong expert consensus on the effectiveness of cannabinoids. This may change as the search for alternative drugs, particularly for chronic pain, intensifies. While there are some areas that will likely see their use increase (you justly highlight neuropathic pain), my understanding is that current evidence doesn't reliably indicate their effectiveness for severe pain. All this said, there are good reasons to believe they are understudied, both as single interventions and as adjuvants. I should perhaps have elaborated on this and similar research avenues in the article. Thank you for bringing attention to this issue.

  • Opioid medications, although controlled and functionally inaccessible, are legal medicines in all countries. With few, well-evidence cannabinoid medications approved for use, and only in a handful of countries, it's unlikely that fighting to approve members of a controversial drug class of questionable efficacy for many medical indications is the best way to bring pain relief to patients in developing countries (It could be incredibly effective if generating widespread acceptance of cannabinoid medications, through a long causal chain, ended up driving more rational controlled substances policies. But this is far from a neglected and tractable cause).

For the above two reasons, the movement to increase access to opioid medications has historical precedent on its side and solid expert consensus on their efficacy (even if their dangers are debated). It seems that they comprise an essential component of the best solution (however imperfect) to the gross deficiency of analgesia in the majority of contexts globally. But you're correct to highlight what may be the least explored part of the analysis.

Comment author: Julia_Wise 02 February 2017 01:45:50PM 18 points [-]

I had no idea things were so bad in this area.

I'm so pleased to see this kind of research on the Forum! Thank you for the work that went into this.

Comment author: Lee_Sharkey 02 February 2017 09:06:33PM 5 points [-]

Thanks Julia! Glad to have the chance to share

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