Transplanting a Seattleite

Here’s an odd one.

https://www.science.org/content/article/war-prediabetes-could-be-boon-pharma-it-good-medicine

I have some mixed feelings about this. It quotes John Ioannidis favorably, and during the pandemic he was pretty vocal in ways that people got pretty mad about and I just don’t know what to think of him.

I was kind of startled by this paragraph:

“A 2011 study in JAMA examined health outcomes in women living in stressful, low-income housing projects who had been randomized into three groups: One got a voucher for better housing and help moving, one a voucher for moving to any area without help, and a control group got neither. Women who got the most housing assistance suffered the least obesity and diabetes—over 20 years, about 15% had become diabetic, compared with 20% in the control group.”

I landed in this article because I got curious about old people (>80 years of age, come on, that is old, don’t argue with me) taking diabetes medication that they did not need (that doctors had told them they did not need). I had heard about a friend’s father doing this, and then I recently learned that I knew someone more closely related to me who was doing this. I wondered if this was common and tried to design a search to answer the question, failed, but ran across interesting other things such as this.

I guess we really should focus on housing first.

Also, I ran across one of those cool Danish studies about olds taking diabetes medication, when (if) they discontinued, when they died, lots of interesting statistics.

Basically, if you are taking medication for your diabetes or prediabetes or whatever, it is in hopes of benefiting about 7 years in the future from reduced risk of wtf. If you are over 75, it’s not clear whether there is any hope of there being such a benefit, and if you are well into your 80s, the odds are very much against living long enough to enjoy it, even if there would be one if you did.

I gotta say, revelatory. I love shit like this. Perspective is all.

You are probably trying to avoid the news, so following this link right now could lead to problems for you.

https://www.nytimes.com/2020/10/27/health/meth-addiction-treatment.html

I will summarize in detail instead! OK, basically describe the underlying thing and sprinkle with my own opinions.

There is a thing called “contingency management” for treating addiction. If you are treating opioid addiction, medication management is the gold standard, but not for people who have trouble with stimulants, especially meth. If you have any familiarity with incentives, you know some of the following:

(1) Incentives can be “intrinsic” or “extrinsic”. “Intrinsic” incentives are good-feelings produced by something inherent in the action / behavior / activity. For example, if you love looking at a completed jigsaw puzzle, then this is an “intrinsic” reward for doing jigsaw puzzles. If someone pays you for doing a jigsaw puzzle (or cooks you dinner in exchange for helping with a jigsaw puzzle, or praises you for doing a jigsaw puzzle), this is an “extrinsic” incentive or reward.

(2) Contrary to literally everything you have ever heard about good parenting, uncertainty of extrinsic rewards makes them way more effective as incentives. If literally _every single time_ you feed the dog, your parent says, “You are a good boy, Johnny”, then the day the parent does not say that is the day you stop feeding the dog. But if your parent says, “You are a good boy, Johnny”, about 1 our of 3 times you feed the dog, and it is not predictable (like you sometimes get it twice in a row, and sometimes you go 5 times without hearing it), you will _never_ stop feeding the dog and you might get a new dog when the dog dies, in hopes that the parent will say you are a good boy, and you might even keep trying to get the good boy after you have moved out and/or the parent has died.

(3) Whenever people receive extrinsic rewards for an activity, whether it is consistent or inconsistent and _even if they originally did the activity for intrinsic reasons_, they tend to stop. So, if you turn your hobby into a job, and then quit getting paid, you will probably NOT go back to doing it as a hobby (there are exceptions). If you quit using meth because you are getting paid (unevenly) for not using, then when you quit using, you are at very high risk of relapse.

Some genius figured, hey, let’s set up some erratic extrinsic rewards for people passing their drug test / showing up for therapy or group / getting detoxed, etc. One version involves pulling pieces of paper from a bowl. Some say, “You are a good boy, Johnny”, some are $1, $10, $25, whatever. Usually, it is not cash cash, but constrained cash (card usable at a certain group of coffee shops in the facility, or one of those EBT type cards that does not let you buy alcohol or whatever with it. Maybe it is coupons for free egg mcmuffin or whatever.

Lots of people have lots of issues with this, and an obvious one is, while people do show up for their therapy, and they start to get the intrinsic benefits of therapy / group / whatever, an awful lot of people relapse when the extrinsic (money) rewards stop entirely. OTOH, keeping them going forever would probably be cheaper than what we do with these kinds of people, so there are people in favor of permanently instituting this as a recovery management tool.

I think the whole thing is pretty interesting, and since AA thinks you should go to AA meetings forever, and people on methadone are expected to be on methadone forever, and in general, people need money to live, contingency management (compensating people with really serious meth issues) seems like an entirely plausible strategy to me. I mean, we gotta eat to live, and people with Borderline Personality Disorder are expected to need maintenance therapy forever and all that is more expensive than this. If you want people to show up to take their drug test, paying them to do so is one of the cheapest ways of getting them to be there (arresting them and/or assigning someone and paying that person to track them down and drag their ass in are all more expensive). If on top of that, paying them erratically can get them to take the drug test _and not use drugs so they test negative_, well, bonus!