Sorry I am just seeing this comment now, 4 years after you posted it! In the full version of the report ( http://www.harvardea.org/s/Final-Presentation-PAF-LJAF-Report-on-Opioid-Epidemic-clean.pdf ), we point out that the evidence for these interventions is shoddy. However, even if they are only providing placebo effect, they can still have a great positive value in substituting for opioids as a treatment for chronic pain. Opioids also don't work, but they cause much more damage than chiropractic or acupuncture could ever do.
Some books are more important than others. E.g., Thinking Fast and Slow is much more foundational to the EA mindset than the Structure of Scientific Revolutions by Kuhn (IMHO but hopefully that's not very controversial). I think the visualization would benefit from showing some of the books as larger and others as smaller.
It would be cool if you could mouseover/click on books to get more info about them. Some of the titles are too small to read, even when zoomed in.
Medical marijuana fell outside the scope of our consulting project, but I think the evidence is weak for medical marijuana as a promising intervention: "When researchers extended their analysis through 2013, they found that the association between having any medical marijuana law and lower rates of opioid deaths completely disappeared. Moreover, the association between states with medical marijuana dispensaries and opioid mortality fell substantially as well." https://www.rand.org/news/press/2018/02/06.html
It's definitely an interesting/intriguing idea, but it also carries risks of increasing some of the harms associated with marijuana use. Curious to see more evidence come out about it.
Hi, I'm the Founder of the Philanthropy Advisory Fellowship. We've published a bunch of our reports on our website: http://harvardea.org/philanthropy-advisory-fellowship/ We often post them in the EA forum as well. Sorry it was hard to find.
Thanks for writing up this review of Mental Health as an EA cause area! As you know this is an issue near and dear to my heart. You've done a great job summarizing many of the most interesting and important issues in this space.
I wanted to point out a few areas where I think this report could be improved:
Trace Lithium: I think it is important to distinguish between "Lithium in the Water Supply" as a research topic (looking at naturally varying levels of lithium) versus as an intervention. If we determine that the trace lithium hypothesis is correct, i.e. that lithium is a nutritionally necessary mineral that many people are deficient in, then the best intervention would be for the FDA to issue a Recommended Daily Intake so that it gets added to fortified foods, such as vitamins. This way, people can see when Li has been added to their food, and have autonomy over consuming it. Adding lithium to the public water supply would be ethically problematic, politically difficult, and unnecessary.
Unfortunately, evidence for the trace lithium hypothesis has weakened since OpenPhil wrote their report, due to this study in Demark (however, the range of Li concentrations was limited): http://www.mdpi.com/1660-4601/14/6/627/pdf
Suicide and Crisis Hotlines: This is a promising area for research. I haven't seen any strong RCT's on these interventions yet.
Marijuana and Opioid overdoses: New evidence has come out since you wrote this post, showing a more complex relationship. The author of the study said, "Before we embrace marijuana as a strategy to combat the opioid epidemic, we need to fully understand the mechanism through which these laws may be helping and see if that mechanism still matters in today's changing opioid crisis.”
See: https://www.rand.org/news/press/2018/02/06.html
MDMA for PTSD: While promising, I think the risk profile of MDMA and worldwide perception and political realities around it make it a less tractable intervention. I think Propranolol is more promising because it's already on the WHO List of Essential Medicines and very safe, as I argued in my report: http://www.harvardea.org/blog/2016/7/13/paf-mental-health-in-sub-saharan-africa
DARE: The bulk of evidence on the original DARE program showed that it had no effect -- I think it's an overstatement to say it increased drug consumption. It's also important to point out that DARE has been overhauled with help of the research community, and their new program, Keepin' it Real, has shown modest signs of success: https://www.scientificamerican.com/article/the-new-d-a-r-e-program-this-one-works/
Methadone: I haven't read Elizabeth Pisani's book, but I don't think it's fair to say that it doesn't reduce addiction -- it's more accurate to say it doesn't reduce dependence. Addiction is defined in the DSM-V as causing problems in the patient's work/personal life, so when patients are stabilized on methadone maintenance programs (as many are), working and living normal healthy lives, they are no longer considered addicted.
Looking forward to the next iteration of this!
Eric
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.
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.
Re: Propranolol, I spoke with Dr. Alain Brunet at McGill University, who conducted some of the studies you're referring to and was very helpful in explaining the science behind it and the potential.
Any update on how the project is going?
Sorry I am just seeing this comment now, 4 years after you posted it!
In the full version of the report ( http://www.harvardea.org/s/Final-Presentation-PAF-LJAF-Report-on-Opioid-Epidemic-clean.pdf ), we point out that the evidence for these interventions is shoddy.
However, even if they are only providing placebo effect, they can still have a great positive value in substituting for opioids as a treatment for chronic pain. Opioids also don't work, but they cause much more damage than chiropractic or acupuncture could ever do.
I love it!
Two suggestions:
Thanks for doing this!
For #6, what is your source that temperature increases are proportional to log(CO2 ppm)? This paper indicates that it's a simple proportional relationship, no log: https://iopscience.iop.org/article/10.1088/1748-9326/11/5/055006#erlaa23b8f1
Medical marijuana fell outside the scope of our consulting project, but I think the evidence is weak for medical marijuana as a promising intervention: "When researchers extended their analysis through 2013, they found that the association between having any medical marijuana law and lower rates of opioid deaths completely disappeared. Moreover, the association between states with medical marijuana dispensaries and opioid mortality fell substantially as well." https://www.rand.org/news/press/2018/02/06.html
It's definitely an interesting/intriguing idea, but it also carries risks of increasing some of the harms associated with marijuana use. Curious to see more evidence come out about it.
Hi, I'm the Founder of the Philanthropy Advisory Fellowship. We've published a bunch of our reports on our website: http://harvardea.org/philanthropy-advisory-fellowship/
We often post them in the EA forum as well. Sorry it was hard to find.
Hi Elizabeth,
Thanks for writing up this review of Mental Health as an EA cause area! As you know this is an issue near and dear to my heart. You've done a great job summarizing many of the most interesting and important issues in this space.
I wanted to point out a few areas where I think this report could be improved:
DALY count: This article provides good reasons why mental health really repferents 13% rather than 7% of global DALY burden: https://www.ncbi.nlm.nih.gov/pubmed/26851330
Trace Lithium: I think it is important to distinguish between "Lithium in the Water Supply" as a research topic (looking at naturally varying levels of lithium) versus as an intervention. If we determine that the trace lithium hypothesis is correct, i.e. that lithium is a nutritionally necessary mineral that many people are deficient in, then the best intervention would be for the FDA to issue a Recommended Daily Intake so that it gets added to fortified foods, such as vitamins. This way, people can see when Li has been added to their food, and have autonomy over consuming it. Adding lithium to the public water supply would be ethically problematic, politically difficult, and unnecessary. Unfortunately, evidence for the trace lithium hypothesis has weakened since OpenPhil wrote their report, due to this study in Demark (however, the range of Li concentrations was limited): http://www.mdpi.com/1660-4601/14/6/627/pdf
Suicide and Crisis Hotlines: This is a promising area for research. I haven't seen any strong RCT's on these interventions yet.
Marijuana and Opioid overdoses: New evidence has come out since you wrote this post, showing a more complex relationship. The author of the study said, "Before we embrace marijuana as a strategy to combat the opioid epidemic, we need to fully understand the mechanism through which these laws may be helping and see if that mechanism still matters in today's changing opioid crisis.” See: https://www.rand.org/news/press/2018/02/06.html
MDMA for PTSD: While promising, I think the risk profile of MDMA and worldwide perception and political realities around it make it a less tractable intervention. I think Propranolol is more promising because it's already on the WHO List of Essential Medicines and very safe, as I argued in my report: http://www.harvardea.org/blog/2016/7/13/paf-mental-health-in-sub-saharan-africa
DARE: The bulk of evidence on the original DARE program showed that it had no effect -- I think it's an overstatement to say it increased drug consumption. It's also important to point out that DARE has been overhauled with help of the research community, and their new program, Keepin' it Real, has shown modest signs of success: https://www.scientificamerican.com/article/the-new-d-a-r-e-program-this-one-works/
Methadone: I haven't read Elizabeth Pisani's book, but I don't think it's fair to say that it doesn't reduce addiction -- it's more accurate to say it doesn't reduce dependence. Addiction is defined in the DSM-V as causing problems in the patient's work/personal life, so when patients are stabilized on methadone maintenance programs (as many are), working and living normal healthy lives, they are no longer considered addicted.
Looking forward to the next iteration of this! Eric
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.
Re: DALY's for physical vs. mental health, in our full report we cite Vigo 2016 ( http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00505-2/abstract ) which lays out a strong argument for using a 2x adjustment for mental health DALY's. That's the approach we take in the paper.
Re: Propranolol, I spoke with Dr. Alain Brunet at McGill University, who conducted some of the studies you're referring to and was very helpful in explaining the science behind it and the potential.