Macro Roundup

"...Last year there were 1,187 drug-related deaths in Scotland, a record, and a staggering increase of 27 percent from the year before. Overdoses are more common in Scotland, by some measures, than even in the United States...."

As Scotland’s ‘Trainspotting’ Generation Ages, the Dead Pile Up

GLASGOW — Tony Nugent was clean for almost seven years before he relapsed.

He found that heroin, cruel to the young, is even less forgiving with age.

Mr. Nugent had been using the drug on and off since he was 19, but overdosed the first time he shot up again. He has overdosed three more times since last year.

“I’ve nearly died four times,” said Mr. Nugent, who turns 43 this month. “It’s getting harder for me to recover as I get older.”

Still, he considers himself lucky, especially living in what is now being called the “drug-death capital of the world.”

Last year there were 1,187 drug-related deaths in Scotland, a record, and a staggering increase of 27 percent from the year before. Overdoses are more common in Scotland, by some measures, than even in the United States.

“We’re seeing diseases that you would associate with old age in a lot of these middle-aged men with a long history of drug use,” said Dr. Carole Hunter, the lead pharmacist for Glasgow Addiction Services. “What your body tolerates at 18 it doesn’t tolerate at 38 or 48.”

Drug deaths aren’t new in Scotland. More than two decades ago, the grueling life of addiction in Edinburgh was the subject of the novel-turned-film “Trainspotting.”

What’s new is how many people are dying.

“I remember there was outrage when the headlines said ‘One Death Every Day From Drugs,’” said Andrew McAuley, a senior research fellow on substance use at Glasgow Caledonian University, referring to a national investigation into drug deaths in 2003. “That seems like glory days. We’re four times that now.”

There are almost 60,000 drug users in Scotland with routine and prolonged use of opioids or benzodiazepines. Many also suffer from physical and mental health issues too, putting them at greater risk of dying from an overdose.

Mr. Nugent is one of them. He has been treated for deep-vein thrombosis, hepatitis C and skin abscesses. Lately, he said, he had been urinating blood.

The United States is three decades into its own opioid crisis, and with its drug users aging, experts might do well to look at how Scotland responds. The United States has a much larger number of overall drug users, many of them are turning to deadlier drugs like fentanyl, and, in general, they have less access to drug treatment than users in Scotland.

“There are lessons to be learned internationally as many countries grapple with this,” said Dr. Jeffrey Samet, a professor at Boston University who specializes in substance use disorders.

Path to Trouble

Scotland wasn’t always the “sick man of Europe.”

Until around 1950, life expectancy there was on par with most of Western Europe, or better. But after World War II, things in Scotland improved more slowly than in any other Western European country.

“The jigsaw is complex,” said Dr. McAuley, the Glasgow researcher. “It’s our history, it’s the way we consume drugs, it’s the chronic underfunding and underperforming treatment services we have. Underline that with austerity and welfare cuts in recent years, and you’ve got the perfect storm for this to happen.”

Many of Scotland’s struggles grew out of social and economic policy changes made in the late 1970s, according to David Walsh, a researcher at the Glasgow Center for Population Health who has studied Scotland’s high mortality. The conservative government in London at the time considered industrial cities like Glasgow to be “declining” and pushed for rapid economic restructuring.

Scotland’s leaders made contentious policy decisions at home, too. In Glasgow in particular, said Mr. Walsh, officials prioritized commercial development and clearing slums, relocating entire communities to isolated public housing estates that were poorly maintained.

“There’s a very clear relationship between socioeconomic factors and health,” Mr. Walsh said. “Evidence shows people can turn to alcohol and drugs to cope with difficult circumstances.”

As far-reaching changes hit Scotland, heroin flowed into Europe. A supply route linking Afghanistan to Iran opened up in the 1980s, making the drug more available — and affordable — than ever. In Scotland, this produced what came to be known as the “Trainspotting” generation.

“Before 1980, our police drug squad said there were maybe 50 people in Edinburgh using heroin, and we knew them all,” said Roy Robertson, a professor of addiction medicine at the University of Edinburgh. “Then around 1980 there was this wave of drugs, and that availability stimulated the epidemic.”

Strides, and Stumbles

For years, Scotland made strides in curbing drug deaths.

Needle exchanges were introduced in the 1980s and naloxone, the lifesaving overdose medication, has been in widespread use since 2011. Opioid-substitute therapies like methadone — which is tightly regulated in the United States — are free and available at most pharmacies through the nationalized health care system.

But in 2016 the Scottish government cut funding to alcohol and drug prevention services by more than 20 percent, from 69 million pounds a year down to 54 million. The funding has since been restored, and the Scottish government pledged an additional 20 million pounds, starting this year.

“What would you expect to happen to a country with an opiate addiction problem if you progressively remove treatment? The death rate would steadily go up,” said John Strang, a professor at King’s College London who has researched addiction treatment for over 30 years.

About 40 percent of users in Scotland are currently in treatment, according to Dr. Lesley Graham of the National Health Services of Scotland. In England that figure is closer to 60 percent. The challenge for Scotland is to get more people into treatment — and to keep them there.

When Daniel Hamilton arrived at the Edinburgh Access Practice on a Monday afternoon, he didn’t think he’d leave that day with a prescription for methadone, the opiate substitute used to curb heroin cravings. In his hometown, Perth, getting a prescription can sometimes take months, he said. (A review of cases from the National Health Service found that the median wait for treatment in the region was eight weeks.)

“You could get a bad batch of heroin and die by then,” he said.

The Edinburgh Access Practice is trying to get people into treatment faster and start addressing the issues behind their drug use. Its staff includes a mental health team as well as social workers and housing and employment specialists.

But facilities like this one are rare. Experts say Scotland needs to scale up and improve access to existing services, and then introduce approaches like heroin-assisted treatment centers or supervised drug consumption facilities.

“We’ve managed to keep a lot of the aging cohort alive through our current drug treatment services, but they get to a certain point where that blanket is not enough,” Dr. McAuley said. “They need respiratory care, they need mental health care, they need help with housing, employment, welfare and a whole host of other things.”

Controlled substances like heroin, however, fall under the British government’s jurisdiction, and conservative lawmakers have resisted proposals for more progressive drug policy.

“The U.K. government has been clear that there is no legal framework for the provision of drug consumption rooms and there are no plans to introduce them,” the Home Office said in a statement.

Scotland’s public health minister, Joe FitzPatrick, lamented that position.

“I know the instinct from the U.K. government is that they don’t want to be seen in any way to be condoning illegal drug use,” he said. “But people are dying. We need to do things that at first feel difficult.”

Two Friends

Scotland has largely managed to avoid America’s deadliest opioid, fentanyl: Only 12 deaths last year involved any trace of the drug.

Health officials can do little but hope that remains the case.

“If fentanyl does come here, it will be kind of endgame type stuff,” Dr. McAuley said.

Mr. Nugent said he had not seen fentanyl in Glasgow yet. He’s more worried about the influx of “street Valium,” or etizolam. “People are dying with one bad pill,” he said. Etizolam was found in nearly half of all drug deaths in Scotland last year.

Mr. Nugent said he steered clear of it, but his best friend, James Muir, is less cautious. Mr. Muir is homeless in Glasgow; Mr. Nugent planned to check himself into a rehab center this fall.

He worries about what will happen to Mr. Muir when he’s gone.

“I don’t know what’s going to become of him,” he said. “I hope that someone will look after him the way I do.”

"...A better path of deterrence would be to focus on identifying potential risks and separating them from the means of harm. The use of Big Data by law enforcement to identify patterns of dangerous activity would be helpful….look to overhaul federal privacy laws that are a barrier to reporting potential threats. These include the Health Insurance Portability and Accountability Act (Hipaa) and the Family Educational Rights and Privacy Act (Ferpa). Federal law and Justice Department regulations disqualify individuals who have been committed to a mental institution or adjudicated as mentally deficient from owning firearms and are noted in the NICS checks. Yet state participation in NICS is voluntary, and many remain reluctant to submit health records for fear of violating Hipaa. A December 2018 report from the Federal Commission on School Safety noted that states and localities are also confused about when it is appropriate to share student records with officials or parents under Hipaa and Ferpa. The George W. Bush and Obama Administrations tried to clarify these rules related to public safety, but without apparent success. Congress should update them to reflect the danger from mass killers, and it can drag the 1974 Ferpa into the digital age, making data more easily manageable...."

Editorial Board, "Flagging Future Killers," Wall Street Journal, August 6, 2019, https://www.wsj.com/articles/flagging-future-killers-11565132691

Some useful steps to identify and deter dangerous individuals.

The Dayton and El Paso shootings have spurred familiar calls for more gun control, and by all means let’s have a debate. But the focus should be on denying weapons to the potential killers rather than on gun laws that may be politically satisfying but won’t make much difference.

Start with the calls for more “background checks,” which implies none now exist. Yet nearly all gun purchasers today have their backgrounds checked on the spot via the National Instant Criminal Background Check System (NICS). Most mass shooters obtained their guns through licensed dealers after checks, or from family members. The Dayton and El Paso killers, and the Gilroy, Calif., shooter of late July obtained their firearms legally.

Democrats want to expand background checks to person-to-person sales, though policing that would be a challenge as most such sales could be done off the books. They also want to extend to 10 days from three the amount of time dealers must wait to get a response from the background check system before proceeding with a sale. Senators Pat Toomey (R., Pa.) and Joe Manchin (D., W.Va.) want background checks to cover unlicensed sales at gun shows and online, but exempt sales between friends and family.

Congress should have that debate, but no one should think they would reduce the number of mass shootings. Most mass shooters don’t have a criminal history that would pop up in the background system. There is also no evidence that longer waiting periods reduce suicides, homicides or mass shootings. Determined killers can always get a weapon.

A better path of deterrence would be to focus on identifying potential risks and separating them from the means of harm. The use of Big Data by law enforcement to identify patterns of dangerous activity would be helpful, as Holman Jenkins Jr. notes nearby.

Congress can also look to overhaul federal privacy laws that are a barrier to reporting potential threats. These include the Health Insurance Portability and Accountability Act (Hipaa) and the Family Educational Rights and Privacy Act (Ferpa). Federal law and Justice Department regulations disqualify individuals who have been committed to a mental institution or adjudicated as mentally deficient from owning firearms and are noted in the NICS checks.

Yet state participation in NICS is voluntary, and many remain reluctant to submit health records for fear of violating Hipaa. A December 2018 report from the Federal Commission on School Safety noted that states and localities are also confused about when it is appropriate to share student records with officials or parents under Hipaa and Ferpa.

The George W. Bush and Obama Administrations tried to clarify these rules related to public safety, but without apparent success. Congress should update them to reflect the danger from mass killers, and it can drag the 1974 Ferpa into the digital age, making data more easily manageable.

Congress can also work with states and localities to pass emergency protection orders. Some 17 states and Washington, D.C., now have these “red flag” laws permitting police or family members to petition a judge to temporarily remove firearms from individuals deemed a danger to themselves or others.

South Carolina Senator Lindsey Graham this week said he has bipartisan support for legislation for grants to states enacting red-flag laws. Congress could also do a service by advising on model legislation. A good law would provide adequate due process that lets flagged individuals challenge the order; requires judges to rule on the basis of clear and compelling evidence; and includes criminal penalties for anyone bringing false accusations.

Red-flag laws should also go beyond mere firearm confiscation. The mental-health lobby is a more formidable obstacle here than the gun lobby. Most states refuse to reform their involuntary commitment laws, making it impossible to provide help for the severely mentally ill. Yet if an individual is dangerous enough to strip of a constitutional right, the government should also insist on treatment, and in some cases temporary commitment to a psychiatric facility.

There is no single answer to mass shootings, but most of the quick solutions on offer would provide false comfort. That’s true of gun restrictions short of outright bans or confiscation that would run afoul of the Second Amendment. The immediate priority should be to reform laws and practices to deny firearms to those who are a danger to the public.

matches Guzman's findings on the utility of R&D tax credits (though this paper doesn't include his research)

"....Market economies are likely to under-provide innovation, primarily due to fact that knowledge spills over between firms. This article has discussed the evidence on policy tools which aim to increase innovation. We condense our (admittedly subjective) judgements into Table 2, which could be used as a toolkit for innovation policymakers. Column 2 summarizes our read of the quality of the currently available empirical evidence in terms of both quantity of papers and credibility of the evidence provided by those studies. Column 3 summarizes the conclusiveness of the evidence - for example, although there are some credible approaches for estimating the impact of intellectual property, the policy implications of the available findings are unclear. Column 4 scores the overall benefits minus costs, in terms of a light bulb ranking where three is the highest; this is meant to represent a composite of the strength of the evidence as well as the magnitude of average effects.Columns 5 and 6 are two other criteria: first, whether the main effects would be short-term, medium term or long-term; and second, the likely effects on inequality. Different policymakers (and citizens) will assign different weights to these criteria....In the short-run, research and development tax credits or direct public funding seem the most effective, whereas increasing the supply of human capital (for example, through expanding university STEM admissions) is more effective in the long-run. Skilled immigration has big effects even in the short-run. Competition and trade policies probably have benefits that are more modest on innovation, but are cheap in financial terms and so also score highly. One difference is that R&D subsidies and trade policies are likely to increase inequality, partly through increasing the demand for highly skilled labor and partly, in the case of trade, because some communities will endure the pain of trade adjustment and job loss. By contrast, increasing the supply of highly skilled labor is likely to reduce inequality by easing competition for scarce human capital...."

Nicholas Bloom, John Van Reenen and Heidi Williams, "A Toolkit of Policies to Promote Innovation," Center for Economic Performance, July 2019, https://ideas.repec.org/p/cep/cepdps/dp1634.html

Though this would be of interest in context of op-ed draft. Though seems high

"...Only 38 percent of VC funds tracked over two decades produced gains exceeding the traditional 8 percent hurdle, according to a statement Monday from the alternative-assets data provider. Hurdle rates are time sensitive as they’re typically calculated as an internal rate of return....The average holding periods in venture capital have risen, according to eFront. Funds created from 1999 to 2012 backed companies for an average 5.7 years before an exit, up from 3.6 years for vintages tracked from 1992 to 1998, the firm found...."
Christine Idzelis, "Venture Capital Struggles to Meet Hurdle Rate,"Institutional Investor, July 15, 2019, https://www.institutionalinvestor.com/article/b1g92ldh2p8k2r/Venture-Capital-Struggles-to-Meet-Hurdle-Rate

Note, 2020 update to this paper is attached

“This paper presents results from the third year of a multi-year, pre-committed research design for analyzing recent minimum wage changes. Using ACS and CPS data through 2017, we find thatrelatively large minimum wage increases reduced employment among low-skilled individuals by just over 2 percentage points. The effects of smaller increases are more variable and estimates for inflation-indexed increases tend toward moderately positive values.The effects of smaller increases are relatively more positive when we analyze the CPS. The most recently enacted minimum wage changes tend to be positively correlated with employment among low-skilled individuals, while relatively early and large increases are strongly negatively correlated with employment. Analysis of future data will be needed to determine whether this apparent difference between short- and medium-run effects is systematic.”

Jeffrey Clemens and Michael Strain, “Minimum Wage Analysis: Using a Pre-Committed Research Design: Evidence Through 2017,” American Enterprise Institute, June 2019, https://www.aei.org/wp-content/uploads/2019/06/Strain-Minimum-Wage-WP-2019.pdf