Drug liberalization ballot initiative
cost-effectiveness – minimum-benefit
This model is out of date. For our latest work on ballot initiative impact, see our best-guess cost-effectiveness analysis.
The main research product of Enthea so far is our cost-effectiveness analysis of drug liberalization as a mental health intervention. Details follow.
In a nutshell:
- If it polls well, a California ballot initiative that increases medical access to psychedelic drugs is a promising intervention in terms of DALYs averted.
- We estimate the cost-per-DALY-averted to range from $52,000/DALY to $442,000/DALY, with a best-guess estimate of $119,000/DALY. Full analysis available here.
- This figure is an estimate of the minimum expected benefit from a ballot initiative, not the total expected benefit. Many of the outcomes that matter most are not included in the analysis (e.g. pushing US federal drug policy away from a crime model & towards a public health model), as they are speculative and difficult to model.
The model is quite rough; we're very grateful for comments and critiques of it.
Major caveats & considerations:
- The model assumes that a ballot initiative polls well. Our current understanding is that if polling looks promising, then there's a high chance of the initiative succeeding. If polling doesn't look promising, there's minimal chance of success.
- Because of the binary distribution of outcomes, we didn't include a linear discount for “probability that initiative polls well.” Instead, the model is to be read as if the initiative polls well. If the polling isn't promising, a ballot initiative isn't worth pursuing at this time.
- An important takeaway here: polling on drug liberalization is important for assessing the tractability of an initiative. We plan to write more about this in the future.
The model does not include many of the benefits could plausibly result from increasing access to psychedelics, including:
- (for psychedelic users) Alleviation of mild depression and anxiety
- (for psychedelic users) Anti-addiction aid for behavioral addictions (gambling, online gaming, social media, etc.)
- (for psychedelic users) Improved psychological openness
- (for psychedelic users, speculative) Improved relationships between friends, co-workers, and significant others
- (for psychedelic users, speculative) Improved self-efficacy
- (societal) Reduced sentences for drug offenders
- (societal) Increased personal liberty (which appears to correlate strongly with self-reported life satisfaction) (a)
- (societal) Pushing US federal drug policy towards a public health model, i.e. away from a crime model
- Most of the modeled cost comes from costs of treatment, not costs of the ballot initiative.
- Costs of treatment are included to avoid confusions around charitable leverage (a).
- Costs of treatment are speculative, as psychedelic treatments aren't currently carried out. We estimated the cost-of-treatment by assuming that each patient would be treated under a protocol similar to the protocols of the pilot studies for psilocybin and MDMA (psychotherapy sessions before and after the dose, sitter present during the dose).
Q & A:
What intervention is being modeled, exactly?
- The analysis models the costs & benefits of a ballot initiative that increases access to psychedelics such that sufferers of depression, PTSD, alcoholism, and tobacco addiction can receive psychedelic treatment for these conditions in California.
- The analysis is intentionally agnostic re: the policy specifics of such an initiative. We are still learning about the strategic landscape here, and are currently unsure what specific initiative text would be best.
Why model mental health impacts if the largest benefits would come from other impacts?
- Minimum expected benefit: the mental health benefits from psychedelics are one of the least speculative benefits of liberalizing US drug policy. Our model gives the expected benefit a ballot initiative would achieve at minimum, if all other impacts were net zero. We plan to write more about other plausible benefits soon.
- Easier to model: other impacts are complicated by flow-through effects, etc. It would be very difficult to build a believable quantitative analysis of these impacts.
Is a ballot initiative cost-effective on the grounds of mental health benefits alone?
- It depends on what you mean by cost-effective.
- Public health interventions are generally considered “cost-effective” if cost-per-DALY is 1-3x gross national income per capita. GNI per capita in the US (a) is $57,500, so a “cost-effective” intervention in the US is between $57,500 and $172,500 per DALY. By this criterion, the mental health effects of a ballot initiative are cost-effective under best-guess and optimistic assumptions in the model (and not cost-effective under pessimistic assumptions).
- GiveWell top charities achieve much lower cost-per-DALYs with interventions in the developing world (on the order of $100s or $1,000s per DALY). However, these results rest on philosophical assumptions about population ethics (for AMF, discussion here (a) and here (a)) and empirical interpretations of the interventions' effects on happiness and income (for GiveDirectly and deworming interventions, some discussion here(a)).
- We don't want to take a position on these issues here; we raise them only to point out that arriving at apples-to-apples comparisons of heterogenous interventions is very complicated, and that there are reasonable assumptions under which GiveWell top charities are not extraordinarily cost-effective compared to other interventions.
- Mental health interventions have the benefit of directly increasing life satisfaction (which physical health and economic development interventions can only do indirectly).
- Further, our analysis is not attempting to model the full impacts of a drug liberalization initiative. Rather, it's attempting to model the minimum benefit we should expect from such an initiative, even if all the speculative benefits turned out to have no impact.
Why doesn't the model account for adverse effects of psychedelics, like bad trips?
- Contrary to common belief, psychedelics are quite safe, and very nontoxic – see the “Background and safety” section here (a), as well as the “Safety of psychedelics” section of Nichols 2016.
- Carbonaro et al. 2016 surveyed 2,000 psychedelic users who self-reported having a “challenging experience” with psychedelics. Despite the difficulty of the experience, 84% reported benefiting from the bad trip. Given this result, it's not obvious that bad trips are pathological.
One plausible strategy for increasing access to psychedelics is to decriminalize all drugs. Wouldn't all-drug decriminalization cause a major uptick in use of addictive drugs?
- It's definitely possible, though Portugal decriminalized all drugs in 2001 and didn't see an uptick in drug use.
- Assessing this impact is complicated – all-drug decriminalization would increase access both to addictive drugs (e.g. opioids) and psychedelic anti-addiction treatments for these drugs; it's unclear what the net impact of this would be.
Thanks to Chris Smith and an anonymous collaborator for their help building the model and thinking through relevant considerations.