clausewitz2

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So, @psychacad , let's put anything quantitative aside for a minute to respect possible allergies. Say you did succeed in doing something that increased a patient's sense of community. Arguendo whatever you do works. How would you know that it had? How would you know if it didn't work? How would you tell the difference?

I think if you can lay something out we can understand where you're coming from a little better.

Be super suspicious of the impulse to say you'd just know or intuition, because that impulse is always going to give you the answer you want to be true regardless of the facts of the matter.

As an aside, well-trained psychologists are the people -least- likely to mindlessly apply rating scales.
 
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Shufflin

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Slavery wasn't "the norm" in most nations pre-industrialization. It wasn't really that big of an enterprise until the colonization period. Pre-colonization societies were fairly simple, and working the fields, while hard, was a task that could only be performed from dawn till dusk for a few months of the year. For most of the year, there was minimal work for serfs and non-artisan peasants to do. The work that they did do was cognitively simple, and once mastered a single time would never have to be altered or relearned. Life may have been monotonous, but monotony brings simplicity, and reliance on one's neighbors brings the comfort of community
Love your posts, but correction here for the sake of knowing our history. Slavery was very much the norm in ancient Europe, ancient Mediterranean including andcient Greece and Rome, and north African regions for thousands of years. In the major cities of classical ancient era, such as Rome, Athens, Alexandria, Rhodes, etc, there were at times more slaves per capita than free men. The victors of massive war campaigns that would last years brought back not only precious metals, religious relics, and supplies, but also an overwhelming number of slaves who were prisoners of war and forced into labor. This was one of the main reasons for the eventual fall of Rome, an over-abundance on slaves to cultivate vast territories that they cared little about while the aristocrats migrated to the inner cities.

Civilizations acquired, depended on, and lost control of slaves on a regular basis and massive scale. (history is a study of mine)
 
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erg923

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As an aside, well-trained psychologists are the people -least- likely to mindlessly apply rating scales.
Self-efficacy, "Sac up", show me, measure it, ROI, industry best practices, MI, least intensive level of care necessary. Music to my (managed care) clincal psychological science ears. :)
 
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So, @psychacad , let's put anything quantitative aside for a minute to respect possible allergies. Say you did succeed in doing something that increased a patient's sense of community. Arguendo whatever you do works. How would you know that it had? How would you know if it didn't work? How would you tell the difference?

I think if you can lay something out we can understand where you're coming from a little better.

Be super suspicious of the impulse to say you'd just know or intuition, because that impulse is always going to give you the answer you want to be true regardless of the facts of the matter.

As an aside, well-trained psychologists are the people -least- likely to mindlessly apply rating scales.
I would use a combination of black magic and telepathy.

In all seriousness, this isn't the point at all. I understand missing it once, twice, but I explained several times, hence my suspicion that erg23 is trolling. Also a great deal of shifting sand.

But to answer your question, as hilariously condescending as it is, it's the things that erg23 mentioned which I agreed with (i.e inquire about their patterns of relationships, collateral, getting a job, community involvements, attending groups, personal report...etc). LOL.

The point though is that we don't need a "standardized measuring instrument" to justify an intervention. These don't solve our inherent problems with measurements and accuracy anyways, littered all over psychiatry. Heck, DSM which is the standard of care, is not based on "standardized instruments". But the impulse though is that since they are associated with "science", people tend to think that this is synonymous with objectivity. it is absolutely not.
 
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Mad Jack

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Love your posts, but correction here for the sake of knowing our history. Slavery was very much the norm in ancient Europe, ancient Mediterranean including andcient Greece and Rome, and north African regions for thousands of years. In the major cities of classical ancient era, such as Rome, Athens, Alexandria, Rhodes, etc, there were at times more slaves per capita than free men. The victors of massive war campaigns that would last years brought back not only precious metals, religious relics, and supplies, but also an overwhelming number of slaves who were prisoners of war and forced into labor. This was one of the main reasons for the eventual fall of Rome, an over-abundance on slaves to cultivate vast territories that they cared little about while the aristocrats migrated to the inner cities.

Civilizations acquired, depended on, and lost control of slaves on a regular and massive scale.
Yeah, I kind of had to clarify that I was really thinking about a very specific point and place in time. That was my bad for over generalizing
 

erg923

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The point though is that we don't need a "standardized measuring instrument"
There is no such thing as a "subjective" measuring instrument.

If it is not "standardized" how is it reliable? If it not reliable, what does it mean? If it is not reliable, how is it valid?
 
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clausewitz2

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I would use a combination of black magic and telepathy.

In all seriousness, this isn't the point at all. I understand missing it once, twice, but I explained several times, hence my suspicion that erg23 is trolling. Also a great deal of shifting sand.

But to answer your question, as hilariously condescending as it is, it's the things that erg23 mentioned which I agreed with (i.e inquire about their patterns of relationships, collateral, getting a job, community involvements, attending groups, personal report...etc). LOL.

The point though is that we don't need a "standardized measuring instrument" to justify an intervention. These don't solve our inherent problems with measurements and accuracy anyways. Heck, DSM which is the standard of care, is not based on "standardized instruments". But the impulse though is that since they are associated with "science", people tend to think that this is synonymous with objectivity. it is absolutely not.
The post you initially responded to did talk about measuring outcomes, but I just looked back - it literally said nothing about rating scales. Read it if you don't believe me. That was initially your contribution it appears.

What you lay out for how you would determine if someone is building a stronger sense of community sound like a set of facts about the world that are correlated with but not isomorphic to the thing you think should be promoted. They may even be discrete facets of the thing itself.

Sounds a hell of a lot like empirically-keyed measurements to me (if significantly less formal)...

Since at no point did @erg923 or...anyone else I can see argue for determining success or failure of interventions entirely or chiefly on the basis of standardized rating scales, and you agree that to find out if something is working, you should -take some measurements-, what precisely is your objection?
 
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The post you initially responded to did talk about measuring outcomes, but I just looked back - it literally said nothing about rating scales. Read it if you don't believe me. That was initially your contribution it appears.
It specifically mentioned measurements through standardized instruments. The post is already quoted. Here again: " How do you measure a "stronger sense of community"? And if it's not measurable, what's the point of insisting that it's "better" or "worse"? These statements are basically meaningless. If it is somehow measurable (by standardized instruments, etc), why aren't you measuring it? "

And see above, I was right on the trolling.
 

clausewitz2

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It specifically mentioned measurements through standardized instruments. The post is already quoted.

And see above, I was right on the trolling.
Nope, here it is:

"Treatment goals should be measurable (anything that exists can be measured...that's the definition of exists), as well as realistic/obtainable at each stage of psychiatric/psychological treatment. That was like day 2 in my Ph.D. program. Otherwise, its just your opinion/point of view. Which is subject to enumerable cognitive biases and fallacies. This is not new, and a bit sad that a physician would have to reminded otherwise"

Your post started with a comment about day 3 of your program and flaws of rating scales, a weird comment indeed if it wasn't keying off this.

There's no trolling here, I assure you. I think regulars on this forum can assure you I am earnest well past the point of fault.

Also, if it is something for which a standardized measure exists, why do you decline to use that information?
 
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Nope, here it is:

"Treatment goals should be measurable (anything that exists can be measured...that's the definition of exists), as well as realistic/obtainable at each stage of psychiatric/psychological treatment. That was like day 2 in my Ph.D. program. Otherwise, its just your opinion/point of view. Which is subject to enumerable cognitive biases and fallacies. This is not new, and a bit sad that a physician would have to reminded otherwise"

Your post started with a comment about day 3 of your program and flaws of rating scales, a weird comment indeed if it wasn't keying off this.

There's no trolling here, I assure you. I think regulars on this forum can assure you I am earnest well past the point of fault.
What you're quoting here isn't what started the discussion. That was a reply to my post which was a reference to sluox's mention of standardized instruments as necessary for any intervention (which was again quoted in my earlier post). Hence, my point has been all along the way about that. I understand this may not have been clear at first. But this is the third, fourth time, it's being cleared. I disagree with you on the trolling, and we'll leave it at that.
 

clausewitz2

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What you're quoting here isn't what started the discussion. That was a reply to my post which was a reference to sluox's mention of standardized instruments as necessary for any intervention. Hence, my point has been all along the way about that. I understand this may not have been clear at first. But this is the third, fourth time, it's being cleared. I disagree with you on the trolling, and we'll leave it at that.
Can't believe I'm saying this, but what would be objectionable about taking some combination of the factors you mentioned when you'd be considering whether your intervention worked, weighting them in some way, norming them on whatever population is relevant, and then using this to assess how well your intervention is working?

Even the phenomenological psychiatry people use stuff like EASE nowadays.
 

erg923

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Can we just agree that it's Odeon (by Panther). And that 60% of the time it works every time?

I mean, its as logical as saying we don't need a standardized measuring instruments
 
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Can't believe I'm saying this, but what would be objectionable about taking some combination of the factors you mentioned when you'd be considering whether your intervention worked, weighting them in some way, norming them on whatever population is relevant, and then using this to assess how well your intervention is working?

Even the phenomenological psychiatry people use stuff like EASE nowadays.
It's not strictly objectionable, but it isn't NECESSARY to implement an intervention - which was the point being made. As I said, I'm not opposed to utilizing standardized rating scales when your clinical judgement calls for them and you can interpret them in the right context. Hope it's clear now.
 
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Bartelby

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Coming back to the original topic, Saving Normal by Allen Frances presents a very interesting view on one aspect of the problem the OP describes. It is written by the chair of DSM-IV and makes the case that we are medicalizing normal experiences and behaviors.
 
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birchswing

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Coming back to the original topic, Saving Normal by Allen Frances presents a very interesting view on one aspect of the problem the OP describes. It is written by the chair of DSM-IV and makes the case that we are medicalizing normal experiences and behaviors.
I was reading about the new proposed RDoC, and part of it (if I understand this correctly) is that they are trying to document not just biological issues that lead to abnormal behavior/health but also the biology that explains normal behavior/health--across the entire spectrum.

This is really off topic, but in reading about the RDoC, they made it sound like it was necessary to create it because there was such a huge body of biology knowledge that is currently inaccessible because there is no framework to process it. That struck me as both intriguing but also a bit mystifying. They're sort of saying there might be something important in the research they've done, but they don't know it yet? What might lead a researcher to not realize they had made an important discovery?
 

thepoopologist

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Recently started my first job after residency here. It's outpatient, pretty good situation for me, they pay decently, give good clinical/administrative support, nobody's breathing down my neck to bang through 4 patients an hour. Most patients don't feel the need to talk to me for a full 30 minutes at every follow-up, which is fine. But I sometimes can't shake the feeling that I'm just giving people pills to help them cope with a reality that is 1) collectively designed by all of us and 2) dissolves any sense of community or interpersonal connectedness by design. Of course they're all anxious wrecks. They are living in artificial scarcity in a world of natural abundance, whether material, spiritual, etc.

I do see patients that I believe genuinely need whatever stuff they are taking. But for the most part, many of them are asking me to numb them, and the DSM gives me license to do so. I want to tell them that they don't need Zoloft, they need community. They need connection to the land. They need to re-sync with the rhythms of nature. Isn't this how most humans lived for the past 200,000 years?

I expect to be fully humiliated for this post on SDN. Do your worst!

If it was as easy as telling them that then I'd have everyone cured after the first visit.

Also:
 

thepoopologist

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My thought process during the short time I was outpatient

1. The person is here for a reason. What is the reason.

2. Is engaging them because of that reason more beneficial for them. Or is cutting them off immediately more beneficial. Also is cutting them off more beneficial in the sense that you can do better for your other patients. If you engage them, the reasons they keep coming might change.

3. Are meds in the picture. Are they long term or short term. Is the goal to continue or decrease or change them. What are the target symptoms and has there been any benefit or not.

Nowhere do I tell them that I'm dulling their minds and turning them into zombies, or that their state of mind is the product of systemic oppression, because maybe they're doing great on Zoloft and they tell me the reasons. On the other hand there are patients that do want to dull their senses because of crappy life syndrome or unending anxiety but they never ask for Zoloft, they ask for harder stuff and that's when I have to tell them what they're doing.
 

FatherPsychiatry

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Coming back to the original topic, Saving Normal by Allen Frances presents a very interesting view on one aspect of the problem the OP describes. It is written by the chair of DSM-IV and makes the case that we are medicalizing normal experiences and behaviors.
That is a great book. Helped me to understand the challenges I had in PGY3 outpatient year, where I felt I was medicalizing people's very appropriate stress. Daniel Carlat's Unhinged was another such book.
 

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I was reading about the new proposed RDoC, and part of it (if I understand this correctly) is that they are trying to document not just biological issues that lead to abnormal behavior/health but also the biology that explains normal behavior/health--across the entire spectrum.

This is really off topic, but in reading about the RDoC, they made it sound like it was necessary to create it because there was such a huge body of biology knowledge that is currently inaccessible because there is no framework to process it. That struck me as both intriguing but also a bit mystifying. They're sort of saying there might be something important in the research they've done, but they don't know it yet? What might lead a researcher to not realize they had made an important discovery?
It's not that the neurobiologists don't understand their own data, it's that the DSM structure has made it difficult to transmit that information to clinicians where relevant because it doesn't fit *their* knowledge structure.

Also the DSM was forcing research designs that were not based in biology. Inclusion/exclusion criteria for clinical research in psychiatry have traditionally relied heavily on DSM criteria, because that's the framework used by clinicians.

But the DSM criteria do not correspond to the domains identified by basic and translational neuroscientists, are really bad at identifying unique and mutually exclusive categories, have horrible inter-rater reliability, and rely on kludgy if-not-better-explained-by criteria to artificially reduce the broad phenotypic overlap across diagnoses. Hence the attempt with RDoC to create a new framework that would be more biologically based and recognize domains that span multiple DSM categories.
 
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I have to admit something here.

As a psychiatry resident, I was taught the RDoC by multiple PhDs in psych. Even read about it online.

And so far I still have no idea what RDoC is about. Yes yes I know the terms and I can say it too, but I heard from PhDs that RDoC would "be the next psychiatry revolution" and I always failed to see that lol
 

birchswing

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It's not that the neurobiologists don't understand their own data, it's that the DSM structure has made it difficult to transmit that information to clinicians where relevant because it doesn't fit *their* knowledge structure.

Also the DSM was forcing research designs that were not based in biology. Inclusion/exclusion criteria for clinical research in psychiatry have traditionally relied heavily on DSM criteria, because that's the framework used by clinicians.

But the DSM criteria do not correspond to the domains identified by basic and translational neuroscientists, are really bad at identifying unique and mutually exclusive categories, have horrible inter-rater reliability, and rely on kludgy if-not-better-explained-by criteria to artificially reduce the broad phenotypic overlap across diagnoses. Hence the attempt with RDoC to create a new framework that would be more biologically based and recognize domains that span multiple DSM categories.
That makes sense—I mean I don't know if anything will come of it, but it's logical at least.

I guess my question is then, do they think they are sitting on some silver bullet that once applied funneled into this framework will be actionable, or is this all blue skies research right now?

As an example (making this up) say that they find people who have been called ADHD actually have the same biological process as someone who has been called OCD and they're both related to short-term memory issues (I made all that up), and therefore some treatment in a completely different area like dementia would help both (again made up)?

Is it that they have such knowledge now and they're waiting to put it into this new system? Or has nothing yet been synthesized that would lead to such knowledge?
 

thepoopologist

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That makes sense—I mean I don't know if anything will come of it, but it's logical at least.

I guess my question is then, do they think they are sitting on some silver bullet that once applied funneled into this framework will be actionable, or is this all blue skies research right now?

As an example (making this up) say that they find people who have been called ADHD actually have the same biological process as someone who has been called OCD and they're both related to short-term memory issues (I made all that up), and therefore some treatment in a completely different area like dementia would help both (again made up)?

Is it that they have such knowledge now and they're waiting to put it into this new system? Or has nothing yet been synthesized that would lead to such knowledge?

As a non-academic.

There is no silver bullet. Rdoc is just a way of categorizing mental illness that supposedly respects what we know of its biological underpinnings. So instead of research based on intermittent explosive disorder, its research based on aggression, which can be seen in multiple DSM and medical dx's. It is also supposedly a way that future research will have more permanence since one of the other problems is that a lot of results based on DSM are negated by the fact that DSM revises their criteria in sometimes significant ways. It was created by Thomas Insel in reaction to DSM 5 in 2013, and the Allen Frances book everyone's referring to "Saving Normal" also came out around this time, politically and in their argument clinically there was a lot of pushback as to DSM 5's usefulness. My 2 cents is, sure why not, whole thing is needs to be re-examined anyway. DSM 5 is supposedly organized in a fashion that pays more attention to biological underpinnings - the criteria of some dxs have changed, the meta structure is slightly different - however it is still essentially a revision of the same thing, lists of syndromes. The explanation I heard about the poorer inter-rater reliability (that different psychiatrists may not all dx bipolar d/o in a patient for example) is that it was a reasonable sacrifice for improved validity (that the criteria for bipolar d/o was actually reflective of the syndrome seen in the disease). The practical problems are that DSM is used in legal system and used by health insurers to make big time determinations and so the research based on Rdoc better have some major breakthroughs before DSM can be done away with.
 
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My two sentence description of RDoc is that it's merely a research framework: instead of starting with DSM dx to search for biological correlates, you investigate different cognitive/behavioral/emotional/phenomenological domains separately and see where they overlap and where they don't, and how that actually corresponds to the DSM. The assumption is that the way DSM diagnoses are categorized does not match up to actual biological discrete disease categories and so this approach might lead to breakthroughs in the biological understanding mental illness. It has yet to have any clinical relevance.
 
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clausewitz2

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As a non-academic.

There is no silver bullet. Rdoc is just a way of categorizing mental illness that supposedly respects what we know of its biological underpinnings. So instead of research based on intermittent explosive disorder, its research based on aggression, which can be seen in multiple DSM and medical dx's. It is also supposedly a way that future research will have more permanence since one of the other problems is that a lot of results based on DSM are negated by the fact that DSM revises their criteria in sometimes significant ways. It was created by Thomas Insel in reaction to DSM 5 in 2013, and the Allen Frances book everyone's referring to "Saving Normal" also came out around this time, politically and in their argument clinically there was a lot of pushback as to DSM 5's usefulness. My 2 cents is, sure why not, whole thing is needs to be re-examined anyway. DSM 5 is supposedly organized in a fashion that pays more attention to biological underpinnings - the criteria of some dxs have changed, the meta structure is slightly different - however it is still essentially a revision of the same thing, lists of syndromes. The explanation I heard about the poorer inter-rater reliability (that different psychiatrists may not all dx bipolar d/o in a patient for example) is that it was a reasonable sacrifice for improved validity (that the criteria for bipolar d/o was actually reflective of the syndrome seen in the disease). The practical problems are that DSM is used in legal system and used by health insurers to make big time determinations and so the research based on Rdoc better have some major breakthroughs before DSM can be done away with.
The DSM categories were explicitly and deliberately designed to facilitate reliability and reproducibility, so that the same evaluators interviewing the same patients would reach the same diagnoses. This is why despite all kinds of thick descriptions of the phenomenology of various experiences, DSM criteria are overwhelmingly based on behaviors that can be observed or very broad reports of experience, no careful analysis required.

The fact that the kappa for MDD in the DSM V field trials was < 0.5 is even more damning in this respect.
 

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Anybody a fan of the moth podcast. Listening on npr tonight to a physicist talk about taking antidepressants and being numbed. Pretty critical of psychiatry.
 
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sloh

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Anybody a fan of the moth podcast. Listening on npr tonight to a physicist talk about taking antidepressants and being numbed. Pretty critical of psychiatry.
"The Decadent Society"

Listening to Soma

"Then, too, our age also offers more literal varieties of the lotus plant. Those well-behaved young people are the most medicated generation in history, from the drugs prescribed to ADHD-diagnosed boys to the antidepressants prescribed to anxious teens. Most of the medications are designed to be calming, relaxing, offering a smoothed-out experience rather than a spiky high. The increasingly legal drug of choice for adults is marijuana, which its advocates argue doesn’t inspire as much dangerous behavior as alcohol and hard drugs, making the prototypical stoner a far more harmless figure than the prototypical drunk. Even the evidence that it sometimes encourages aggression, though, might mean that the drug resembles the Internet in making a small minority more violent but tranquilizing the majority—so that for most people, a stoned society is more likely to be a dreamily contented society than an unstable or angry one, and the spread of pot will make an age of stagnation seem mostly like a chill good time. Then there is the opioid epidemic, which swept across the unhappiest parts of white America without anyone noticing because the drug itself quiets rather than inflames, supplying a gentle euphoria that lets its users simply slip away, day by day and bit by bit, without causing anyone any trouble.

“The drugs now conquering America are downers: they are not the means to engage in life more vividly but to seek a respite from its ordeals.” And unlike pot, opioids are antisocial drugs, offering bliss that’s best experienced in solitude."


-Ross Douthat
 

resident1985

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"The Decadent Society"

Listening to Soma

"Then, too, our age also offers more literal varieties of the lotus plant. Those well-behaved young people are the most medicated generation in history, from the drugs prescribed to ADHD-diagnosed boys to the antidepressants prescribed to anxious teens. Most of the medications are designed to be calming, relaxing, offering a smoothed-out experience rather than a spiky high. The increasingly legal drug of choice for adults is marijuana, which its advocates argue doesn’t inspire as much dangerous behavior as alcohol and hard drugs, making the prototypical stoner a far more harmless figure than the prototypical drunk. Even the evidence that it sometimes encourages aggression, though, might mean that the drug resembles the Internet in making a small minority more violent but tranquilizing the majority—so that for most people, a stoned society is more likely to be a dreamily contented society than an unstable or angry one, and the spread of pot will make an age of stagnation seem mostly like a chill good time. Then there is the opioid epidemic, which swept across the unhappiest parts of white America without anyone noticing because the drug itself quiets rather than inflames, supplying a gentle euphoria that lets its users simply slip away, day by day and bit by bit, without causing anyone any trouble.

“The drugs now conquering America are downers: they are not the means to engage in life more vividly but to seek a respite from its ordeals.” And unlike pot, opioids are antisocial drugs, offering bliss that’s best experienced in solitude."


-Ross Douthat
I was referring to passions and protons by Benjamin Lillie
 
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