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August 20, 2009 3:13 PM   Subscribe

The first ever North American study into prescribing diamorphine to addicts was published today in the New England Journal of Medicine. And the outcomes are positive. This is the latest in a growing line of research studies into diamorphine prescribing. The Netherlands and Switzerland have both completed major studies that showed extremely positive outcomes in treatment resistant populations. Germany has recently begun a study along these lines, and a British study is about to report it's outcomes any minute now.

How often must a positive outcome be replicated before something becomes part of mainstream treatment provision?
posted by PeterMcDermott (56 comments total) 5 users marked this as a favorite

 
How often? A lot more times still I suspect.

I take Oxycodone for pain, with a well documented cause, and even then it has been a nightmare getting adequate prescriptions even though it works well with few negative side-effects (if any) and no abuse on my part. The political roadblocks in place for prescribing opiates in general are huge, and the few doctors who have dared to do the right thing for their patients have often paid a steep price.
posted by glider at 3:31 PM on August 20, 2009 [4 favorites]



How often must a positive outcome be replicated before something becomes part of mainstream treatment provision?


Please don't do this.
posted by lalochezia at 3:31 PM on August 20, 2009 [2 favorites]


The political roadblocks in place for prescribing opiates in general are huge,

I think a Godwin corollary to invoking Michael Jackson is in order before I proceed with a comment.
posted by vectr at 3:43 PM on August 20, 2009 [2 favorites]


I suspect that since it helps people get off drugs without suffering (as much) or dying or getting their just desserts somehow (because, you know, they're addicts and anything that even whiffs of treating them as human beings just Isn't Done) there could be 10 million studies showing that this is the best treatment for heroin and it still wouldn't become a mainstream treatment option in the U.S.
posted by rtha at 3:47 PM on August 20, 2009


Which reminds me, at one of my recent doctor's appointments MJ was in fact raised as a warning regarding pain killer use/misuse.
posted by glider at 3:48 PM on August 20, 2009


Well then, if your Doctor raised it... ahem.
posted by vectr at 3:53 PM on August 20, 2009


Accidental drug overdose - from both legal and illegal drugs - now ranks second only to auto collisions among the leading causes of accidental deaths in the United States, surpassing firearms-related deaths.
posted by rtha at 3:54 PM on August 20, 2009 [1 favorite]


It's interesting that the entire rest of the internet is discussing this today as: Study finds best treatment for heroin addicts is...heroin.
posted by M.C. Lo-Carb! at 3:58 PM on August 20, 2009


And the outcomes are positive.

Well, yeah, except for the whole "let's give to heroin to heroin addicts part."
posted by dhammond at 3:59 PM on August 20, 2009


It's not really a treatment for heroin. It's just replacing street drugs with pharmaceutical drugs, in a supervised setting. While I'm all for that, and it kills the street drug trade and the risks of injecting street drugs as intended, it's going to read politically as "legalizing heroin," and thus test after test after test will lead exactly back to the looming negative campaign ad of the opponent of whatever politician supports this idea.

In other words, forget it.
posted by Devils Rancher at 3:59 PM on August 20, 2009 [1 favorite]


Just to make clear, "diamorphine" is another name for "heroin".
posted by Chocolate Pickle at 3:59 PM on August 20, 2009


Meh. The US is so caught up with neo-puritanical attitudes about how bad it is to get high. It's not my bag, but whatever. Just stay at home to do it so I don't have to deal with your freaked out trips in public or on the roads. As for this, I don't see how people can argue against harm reduction.
posted by GuyZero at 4:01 PM on August 20, 2009


I suspect that since it helps people get off drugs without suffering (as much) or dying or getting their just desserts somehow.

This is it.

These silly researchers are treating drug addiction as a health issue, when we know what it really is...a SIN, committed by bad, nasty people.
posted by Jimbob at 4:04 PM on August 20, 2009 [15 favorites]


I live in the city with the worst HIV epidemic in the US, and members of Congress, who unfortunately are anti-democratic and have the authority to affect our local laws, are working hard to kill our successful needle exchange program. Diamorphine doesn't have a chance.
posted by OmieWise at 4:08 PM on August 20, 2009


And the outcomes are positive.

Well, yeah, except for the whole "let's give to heroin to heroin addicts part."


Do you bemoan making condoms available to people who are having sex anyway?
posted by rodgerd at 4:14 PM on August 20, 2009 [5 favorites]


Just stay at home to do it so I don't have to deal with your freaked out trips in public

I can only assume you get your information on the effects of heroin from old episodes of Dragnet.
posted by item at 4:16 PM on August 20, 2009 [10 favorites]


How often must a positive outcome be replicated before something becomes part of mainstream treatment provision?

This isn't treatment, it's maintenance.

I'm all for decriminalization, taking drugs out of the streets, and treating it as a medical problem, but this study basically answers a sociological question with the not-very-earth-shattering conclusion that "if you give people heroin, they'll keep coming back."
posted by dhammond at 4:17 PM on August 20, 2009


This isn't treatment, it's maintenance.

Perhaps it depends on whether your perspective is that this is maintaining a level of drug use, or maintaining (containing?) its side effects, like diseases and crime.

To some people, condom distribution maintains a level of sexual behavior they are not comfortable with. From another angle, handing out condoms maintains lower rates of abortion and HIV and other STDs.

If the larger picture is reducing avoidable harm and suffering, then maybe it doesn't matter as much which perspective is held, in light of the positive consequences from taking action.

In other words, is trying to do something a certain way more important than what you're trying to accomplish in the first place? It's that balance of idealism and practicality, I guess.
posted by Blazecock Pileon at 4:25 PM on August 20, 2009 [6 favorites]


I can only assume you get your information on the effects of heroin from old episodes of Dragnet.

I kinda conflated ever drug in general with heroin there, ok, my bad.
posted by GuyZero at 4:26 PM on August 20, 2009


Just don't shoot up and drive is all I'm sayin'.
posted by GuyZero at 4:28 PM on August 20, 2009


: How often must a positive outcome be replicated before something becomes part of mainstream treatment provision?

Good question.

I'd say at least several million cases. I think a drug should be studied in at least, say, half a dozen countries, and over the course of at least ten years, before it's deemed 'safe and effective.' There's too much at stake to be anything less than extremely cautious; that's how drug testing should be, I think. I don't think people realize just how diverse the medical systems are in western countries; there's no reason at all to expect that a medical study done in, say, Italy has the weight or professional quality that a study done in the UK would. Every country that condones a drug should ideally be able to do its own testing; and the more independent testing that accumulates, the more information we all have about a drug and its effectiveness.
posted by koeselitz at 4:28 PM on August 20, 2009


As for this, I don't see how people can argue against harm reduction.

They are BAD PEOPLE and we are giving them drugs FOR FREE!
posted by benzenedream at 4:32 PM on August 20, 2009


The interesting thing about the Swiss program that I recall hearing is that it effectively made heroin an "old person's drug" -- after the drug was "de-stigmatized", the users began talking about their addictions openly, not fearing legal repercussions, and it changed from being a racy, exciting underground thing, to one similar to kidney dialysis, where you've got to sit and wait for a few hours while you get your drug.

I really wish the U.S. policymakers weren't so willing to say, "yes, but isn't there some way we could punish these people?" when it comes to harm reduction.
posted by boo_radley at 4:35 PM on August 20, 2009 [5 favorites]


Never. There are too many American authorities invested in the drug war. We will have to wait for them all to die, slowly, from cancer, in terrible pain from under-medication for pain.
posted by bad grammar at 4:37 PM on August 20, 2009 [5 favorites]


We've been studying diamorphine for 135 years. It's not like we're going to suddenly discover it causes cancer or something. This study is more about addict behavior, not so much heroin itself.
posted by ryanrs at 4:41 PM on August 20, 2009


Just don't shoot up and drive is all I'm sayin'.

Now you tell me.

Actually, back in my shooting up days I'm ashamed to admit I did this all the time. Really fucking stupid and I'm lucky the worst things that happened to me were a couple of single car fender benders and one arrest for nodding out in a 7-11 parking lot with my works sitting out in the open.

As for heroin maintenance programs in the states, I wish it were otherwise, but no goddamn way will it happen during any of our lifetimes. Heroin junkies are stigmatized arguably worse than any other type of addict, which is ridiculous considering how low-profile most are. The drug alone seldom kills - it's dangerous misuse that could be greatly reduced by maintenance programs.
posted by item at 4:42 PM on August 20, 2009


...that kills.
posted by item at 4:43 PM on August 20, 2009


How often must a positive outcome be replicated before something becomes part of mainstream treatment provision?

I don't know. I really don't. There's no method to the madness.
posted by motty at 4:43 PM on August 20, 2009


I scream, you scream, we all scream for diacetylmorphine!
posted by Tube at 4:48 PM on August 20, 2009


This isn't treatment, it's maintenance.

It's both: maintenance treatment is treatment. What you probably wanted to say is that this is maintenance, not a cure. Unfortunately, medical science at this time can provide no broadly reliable cure for addiction, as it can't for a number of other conditions. So maintenance is what we've got-- the perfect is the enemy of the kinda OK in this situation.

The study enrolled patients who were previously unsuccessful at treatment with methadone or other modalities. From the study data tables, a grand total of three participants were abstinent at the end of the study period, two in the methadone group and one in the heroin group. This represents less than two percent of either group, and there's no way there's a statistically significant difference between the two in this measure. This is reflected in the outcome measures that were chosen: abstinence from illegal drug use and abstinence from other illegal activity. In their pooled statistic at least, heroin represents the superior therapy. So in terms of a maintenance therapy, where the outcomes measured can be reasonably translated to harm reduction for the addict, and in the second case society as a whole, heroin makes sense as a second-line maintenance after methadone.

One caveat is the probability of adverse events (i.e. overdoses), which was much higher in the heroin treatment group. However, proponents of the heroin approach would argue that the clinical setting of administration reduces the risks associated with overdose, an argument which seems reasonable to me.

The associated editorial is interesting in that it addresses long-term shifts in treatment policy both in legal and medical terms, pointing out how different countries have addressed treatment for addiction. The United States is as you'd expect strongly on one side of this conversation from a legal standpoint, but it's interesting to see the continuum that occurs in the European countries.
posted by monocyte at 4:59 PM on August 20, 2009


Anyone mention yet that maintaining addicts on medical heroin would cost substantially more than maintaining them on methadone? No? Probably nothing.

This isn't treatment, it's maintenance.

Sure, but so is methadone, which is what it's being compared to. The study suggests that people on heroin maintenance are doing less street drugs and committing less crimes than people on methadone maintenance, and staying with the program longer.. The other argument is a little softer, it would be nice (though probably difficult) to quantify it: that if people are in a medical system longer they may be more likely to ultimately seek treatment to actually get off drugs.

And yes, I would imagine in America (at least) any rational discussion of it where that discussion would actually matter would have a very tough time not being derailed by the whole "you're just giving heroin to heroin addicts" dismissal.
posted by nanojath at 5:22 PM on August 20, 2009


This isn't treatment, it's maintenance.

So, um, insulin for diabetics, not treatment? Addiction is *not* defined as being physically dependent on a drug, otherwise all pain patients on long term opioids, many people on antidepressants and many people on blood pressure meds are addicts.

Addiction *is* defined as compulsive use despite negative consequences (summary of DSM definition)-- and the people in the heroin trials aren't having negative consequences, the consequences are positive. So, while they may be drug dependent, they aren't actively addicted any more if they aren't using on top.

We don't know if these people had a pre-existing deficit in their opioid systems, we don't know if being on opioids long-term has made them unable to adjust to life without them, we don't know if heroin is, say, treating their depression. But whatever the case is, even the Betty Ford Center now recognizes that recovery doesn't have to mean abstinence: if you are no longer having negative consequences from your addiction, you're in recovery even if you're on maintenance.

and p.s. Propofol, which seems to be what killed Michael Jackson, isn't an opioid. If he'd overdosed on an opioid, naloxone would have brought him around and if his doctors *didn't* have naloxone on hand given what he was taking and was known to be up to, that would be almost as bad malpractice as giving propofol as a sleeping aid is. Almost.
posted by Maias at 5:25 PM on August 20, 2009


I'm glad they are going with the "diamorphine" label instead of "medical heroin." because the latter would really screw it up with the gateway-drug folks against medical marijuana.
posted by Houstonian at 5:25 PM on August 20, 2009


How often must a positive outcome be replicated before something becomes part of mainstream treatment provision?

Endlessly. Here in the socialist paradise of Canuckistan, the city of Vancouver has been operating a safe injection site for years. As far as I know, every study has shown it to be a rip-roaring success.

Nonetheless, the Harper government [spit!] is doing its damnedest to kill the program. And, by extension, doing its damnedest to kill addicts instead of rehabilitate them.

Fuck Stephen Harper.
posted by five fresh fish at 5:43 PM on August 20, 2009


The Vancouver program, btw, is one in which registered nurses and drug counsellors are on hand, providing clean needles, teaching safe injection practices and — this is the important part — available to drug users who want to kick the habit.

Surprise, surprise, it turns out most people don't want to be addicted. And given an environment in which they meet people who can help them, face to face, and develop feelings of safety and opportunity, most addicts end up asking for help.

It is ugly and stupid to shut down these sorts of programs, especially without offering a replacement program that will be as or more effective.

Can I spit on Stephen Harper again for being an ugly and stupid man? Hell, yes: Stephen Harper [spit].
posted by five fresh fish at 5:53 PM on August 20, 2009 [1 favorite]


This isn't treatment, it's maintenance.

So we should cut of retrovirals to AIDS patients because they're not gonna be cured any time soon? Insulin to diabetics? Ventolin to me?
posted by rodgerd at 6:26 PM on August 20, 2009


Oxygen to them?

Good god, it is time rational people quit allowing irrational people to make decisions that affect our Entire. Freaking. Society.
posted by five fresh fish at 6:29 PM on August 20, 2009


So we should cut of retrovirals to AIDS patients because they're not gonna be cured any time soon?

Reading comprehension's not your strong suit, huh?
posted by dhammond at 6:32 PM on August 20, 2009


Many professionals believe one's brain chemistry is significantly - if not permanently - altered by even brief exposure to recreational opiate use. (I'd agree. Cocaine use, as well.) See: Dopamine. So have some pity on addicts: heroin is a bitch to kick, and we all have different needs based on our brain chemistry, even if unwise choices may have played a part in the state of one's mental affairs.
posted by kozad at 7:20 PM on August 20, 2009


Reading comprehension's not your strong suit, huh?

My reading comprehension's fine. I'm trying to work out if it's your faculties for logic or compassion that are fucked.
posted by rodgerd at 7:21 PM on August 20, 2009


Item:I can only assume you get your information on the effects of heroin from old episodes of Dragnet.

You're pretty high and far-out, aren't you?
posted by dr_dank at 8:33 PM on August 20, 2009


I wish the FPP specified that the addicts in question are heroin addicts. I somehow doubt a similar outcome would result from researchers doling out diamorphine injections to people trying to kick caffeine. (There actually aren't any treatment drugs proven to be effective for stimulant addiction.)

I think a drug should be studied in at least, say, half a dozen countries, and over the course of at least ten years, before it's deemed 'safe and effective.' There's too much at stake to be anything less than extremely cautious; that's how drug testing should be, I think.

But at the same time, holding back a promising, potentially life-saving drug for years just for the sake of being cautious might be just as damaging as releasing it too soon. Pronouncing a drug completely safe and handing it out like candy is one thing, but if a drug is proven to be effective, it's hard to justify denying it to someone just because every possible adverse effect hasn't been catalogued. It's a tough call.
posted by granted at 8:35 PM on August 20, 2009


How often must a positive outcome be replicated before something becomes part of mainstream treatment provision?

Never! 'Cuz we're all tuff and we're gonna kill alla them drug dealers.
posted by telstar at 8:35 PM on August 20, 2009


This isn't treatment, it's maintenance.

So we should disregard something that might make someone's life better because it won't make their life better enough?

It may not be what you're hoping for, or what any of us hope for, but it's what we have right now.
posted by granted at 8:41 PM on August 20, 2009


I'm trying to work out if it's your faculties for logic or compassion that are fucked.

Well, I've already said that "I'm all for decriminalization, taking drugs out of the streets, and treating it as a medical problem," so I'm not really sure what the confusion's about.

As for your other point, comparing an addict's desire for heroin to a diabetic's need for insulin or an AIDS patient's need for retrovirals is a poor analogy. Unlike barbiturate withdrawal, heroin withdrawal isn't inherently dangerous or life-threatening. Denying someone heroin (which, again, I am not even advocating) doesn't inherently pose a threat to one's well being.
posted by dhammond at 9:04 PM on August 20, 2009


I think you need to understand that every intelligent drug policy decision in America -- lots of different intelligent social policy decisions, actually -- have to swim upstream against social conservatives that would actually rather have a less humane society that pays more money to maintain a set of ineffectual policies because those policies better fit their ideologies. On some issues you can get them on the lowering tax payer cost aspect of the evidence supporting harm reduction, but even then a lot of them would rather just continue spending more on law enforcement instead.
posted by The Straightener at 9:08 PM on August 20, 2009 [7 favorites]


What invariably enrages me is that so many people in the US think that it's morally repugnant to get high using a chemical.

It doesn't matter if the drug itself is totally safe; it doesn't matter if it you do it in your own house; it doesn't matter if you don't have kids; it doesn't matter if you grow/make the drug yourself; it doesn't matter if you don't own a car; it doesn't matter if you make a million dollars a year; it doesn't matter if you've never missed a day of work; it doesn't matter if it improves your art; it doesn't matter if you're depressed; it doesn't matter if your job's stressful; it doesn't matter if your dad just died; it doesn't matter if you've just cured cancer.

To these people, your state of mind is their fucking business.

Tell you what: I'll stop getting high when you stop believing in invisible superheroes. Until then, it's about the only way I can fucking cope with your certifiable insanity.
posted by Netzapper at 9:17 PM on August 20, 2009 [9 favorites]


Considering there are still health insurance agencies which consider kidney and liover transplants to be "experimental", I must agree: More times than would make it practical!

Thank goodness, to an extent, we can get off label uses approved! Psychosis...
posted by Jinx of the 2nd Law at 9:32 PM on August 20, 2009


I think the better prospect long term as far as new treatment options here in the states is the 30 day naltrexone injection they've been working on here at UPenn. Once detoxed and injected with this form of naltrexone an addict won't be able to get high on opiates for 30 days. Also, the study participants are provided with a card that has a direct number to the doctor monitoring the program who is available to provide guidance to doctors providing pain treatment to people on naltrexone in the event that they suffer a catastrophic accident or something. I'm not saying it's the right or best option, I just think it dovetails better with the abstinence oriented mindset in the states and once finally FDA approved will meet less resistance to broad implementation. A lot of people on methadone are on it to get through the criminal justice system and if the criminal justice system decides that naltrexone is the way forward once it's approved, you might start to see a major changeover. A lot of addicts might not want to be opiate blocked every 30 days, but if it's a condition of their parole or probation or a part of the plea deal keeping them from doing time, they may change their minds. The drug court I work for just had a major training on this, so this isn't just a hypothetical scenario I cooked up.
posted by The Straightener at 9:43 PM on August 20, 2009


Prescription heroin has a very long history in this country, as the NEJM editorial describes. It's no longer available because of politics, not science. This study shows, as have all the other ones, that prescribed heroin, in a clinical setting, improves people's quality of life, reduces the harms in their life caused by opiate dependence, reduces the costs to society of their opiate dependence, and works better than existing treatments for many people. Trial participants in the heroin/diacetylmorphine arm had better outcomes on pretty much every measure. Methadone is great for what it does, but it doesn't work for everyone, and for those people, prescribed heroin should be available.

I do think that we will have clinical trials of prescribed heroin in the US within 10 years. It took Canada 12 years to get the North American Opiate Medication Initiative (NAOMI) going. We can do it in less time. I believe that public opinion is starting to shift on these things. It will take a little less cynicism and a lot of work, but it can be done.

So, true story, I was sitting in a talk this afternoon, when I got a text telling me to check out this thread. Why? Because the presentation was one of the NAOMI researchers, who worked on this study, talking about the results. A little too much synchronicity for me, thanks. Stop stalking me, Metafilter!
posted by gingerbeer at 10:05 PM on August 20, 2009 [2 favorites]


It's also worth considering that a big difference between methadone and insulin or HIV meds is that people on insulin don't have to go to a controlled environment each morning to take their medication, and they won't be cut off from their medication and forced to reapply to receive it if they miss a dose three days running. There are other big differences in the reality of dispensing methadone versus other medications; for instance, there is only one agency in Philly that is allowed to provide methadone in the prison system, and arranging for a client to receive methadone in prison typically takes 7 days as there are so many hoops to jump through in order to make it happen.

Of course, one solution would be to relax the controls on methadone to make its administration less like a controlled substance and more like a medication, but the law enforcement types will jump in here to point out that there is a black market for the drug and its diversion potential creates a public safety risk that outweighs an addict's right to have methadone more available in the community. These conversations on Metafilter almost always lack this opposite perspective, which I'm not saying is right, but is a big part of the systems where these types of decisions are going to be made, where the discussion over the adoption of new drugs like diamorphine will be moved either forward or backward. At every training I've had on Methadone, Suboxone, Naltrexone, etc. there are reps from the ADA's office, sometimes the head of Philly's narcotics division of the ADA herself, hammering the presenter with questions about what the public safety risks for these drugs are.

These people have the political clout to stall out the implementation of these new drugs. This is in fact happening right now with Suboxone. Suboxone is only a partial agonist, and even contains an opiate blocker. It's impossible to get high off Suboxone by increasing the dose, its overdose potential is basically nil. But it's still nearly impossible to get from a private doctor, and is still very heavily controlled in the few programs that can prescribe as a part of a treatment regimen.

This is the environment that diamorpine is going to be swimming upstream in.
posted by The Straightener at 6:43 AM on August 21, 2009 [3 favorites]


If we use diamorphine as part of a treatment regimen, what are the other parts? I can see that this will reduce crime, HIV, and overdoses, but how does it help the patient kick their addiction? Is it a tapering off method? Or, they receive other drugs to help them kick the habit in addition to the diamorphine? Or is there something else? Or, is this just "keeping the patient comfortable" and kind of giving up on helping them with the addiction problem?
posted by Houstonian at 6:59 AM on August 21, 2009


These conversations on Metafilter almost always lack this opposite perspective, which I'm not saying is right, but is a big part of the systems where these types of decisions are going to be made, where the discussion over the adoption of new drugs like diamorphine will be moved either forward or backward.

Personally, I think involving the police in the conversation is the wrong way to go. Or the criminal justice system in general. I agree that the criminal justice lobby is important to the discussion, but only insofar as they're an obstacle to be overcome.

The police are there to enforce our policy. Asking them about policy is a conflict of interest. It's only slightly less of a conflict of interests than asking prison guards about it. Both of these groups have a vested interest in criminalizing as much behavior as possible, and also in restricting liberty as much as possible--it makes their job "easier", they say.

What's more, without the black market, there would be almost no real crime associated with drugs. Do a lot of flour merchants get killed for their stash? You know a lot of alcoholics knocking over convenience stores for a drink? Legalize it all, and the worst you have is the PCP equivalent of public drunkenness--which, admittedly, is more severe, bug not by a whole lot.
posted by Netzapper at 12:26 PM on August 21, 2009


These people have the political clout to stall out the implementation of these new drugs. This is in fact happening right now with Suboxone. Suboxone is only a partial agonist, and even contains an opiate blocker. It's impossible to get high off Suboxone by increasing the dose, its overdose potential is basically nil. But it's still nearly impossible to get from a private doctor, and is still very heavily controlled in the few programs that can prescribe as a part of a treatment regimen.

This is the environment that diamorpine is going to be swimming upstream in.


This is an important point because the media almost always takes the side of the police here. The Baltimore Sun, for example, did an incredibly biased takedown of buprenorphine, the gist of which was that any diversion to the street of anything is a failure of regulation and is always bad.

In one article, they noted at the top that France had had 167 buprenorphine overdose deaths (all of which were actually deaths caused by drug mixes, not bupe alone)-- only later in the same article did they note that the introduction of buprenorphine had dropped overall overdose rates by 3500.

So, basically, *any* problem mean we rule out addiction drugs-- whereas if you had an antibiotic for a previously untreatable illness that killed 167 (when misused) but saved 3500, they would be singing its praises. If they held other meds to the standards they claim for addiction drugs, they'd never approve anything.

They completely fail to understand if people are using buprenorphine on the street instead of street heroin, doesn't matter that they aren't the patient it was prescribed for-- that substitution is good for public health because the pharmaceutical, mixed antagonist/agonist drug is less risky. I wrote about this here.
posted by Maias at 1:37 PM on August 21, 2009 [1 favorite]


Drug addiction and drug abuse are not properly considered criminal problems: they are healthcare issues and should be treated as such.

Of course, we don't treat them as such, because that's hard. Locking people up is easy.

Our society is sometimes a little too stupid for my tastes.
posted by five fresh fish at 1:51 PM on August 21, 2009


Are you people just going to sit there and let Obama's death panels force everybody onto this stuff?
posted by flabdablet at 7:04 AM on August 22, 2009


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