It’s possible that I shall make an ass of myself. But in that case one can always get out of it with a little dialectic. I have, of course, so worded my proposition as to be right either way (K.Marx, Letter to F.Engels on the Indian Mutiny)
InfoWars founder Alex Jones speaks to the media outside Waterbury Superior Court during his trial on September 21, 2022 in Waterbury, Connecticut. (Joe Buglewicz/Getty Images)
The daughter of the slain principal of Sandy Hook Elementary School has penned an op-ed shedding light on the impact of Alex Jones' perpetuation of conspiracy theories about the mass shooting.
In a piece published by Newsweek, Erica Lafferty, the daughter of Dawn Lafferty Hochsprung, recounted how it felt when conspiracy theorists like Jones began circulating claims about the shooting being a hoax. For Lafferty and family members of other victims, the shooting was anything but a hoax.
"Jones has been in my life for nearly a decade, but not by choice. I was in my late twenties when my mother, Dawn Lafferty Hochsprung, the principal of Sandy Hook Elementary School in Newtown, Connecticut, was killed on December 14, 2012," Lafferty wrote.
"Within days of the shooting, I heard people online saying it was a hoax; the whole thing had been staged and the families were acting. I just thought: 'How can people be saying this?'" Advertisement:
After doing her own research, Lafferty was able to learn more about Jones' history of spreading misinformation. "Over time, I began to connect the dots and figured out who this Alex Jones guy was," she wrote. "I realized much of this rhetoric was stemming from the lies and the hate he was spewing to his audience."
She also shed light on the harassment she was subjected to by Jones far-right audience. "The frequency of this harassment depended on Jones and how often he spoke about Sandy Hook," she wrote, "Whenever he spread his conspiracy theories the abuse amped up. There was sometimes a day or two that I would have some peace.
"Then there were months on end where every single day I would be called an actress or accused of making up my own mom. I would be sent pictures of the school or these doctored photos claiming it wasn't even open on the day of the shooting, all of these crazy things. It was constant, I literally couldn't keep up."
To make matters worse, the former principal's bereaved daughter also explained how Jones' actions stifled her ability to grieve. According to Lafferty, the highly publicized nature of her mother's death complicated things but Jones' attempts to dismiss what transpired made things far worse. Advertisement:
"It was the first time I had ever experienced anything like this. I had grown up in a small town and outside of sporting events I had never even been in the newspaper. So, to have to grieve the murder of my mom in such a public manner was a whole beast in itself. I was never given the opportunity to mourn her in my own way. I was forced to do it on this international platform."
Speaking about the lawsuit, Lafferty wrote, "I think taking legal action against Jones did further open ourselves up to his very extreme audience. I feel like we had to put ourselves out there and continue taking hits from him and his followers in order to take back our lives and stories, but also to protect other people, which I think is the best way I ever could have chosen to honor my mom."
We Should Try to Prevent Another Alex Jones
Oct. 16, 2022 OPINION ZEYNEP TUFEKCI
Alex Jones outside the courthouse in Waterbury, Conn., in September.
Credit...Kirsten Luce for The New York Times Opinion Columnist Zeynep Tufekci's Latest: Dive deep into the internet, technology, politics and society with Zeynep Tufekci's
Alex Jones achieved the epitome of despicability and now has been ordered to pay for it. His lies — that parents of children killed at Sandy Hook Elementary School in 2012 had been actors taking part in a government plot to manufacture a pretext for stricter gun control — were blatant. He did not subtly deceive through misleading framing or cherry-picked facts. He targeted parents of murdered little children, who faced a barrage threats; at least one family had to flee, moving away from where their child was buried.
Now a Connecticut jury has ordered Jones to pay $965 million in damages to several families for his egregious cruelty, adding to a Texas jury award of $49 million in August to another Sandy Hook family.
Defamation lawsuits can provide some relief to victims of horrendous lies, but they cannot fully repair the damage that has already been done.
For example, many Fox News hosts took to claiming voting machine fraud was a reason that President Biden had won the election. They also often invited guests like Rudy Giuliani or Sidney Powell who asserted the same. After Smartmatic, a company that provided voting systems to Los Angeles County during the 2020 election, sent a 20-page legal letter asking for a retraction of “false and defamatory statements,” some Fox News shows ran fact-checking segments, debunking their own lies. Since then, Smartmatic and other voting machine companies have begun defamation lawsuits against Fox News and others. Meanwhile, the lies are still accepted as fact by many supporters of Donald Trump.
Defamation and libel lawsuits can be misused: Companies or individuals with deep pockets can sue scientists who object to claims about their products or newspapers that expose their wrongdoing, for example. The costs of defending against such claims can have a deterrent and silencing effect. But that’s an argument for better protections against frivolous suits, not against holding liars accountable.
Defamation lawsuits are not an easy path to accountability. Plaintiffs must not just prove that statements were false, but also that they caused harm. In the case of public figures, plaintiffs must prove that the defendant either knew the statements were false or that they showed a reckless disregard for the truth.
But the key issue is, the current media ecology makes it lucrative to lie outrageously.
The extent of Alex Jones’s wealth is opaque, but a forensic economist who testified during Jones’s Texas trial estimated that his net worth, combined with that of Free Speech Systems (the parent company of his Infowars media network), is between $135 and $270 million. Jones put Free Speech Systems into Chapter 11 bankruptcy in August; the Sandy Hook families have challenged the legitimacy of that bankruptcy in court.
Jones got his start in talk radio peddling 9/11 conspiracies to great success. In later years, beyond his own webpage hosting his show, he found a home on platforms like YouTube and Facebook, where he could not only broaden his reach, but benefit from being recommended and amplified by the algorithms that prioritize “engagement” — which has often meant pushing inflammatory, tribalizing or conspiratorial content. Many supporters of Donald Trump were — and are — great fans. One comprehensive study from the Harvard Berkman Klein Center (where I’m a faculty associate) found that before the 2016 election, he was the 13th most shared source on Twitter among then-candidate Trump’s supporters. Between 2015 and 2018, his show averaged about $53 million in revenue annually.
In 2018, after outrage over the way social media sites amplified such content, Facebook, YouTube and Spotify, among other major sites, removed his show. But by then, his machinery was in place and, based on witness testimony and Free Speech Systems’ bankruptcy filing, his company continued making millions of dollars each year.
From what, you might wonder? In 2014, most of his then $20 million revenue came from selling supplements like “Super Male Vitality,” according to testimony Jones gave in a court case. After he was banned from major social media platforms in 2018, he expanded his sales, offering a 50 percent discount for at least one of his alleged testosterone boosters to “push back in the fight against globalist agenda” — a bargain at $34.95. Also available at the time was “Survival Shield X-2 — Nascent Iodine,” which Jones’s website describes as having been developed using “Thermodynamic Pressure Sensitive High Energy Sound Pulse Nano-Emulsion Technology.” A newer version of the product is described as derived from “ancient sea salts” found “thousands of feet below the Earth’s surface” and formulated “with our fellow patriots in mind.” Really, it’s a steal at $19.95, all major credit cards accepted.
During the Texas trial, a producer of his show testified that their online store generated over $165 million in revenue during a span of time encompassing a few months in 2015 and the period from 2016 through 2018, by selling survivalist gear, supplements, what-have-you. The trial also revealed that the families had pleaded with him for many years to stop airing lies about their murdered children, because they faced not just direct threats and confrontations, but people who said they’d defile their children’s graves. According to the families, Jones ignored them as those lies increased product and supplement sales.
One might think it’s just this one con man who found a lot of marks (a lawyer for Jones once called him a “performance artist” who is merely “playing a character”), but others have used the same approach.
Many viewers appear to have paid a huge price for that cynical disparagement of lifesaving vaccines.
A recent study in Nature found that areas with higher levels of Fox News viewership had lower Covid vaccination rates, which are associated with higher hospitalization and death rates. This impact of Fox News was independent of local health care capacity or even partisanship. Plus, much of this effect was concentrated on people younger than 65, who might have thought they were safer from Covid, the study authors noted, and perhaps more open to messages of vaccine hesitancy and refusal.
It’s become so easy to lucratively lie to so many people, and we have few realistic and effective defenses against the harms of deceptions like these, not just to individuals but to our society.
“Good speech” isn’t going to push out lies when viewership is so fragmented, nor is the solution “fact checks” of various levels of quality by institutions already not trusted by many.
There have been campaigns to get major social media platforms to act more aggressively to get rid of liars, but why should we trust them to decide who should be banned? What if political winds shift?
What’s the solution? No society can be constantly pulled at its seams like this and escape unscathed. The recent Jones verdict certainly did some damage to the industry of lucrative lying, and perhaps few are as deserving of this result than he is. But laws written for a different era cannot resolve the problems of our current media ecology.
There are no easy, quick solutions, but perhaps a starting point would be to make it harder and less lucrative to lie to huge audiences. Rather than pursuing legally dubious and inadvisable efforts to ban speech or define and target misinformation, regulations should target the incentives for and the speed with which lies can be spread, amplified and monetized.
There could also be new, careful versions of the “Fairness Doctrine” — which required mass broadcasters that essentially held a monopoly on the public sphere to present broader viewpoints on topics of public importance. It wasn’t a perfect solution, and it could be weaponized, but it recognized that “good speech” can confront bad speech only if there is access to the same audiences. Versions for the 21st century might involve a requirement that when blatant or harmful lies on issues of public importance are amplified, the people who are sent those lies are also sent corrections and further explanations.
But we should also work hard at making the rest of society work much better so that liars can’t do as much damage. I keep coming back to how people over 65 have higher rates of vaccination, despite higher Fox News viewership and some in that age group having a greater propensity to believe misinformation. That’s possibly because they are more motivated to brush off lies in light of the higher risk they face from Covid, but perhaps also because Medicare allows them to have medical providers they trust. Similarly, for example, regulating the supplement industry — a common vehicle for conspiracy and political grift — and having stricter standards on advertising claims might help, too.
The work of civilization is not just discovering and unleashing new and powerful technologies, it is also regulating and shaping them, and crafting norms and values through education and awareness, that make societies healthier and function better. We are late to grapple with all of this, but late is better than never.
The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips. And here’s our email: letters@nytimes.com.
Zeynep Tufekci (@zeynep) is a professor at Columbia University, the author of “Twitter and Tear Gas: The Power and Fragility of Networked Protest” and a New York Times Opinion columnist. @zeynep • Facebook
Monday, August 29, 2022
Costlier Medicare Advantage plans do not always offer better quality
Better metrics needed to help consumers make quality-focused choices
Enrolling in a highercost Medicare Advantage plan may not always get seniors better quality health care, according to a new RAND Corporation study.
Examining 15 different measures of quality among large representative samples of people enrolled in Medicare Advantage plans during 2016 and 2017, researchers found that plans that charged a higher monthly premium provided on average only slightly better care as compared to plans with no monthly premium.
Quality varied substantially within each premium cost tier studied, with high-quality care being observed among a number of plans in each of the cost tiers. More than 700 Medicare Advantage plans were part of the analysis.
The findings are published in the latest edition of JAMA Health Forum.
“Paying higher premiums is not necessary to receive high quality care from a Medicare Advantage plan,” said study lead author Amelia M. Haviland, a professor of statistics and public policy at Carnegie Mellon University and an adjunct statistician at RAND, a nonprofit research organization. “Seniors should look at metrics other than premium costs alone when looking for a Medicare Advantage plan that offers a high-quality of care, including direct measures of quality, such as Star Ratings.”
Health care costs are a concern for both consumers and policymakers. People enrolled in Medicare Advantage plans report that price measures such as premium costs and co-pays are their primary consideration when selecting a plan.
To examine the link between premium cost and quality, RAND researchers analyzed information about the care delivered to people enrolled in Medicare Advantage plans. About 40% of the enrollees were in plans with no monthly premium, while 6% were in plans with a monthly premium of more than $120.
Medicare Advantage plans provide coverage for hospital and physician services like traditional Medicare fee-for-service, but typically also offer additional services such as coverage for dental care and eyeglasses. In exchange for additional services and lower co-pays, members are restricted to in-network providers. More than one-third of Medicare enrollees choose Medicare Advantage plans.
The information used to measure the quality of care from Medicare Advantage plans included clinical quality measures based on administrative information such as medical charts involving more than 2 million enrollees. Those quality measures included items such as whether patients received recommended cancer screenings, whether high blood pressure was controlled and whether diabetes was treated adequately.
The analysis also examined surveys of more than 168,000 randomly sampled plan participants who were asked about their experiences with health care, prescription drug coverage and their plan. Those measures included the ability to get care, the ability to get care quickly and getting needed drugs.
Across most measures, people enrolled in the two higher-premium plan tiers reported similar or slightly better experiences on average than enrollees in the lower-premium categories. For example, people enrolled in the highest premium tiers were more likely to receive annual flu shots.
However, on one measure, lower-cost plans offered better care. People enrolled in lower-tiered plans received better care on average for osteoporosis than their peers enrolled in higher-premium plans.
Given that many high- and low-quality plans were found in each of the premium tiers we studied, the premium cost is a poor proxy for assessing the quality of a Medicare Advantage plan,” Haviland said. “Making plan quality information more accessible and salient to consumers is a key to reducing consumers’ costs while improving quality.”
Support for the study was provided by the federal Centers for Medicare & Medicaid Services. Other authors of the study are Sai Ma of Humana, and David J. Klein, Nathan Orr and Marc N. Elliott, all of RAND.
RAND Health Care promotes healthier societies by improving health care systems in the United States and other countries.
Association of Medicare Advantage Premiums With Measures of Quality and Patient Experience
Tuesday, February 15, 2022
CHRIS HEDGES: MASS POLITICS MUST BE ROOTED IN CLASS STRUGGLE
Jason Myles and Pascal Robert of THIS IS REVOLUTION speak with world-renowned journalist and activist Chris Hedges about the George Floyd uprisings, COVID politics, labor unrest, and the state of mass politics in the US today.
From the social upheaval embodied in Donald Trump’s presidency and the 2020 uprisings for racial justice to rampant corporate plunder and increasingly widespread labor unrest, the conditions for an organized mass political movement exist in the US. So, why hasn’t that movement come about yet? Is such a movement possible in the US today? If so, what role can the left play in mobilizing it?
As world-renowned journalist and activist Chris Hedges argues, “Part of the problem with the left [today] is that it’s too engaged in political theater, it’s not engaged enough in political organizing, and it often is not literate in the most important element before us, which is class.” In their latest interview for TRNN, co-hosts of THIS IS REVOLUTION Jason Myles and Pascal Robert speak with Hedges about the possibility of mass politics in our present moment, and about the hard work of building working-class solidarity. Chris Hedges is the former Middle East bureau chief of the New York Times, a Pulitzer Prize winner, and a columnist at ScheerPost. He formerly hosted the program Days of Revolt, produced by TRNN, and is the author of several books, including America: The Farewell Tour, American Fascists: The Christian Right and the War on America, and War Is a Force That Gives Us Meaning.
Pre-Production/Studio: Jason Myles Post-Production: Cameron Granadino
TRANSCRIPT
Jason Myles: Good morning. Good afternoon. Good evening. Welcome to another episode of This is Revolution podcast, in partnership with The Real News Network. If you like what you see with this partnership and you’d like to see more, then please remember to hit the like and subscribe button and, most importantly, hit that bell so you’re notified every time programming like this comes on The Real News. With that out of the way, let me bring in my homie, my dog, my co-host. You may know him as one of the writers for Black Agenda Report. You may know him as a writer for Newsweek. We know him on This is Revolution as the man of the mau-mau hour. He is the Pascal Robert. [applause]
Pascal Robert: Peace and greetings to The Real News audience, peace and greetings to all of our fans and subscribers. What’s going on, Jason Myles?
Jason Myles: It is always weird doing these shows, because we also want you guys to subscribe to our channel as well and watch what we do as well, but we always do things live. So we are constantly interacting. So it is a little strange to not have a chat, the new virtual studio audience, to interact with. But, slowly but surely, we are getting used to our new setup over here at The Real News. Are you excited for our guest today?
Pascal Robert: Very much so.
Jason Myles: We’ve tried to get this gentleman on the show. I think we’ve had on a few of his friends that have tried to help us. Thankfully, for our relationship with The Real News, we were able to finally get him on. Our guest is the Pulitzer Prize – I always have trouble saying that – Pulitzer Prize winning author and journalist, former foreign war correspondent for The New York Times, and he is the host of one of my favorite shows on RT, On Contact. He’s an activist. He’s a teacher. He is the Chris Hedges. [applause] Afternoon, Chris.
Chris Hedges: Thanks. Thanks for having me.
Jason Myles: Thank you for agreeing to come on the show. We’re really excited to have you, even though we don’t have our chat audience here that would be going crazy with questions and comments. Pascal, do you want to start it off with the first question? I know [crosstalk
Pascal Robert: Absolutely. Chris, you’ve been a long-time advocate and activist on the left. I want to ask you a question about the current moment that we are in. In the wake of the fact that we saw a massive online… Excuse me, public activism during the George Floyd protests, with cities all around the country seeing a level of activism that we had not seen since the late ’60s period, and with many voices on the left, particularly publications saying that that did not really translate into organizational movement politics involving the working class, there are some who have speculated that the age of mass politics, because of the hyper technological nature of society with social media, the caliber of popular culture and culture industry production we have, as well as the availability of very poor quality cheap food, has satiated the American body politic so much that we may be in the age where mass politics is obsolete. Can you address that question? Do you believe there’s any truth to the allegation that some on the left are making that mass politics has gone to its wayside in the contemporary moment?
Chris Hedges: Well, it hasn’t, but you touch on a very good point and it’s something that Sheldon Wolin raises in his book, Democracy Incorporated, that access to credit and cheap consumer goods form the role of essentially a political and a social pacifier. You’re very right about that. I asked Wolin before he died… He probably was our most important contemporary political philosopher, was the mentor to Cornel West and Wendy Brown, a lot of other great thinkers. If that access to cheap credit was cut off and if those cheap consumer goods – And we’re now, what’s inflation? Seven, eight percent – No longer became cheap, and this feeds into this system that he called inverted totalitarianism, and by that he meant all of the structures remain the same, the Congress, the courts, the press, but internally corporations have seized the levers of power. Would that perhaps produce a more traditional form of totalitarianism? He agreed. Then I think that’s how we got a figure like Trump, and all indications are that the Democrats are going to shellacked in the midterms.
Unfortunately, waiting in the wings are competent fascists like Mike Pompeo or Tom Cotton or others. We’re saved. People use the word coup for Jan. 6. It’s not that Trump didn’t want a coup, it’s that he was utterly incapable of orchestrating one. You don’t sit and eat Big Macs in front of a TV tweeting while your supporters are storming the Capitol if you want a coup. But someone like Mike Pompeo graduated first in his class from West Point. He’s really dangerous and really venal. Those people would actually carry it out, and then of course we’re getting a kind of administrative coup through the wrath of voting rights regulations that are designed, quite effectively, to lock out the poor people of color, Democratic supporters.
But I think we have to also note that this is a moment of nascent labor activity. You’ve had a series of strikes or union organizing or attempts at organizing at Amazon, Starbucks, Uber, Lyft, John Deere, Kellogg, the Special Metals plant in Huntington, West Virginia, owned by Berkshire Hathaway. I say that only because Warren Buffett has gotten a pass on all this stuff, the Northwest Carpenters Union, Kroger, teachers in Chicago, West Virginia, Oklahoma, Arizona –
Jason Myles: I think it’s all over the country, for that matter.
Chris Hedges: …Hundreds of nurses in Worcester, Massachusetts, the International Alliance of Theatrical Stage Employees. This has all been in the last couple years. The pillage on the part of the very rapacious ruling elite has now become so grotesque. I mean, Wall Street banks recorded record profits for 2021. They milked the underwriting fees from the Fed-based borrowing. They made massive amounts of money from mergers and acquisitions. What did they do with their profits? This is fueled by roughly $5 trillion in fed spending since the start of the pandemic. They used it for what they always use it for, which is to pay themselves massive bonuses and stock buybacks. You inflate the price of the stock and that increases the money that you are paid. This has been true in the defense industry, pharmaceuticals, oil, gas, all of which have had record profits. So we now [crosstalk]
Jason Myles: A practice that was illegal at one point in time.
Chris Hedges: …745 billionaires in the US have seen their net worth grow from $2.1 trillion to $5 trillion since March of 2020. Workers are pushing back. Kroger’s a good example. We can go into Kroger. People are not paid… This is true of Walmart. It’s true at major corporations, I think Walmart’s our largest employer. People, on average, in Walmart work about 28 hours a week, which puts them below the poverty line. So I think that mass politics are not dead, but I think that they’re rooted in the class struggle. I have great admiration, by the way, for the people who took to the streets, many with great risk given the lethality of our militarized police, in the wake of the George Floyd murder. But they didn’t come with a political vision, and they weren’t tied to that class consciousness which is essential, I think, for ultimately pressuring and, hopefully, overpowering and destroying the corporate state.
Jason Myles: Well, let me follow up with that same question about the George Floyd protests of the summer of 2020. How much of that do you think is COVID related? Because we were going through the lockdowns at that time. And how much of that do you think is Trump related, because Trump was definitely doubling down on his racist dog whistling at that time as well?
Chris Hedges: Well, I don’t know if it was COVID related, because people were out in the streets defying the pandemic. I mean, this was before the vaccine. So not only were they risking police retribution but they were risking the pandemic itself. The racist dog whistles by Trump, I mean, you’re talking about a dethroned or dispossessed sense of dethronement by the white working class which fuels this neofascist cult-like Republican party gathered around Trump. I don’t think that that was a major factor in… I think that the protest petered out – You’re probably better on this than I am – But kind of petered out. There was a kind of exhaustion within the protest movement itself.
Jason Myles: Well, the reason why I say COVID, I’m definitely talking about the lockdowns. We didn’t know how long we were going to be locked down. I think most Americans probably thought it was going to be a few months. We didn’t know we’d be looking at 2022. The numbers here in California are ridiculously high. I think we’re even hitting the original lockdown numbers here in California when it comes to infection. When I say COVID related, I mean that frustration of being locked down. I bring that up because, just across the way in Saint Paul a few years before, Philando Castile gets murdered on Facebook Live by police for a traffic stop in front of his girlfriend’s child. The cop actually shot into the car, luckily missing the child, and we didn’t have protests to this level. George Floyd also wasn’t the only person with a high-profile police murder. Who was the young lady in Louisville? I can’t think of her name right now, where the cops did a no-knock warrant on her. That had happened right before George Floyd as well. So, I guess, I’m saying, do you think it was a series of events that led to it? I don’t think it was [crosstalk]
Pascal Robert: Breonna Taylor.
Jason Myles: Breonna Taylor, yes.
Chris Hedges: It’s always a series of events. It’s also… There comes a point in which these kinds of police murders just gather so much weight that people can’t sit inside anymore and accept them, so, of course, people were on the street not just for George Floyd but for, largely, Black people in poor communities across the country who are just gunned down with impunity. So I think there was a cumulative effect that led to the protests. I think that was all there. But you’re right. There’s always a variety. I mean, I covered revolutions in Eastern Europe, I covered the civil war in El Salvador, I spent a lot of time in Gaza covering both of the two Intifadas or Palestinian uprisings. It’s always a series of forces that converge that create an uprising, some of which are economic. What triggers the uprising, you’re also right, is not an event that necessarily is unique in the sense that it didn’t happen in the past, but people have just had enough.
Jason Myles: In that moment where you have all these people mobilized, after you’ve destroyed police stations and the Arby’s and the McDonald’s, did the left lose an opportunity at that moment to truly organize?
Chris Hedges: Well, my sense for these protests is that they were more like flash mobs. Social media is quite effective at creating a flash mob. That’s very different from organizing. Let’s go back to the ’60s, the March on Washington or something. It’s very different from organizing a strike at Kroger’s. We have 8,000 workers now out on strike. Kroger is the fourth largest employer in the country. It’s a supermarket chain that pays its workers slave wages while its CEO, Rodney McMullen, made over $22 million, so doubling what he made in 2018. Kroger workers, like Walmart workers, the average salary is about $29,000. That’s about $16,000 below the $45,000 which most economists would argue is needed to sustain a household. It’s different.
Chris Hedges: I think part of the problem with the left is that it’s too engaged in political theater. It’s not engaged enough in political organizing. It often is not literate in the most important element before us, which is class. Yes, racism, which is always a byproduct of the class war and is used quite effectively to split the working class, that goes all the way back to the tenant farmers in the South, white tenant farmers who economically were not much better off than Black farmers but were fed this myth of whiteness and white superiority. I think it was Lyndon Johnson who said, if you can get somebody to feel racially superior, you can pick their pocket, which was essentially what happened and what happens. So I think the left has become captive to a kind of boutique activism about inclusiveness and multiculturalism. I’m not against any of this identity politics, but the core of resistance in a capitalist society is class. It’s class warfare. Unfortunately, we’re losing big time.
Pascal Robert: Well, I’d like to actually pivot off that question in terms of your last statement. One of the themes that we have on our show, This is the Revolution Podcast, is called the 50-year counterrevolution. The basic premise of that theme is that since the rise of Nixon in ’68, the 50-plus-year counter revolution is that the politics that we’ve seen in America and in the West generally has been a counterrevolution against the New Deal civil rights coalition, moving further and further in a reactionary right-wing direction, bipartisanly. Bipartisanly. One of the analyses that we make as a consequence of this 50-year counterrevolution is the loss of the concept of even challenging capitalism, which revives, after the 2008 crash, with the rise of Occupy, Bernie Sanders, and so on, so forth.
Pascal Robert: Do you think that the contemporary manifestation of what those call the left – Some would argue that we don’t have a left. We only have leftists. I’ve made that argument.
Jason Myles: [crosstalk]
Pascal Robert: …Is making some of the same mistakes of the new left in the 1960s in that it is not rooting its politics in working-class organization and the class makeup of this contemporary manifestation of a left is really made up of faculty lounge, university pedigreed-adjacent individuals, downwardly mobile professorial types who, quite frankly, are not really rooted in a working-class politics. Can we even make that argument about the new left in the ’60s in that posturing radicalism, as opposed to mobilizing the working-class as was done in the ’30s and ’40s, kind of led to a demobilization and the rise of Nixon hardhat riots, if you will?
Jason Myles: As I asked earlier on, when you divorce the movement from its soul, what movement do you really have left?
Chris Hedges: So there’s a lot there, and you raise several, I think, really important points. The left, the radical left let’s call it, the militants, the Wobblies, the old CIO, the Communist Party, which was very important to the working class, kind of written out of American history, was very powerful on the eve of World War I and very effectively crushed by Woodrow Wilson, especially through the use of the Sedition Act and the Espionage Act. People forget that this was then turned immediately on the left, not on German spies. Emma Goldman was deported under it, Eugene V. Debs, the head of the Socialist Party, was imprisoned under it.
Then in the ’30s, again, there was a real class consciousness. Again, the Communist Party was very important in terms of organizing. You’re right to signal the ’60s and it being different. I do think the ’60s were important, but I think that severance from labor was fatal. So you had the AFL-CIO under figures like George Meany and Lane Kirkland supporting Nixon’s war in Indochina and denouncing the hippies in the street. It was largely the working class and poor kids who were fighting the war in Vietnam. They couldn’t get the college deferments. They didn’t have the connections. 60,000 middle-class, largely white kids, fled to Canada, this kind of stuff. We had figures like Bill Clinton or George W. Bush all got deferments, Dick Cheney. They had ways to get out of it.
Now I was just a boy in the ’60s but my father was active in the antiwar movement. He was a veteran from World War II, had fought in North Africa and also in the civil rights movement. So I went to these events. It was actually in ’68, our house was a waystation where Yippies could crash on the floor on their way to Chicago. So this informed much of my childhood, so I think that the organizing, that’s when Ralph Nader organized his very effective consumer movement and, in fact, organized the first Earth Day. I think it was 1970. That’s when you saw the rise of Black power movements, the American Indian movement, feminists, SDS, which was the largest antiwar organization in the country before the Weather Underground. All these figures like [inaudible] destroyed it, in the same way that Huey Newton ultimately destroyed the Black Panther Party. These were important movements and empowering movements and they certainly frightened the ruling elites, which is why in 1971 you got the famous Powell Memo written by Lewis Powell which was the blueprint for the corporate or business interests to fight back. That’s where you get the phrase from the political scientist Samuel Huntington about America’s “excess of democracy.”
The civil rights movement is interesting because legally the civil rights movement achieved integration of Black elite figures, like Barack Obama, for instance, into the power structure, but didn’t address the underlying economic racism that kept the poor poor, which King, of course understood, understood there would never be equal rights without economic justice. Of course, he’s killed in Memphis defending or marching with garbage workers who were going out on strike. Essentially, that’s what my friend Glen Ford used to call Black mis-leadership class. Let me just say, Black Agenda Report is one of the publications I admire and read.
It was a species of colonialism, and if you look, for instance, at the Congo, you saw the rise of the great revolutionary and resistance fighter Patrice Lumumba who is then assassinated by the French and the CIA and replaced with Mobutu who is, of course Black, but will do the bidding of multinationals and the European colonizers. Well, we have the same kind of species of internal colonization by a small Black elite that was willing to sell out and serve the interests of imperialism and capitalism. Obama, I think, being the poster child for this. We got caught up in this idea of identity politics. Well, we have a Black or biracial president, but if you have a Black or biracial president who serves the interests of the war industry and Exxon-Mobile and Goldman Sachs and oversees mass surveillance of the American public and expands the drone program and sides with the bankers who have just fleeced the country and trashed the global economy, then you’re actually not making progress. I mean, having Clarence Thomas on the Supreme Court, who’s a rabid right-wing member of the Federalist Society, although Black, doesn’t… And I think that even to this day if you listen to the discourse, certainly within the corporate media, the fact that Buttigieg is gay or Hillary Clinton is a woman, these are irrelevant. They’re utterly irrelevant, but it’s become quite an effective mechanism to neutralize the left.
Then I want to go to your point about who is the left. Well, you’re right. The vocal left is sitting around faculty lounges or thinks Twitter is real. The real left is marching outside of Kroger’s, although some of them may be Trump supporters, and that, of course, is the point, that building class consciousness not only redirects popular power against a concentrated power, but it is a form of education itself. If we go back and look at the old union movements, even the mainstream movements like the AFL-CIO, education was a huge component. You read Emma Goldman’s autobiography and these people are working for 12 hours in sweatshops in the Lower East Side and then going to Yiddish anarchist or Marxist meeting groups in the evening. All of that needs to come back. There needs to be a fusion with the working class and understanding of how the system has gamed us.
Jason Myles: But would you agree that that figure in the late ’60s and ’70s that you’re describing, because we do – And, sorry, you’re not familiar with the show. We should have sent you some links to the show. Sorry about that. – But we make these video essays for the show, so I have to go through a lot of old archival footage. Whenever I get archival footage from the ’30s and ’40s [if I have to take like] a labor movement, it’s definitely a lot of people conspiring to strike. It’s always labor conspiring to strike against management. That figure gets replaced by the Archie Bunker type of blue collar. He becomes what blue collar is, right? This kind of right wing, racist reactionary, and his hippie daughter and her silly hippie boyfriend become stand-ins for what people view as the left through the ’80s and of course the ’90s.
It’s interesting that you talk about solidarity and class consciousness because I feel like that’s a conversation that is constantly getting conflated, more so online than maybe in the actual organizing world. Because when you actually get out and organize, you do know how to talk to people. We had Luke Mayville on our show a few months back that actually has been organizing in the very red state of Idaho to get some progressive measures passed. One of the first questions that we had asked him was working with racists. He definitely said, well, there’s a difference between working with someone that is racist and politically active. If you’re a Proud Boy or a Three Percenter, you’re not going to get through to that guy. But if maybe you don’t have the right words around your Black and Brown neighbors, maybe we can talk about some issues that we can all agree upon.
Chris Hedges: Well, yeah, exactly. I mean, for instance, let’s look at Kroger. So you now have a strike by Kroger employees, 8,000 unionized employees at King Soopers. They went on strike in Colorado on Jan. 12. I don’t know, I haven’t done a survey, but I’m certain that there are Trump supporters in there. But you keep them focused on an economic injustice and that essentially creates a kind of class consciousness. I mean, that comes out of Marx. That’s right. They suddenly begin to understand where the real configurations of power lie. They understand that their economic suffering is not caused by undocumented people or Black people. Statistically, of course, it’s ridiculous, but Black people or Brown people taking their jobs. There is in that organizing a kind of salutary force that mitigates against the caricatures that racists use.
I just want to be clear that the media loves to focus on the militias, which are not actually much of a threat. They’re easily taken care of probably by even a police SWAT team. The real threat comes from these contractors. I don’t know what Blackwater’s called now, Xe or something. These figures like Erik Prince and these people are all… A lot of them are recruited from the special forces, and I covered war for many years. Special force units are death squads, and they are closely aligned with the Christian right. I mean, this is one of my critiques of Antifa and the Black bloc, not that I don’t fear the rise of the fascist state, but they’re kind of focused on the low-hanging fruit.
We also have to remember that a huge percentage, Roughly, usually, 90% of those who are in combat units are white, and that’s where this Christian fascism, Trump, lies within the military, which also is very dangerous, and of course within law enforcement. So even the FBI has stopped sending out profiles of local right-wing extremists because they have so many ties to police agencies that that information is almost always shared with those extremists, and sometimes, of course, they’re the same people. So there are some very dark forces that are coalescing around us, but going after the Proud Boys or the Three Percenters or the yahoos who stormed the Capitol misses the point. When things get rough, there actually is some kind of real pushback, the state has the ability to employ some very nefarious and dark forces.
When I was at Standing Rock, for instance, we were stopped. They were trying to block the roads so it took us almost a day to drive into Standing Rock. We had to drive all the way around from the north. But we would inevitably come to a checkpoint. These were guys obviously military trained, no name tags, carrying long-barreled weapons, wearing Kevlar vests, who did not identify themselves. They were all private contractors. That is a very frightening reconfiguration, and, of course, allied with law enforcement, but held completely unaccountable.
Jason Myles: Well, we can talk about the privatization of the military. That’d be a whole other show. But one thing that you did touch on, and I know you write about, one thing I appreciate that you write about, is Christian fascism. But I did live for a while with a white Christian conservative family. One thing I found fascinating was that the right had totally infiltrated the churches. One thing we bring up here on this show, Pascal has said it many times, why doesn’t the left organize in religious spaces? Why do we sacrifice these spaces to the right? Why do you think that is? You’ve done extensive work in these spaces.
Chris Hedges: I’m also a graduate of Harvard Divinity School and my father was a minister and my mother went to seminary, so I grew up in the church. Well, the problem is that the liberal – Let’s speak about the white, mainstream church – Went the way of the rest of the culture. So instead of spirituality, which if you read, for instance, Martin Luther King, especially at the end of his book, Strength to Love, he has this kind of explanation of how one stands up against radical evil and malignant injustice. That’s where you are spiritually empowered. It’s quite a beautiful scene. They actually had just thrown a bomb into his house. It became this, how is it with me spirituality, which is just narcissism. The retreat by the church… Now the church was always fractured in the 1960s, so clergy such as my father who were marching against the war and supporting the civil rights movement, had huge opposition within the institution. I don’t want to pretend that the institution itself had signed on for this. But it kept the church vital. It gave it a kind of currency. It spoke in a language that actually reached, especially those who were suffering, from injustice. They gave that all up. They left the city with white flight. Church numbers are declining. I mean, it’s in free fall because they’re not socially relevant, they’re just little religious clubs.
Now you ask about the religious right. I do not look at the Christian right as Christians. They are Christian heretics, and part of the failure of the liberal church was to call these people out for who they are. Jesus did not come to make us all rich. You don’t have to spend three years at Harvard Divinity School as I did to figure that one out. Jesus would not bless the dropping of iron fragmentation bombs on satanic Muslims all over the Middle East – And, by the way, Jesus wasn’t white. The Romans were white. Jesus was a person of color – Would not bless the white race and in particular the white race in America above other races. This is just heretical garbage, and it serves the rise of the Christian right, which is bankrolled by the most retrograde forces of capitalism, Purdue, Tyson Foods. There’s tremendous money coming into this for a reason. It preys on the despair of largely a white working class that has been dispossessed.
I remember people asked me at the start of the Trump campaign how the Christian right could align themselves with a philanderer and a liar and someone like Trump, and I said, no, you don’t understand. These mega pastors are exactly the same as Trump. The only difference is – At least, this is anecdotal – The mega pastors’ sexual interests are probably a little kinkier than Trump’s. But they’re the same people. Just as Trump preyed on the despair of people in his sham universities or his casino, these people prey on the despair of their congregations.
I spent two years writing this book, American Fascists: The Christian Right and the War on America. I interviewed hundreds of followers, sat in creationist seminars and right to life weekends and Trinity Broadcasting, sat through their tapings, and [took] an event. I mean, I was really on the inside. All totalitarian movements embrace a form of magical thinking – This comes from Hannah Arendt, The Origins of Totalitarianism – Because the real world… They couldn’t cope within a reality-based world. So I was in Detroit with Tim LaHaye who wrote the End Times series for another seminar, and there’s these gruesome, detailed, graphic explanations, none of which is in the Bible. Even the rapture isn’t in the Bible, of what’s going to happen to non believers. Their blood is going to boil, and the battles with the anti-Christ. It was really then it struck me that this lust for apocalyptic vengeance is really a lust for a destruction of a reality-based secular world that almost destroyed them. That’s why you can’t argue – You raised this point earlier about the Proud Boys. You can’t argue them out of this belief system because it’s all they have left. In fact, you will evoke tremendous hostility and anger because by attempting to dismantle that belief system you’re going to be pushing them back into the world that almost destroyed them. I don’t use that term lightly.
From the many, many interviews I did, these people suffered, and the suffering was real. It wasn’t fictitious. Evictions, struggles with drug addiction, alcoholism, domestic abuse. I didn’t put it in the book because it was anecdotal, but almost every woman who I interviewed suffered either from domestic or sexual abuse in the Christian right. I went to a pro-life weekend in Valley Forge, Pennsylvania. They asked the post-abortive sisters to stand. There were about 400 women. The whole room virtually stood. But when I started going down and doing interviews, it turns out the woman hadn’t had one abortion; they’d had multiple abortions. They preyed on their guilt. In fact, there was a group called Priests For Life there and they were running weekends where these women would go for a retreat. They would give them dolls and they would tell them these are the children you murdered. You have to name the doll and bathe the doll and beg for forgiveness at the end of the weekend for the murder you committed and make a vow to spend your life fighting the forces of death. These are their words, which is us.
When you get inside this movement it’s very insidious and very dangerous, and it replicates exactly what the Nazis did with the so-called German Christian Church in Nazi Germany, which fused the iconography, language and symbols of the Christian religion with the Nazi Party quite effectively. So when I wrote this book and gave it the title American Fascists there was a lot of blowback, but I think I’ve been proved right. You look at the connecting tissue of Jan. 6 and it is this Christian fascism. It has already built an infrastructure, it’s already hermetically sealed millions of Americans within this structure. It has its own universities, Patrick Henry Law School, Liberty University. It has its own systems of communication. You go into towns, I’ve been there, in places like Ohio, and you can’t even drive down the street faster than about 15 miles an hour because of all the potholes and the boarded up storefronts, and there’s one gleaming structure and that’s the megachurch that’s pulling in $30,000 in donations a Sunday.
So, unfortunately, the neo fascists have done what we didn’t do. Our infrastructure on the left was really built around unions, the old union hall was built around a kind of labor community. We never, unfortunately, had a real labor party in this country after maybe Debs, and that of course is what has hurt us. You need to have a political structure allied with your union movement. Even at the height, I mean, Sweden, which created in the ’70s the welfare state we should all aspire to, had 76% union membership. I think at the highest we were about 34% or something after World War II. Now we’re down to 9%. So we’re almost starting from zero.
But I see, as I mentioned before, these strikes and these heroic mobilizations in Amazon and everywhere else as the one sign of hope. It doesn’t lie in the ballot box. It lies [crosstalk]
Jason Myles: In all fairness to unions, there was a bit of a racist problem here in this country for a while that wouldn’t allow a large part of the workforce [crosstalk]
Chris Hedges: Yes, no, without question. That, of course, crippled the movement. You go all the way back to the Pullman porters strike, which Debs led, and many of the Pullman porters were Black but when they went out on strike, they had not allowed the Black employees to join the union. You had groups like… Well, the reason Black radicals like Paul Robeson and everyone else gravitated to the Communist Party is that it wasn’t racist. There was an inclusiveness –
Jason Myles: [crosstalk] They were against lynching.
Chris Hedges: What’s that?
Jason Myles: They were against lynching at a time when even the Socialist Party wasn’t.
Chris Hedges: That’s right, that’s right. So you’re right that that racial element… That goes back to what we spoke to before, how racism is always a very effective mechanism in the hands of the ruling class to fracture and weaken the labor movement. So, yes, that’s very true. If you look at the UAW strikes in the 1930s there were Black workers. But yes, it’s always been a persistent problem. Then of course the dirty deal that Franklin Roosevelt cut with Democrats in the South is that the resurrection of labor and the ability to unionize would be denied to Blacks in the South, and also denied, of course, the GI Bill, which is how my father went to college.
Pascal Robert: Well, one of the things that I wanted to discuss with you is that, in terms of this working-class history which is a strong part of the left, one of the problems that we’ve had with the contemporary moment in terms of this contemporary left that has developed in the post-Occupy era is that there’s been a conscious effort by those dispatched by the mainstream media, MSNBC type, certain writers, neoliberal folk, to paint this thing called socialism or leftism as a white thing and divorcing the whole over 100-year history of Black leftism or Black working-class socialist politics going back to the populist movement, the Colored Farmers’ Alliance, the Black socialists and communists of the early 20th century, ’30s and ’40s. We’re making it seem like this politics is something that’s just coming out of faculty lounge white kids who are downwardly mobile. We at This is Revolution podcast were very offended by that and thought it was our job to counteract that.
As someone who is a… As I said, I write for Black Agenda Report and have for years, and you have been a fan of that publication. What do you think about the role of the Black radical left in its ability or inability to make the reality of that Black left political history known in the contemporary moment that came around during Sanders and Occupy? Do you think that perhaps an obstacle to the effectiveness of the Black radical left in making that politics known to not only Black working-class people and Black people overall, but overall mainstream America, is that perhaps there was too much of a fetishization of 1972 Black power fought in politics that was a bit unable to be transferred into the contemporary moment?
Chris Hedges: I mean, the Black radical left… And let’s go all the way back to the Black prophetic tradition, which I think is the most intellectual tradition in the United States. I would argue W. E. B. Du Bois probably is the most important intellectual in the United States and American history. You are referring to MSNBC. I mean, these are… Who owns MSNBC? Comcast. It’s their job to discredit. You were talking earlier about the Archie Bunker type. Well, those stereotypes are perpetuated for a reason, and they are stereotypes. The left people are always portrayed, although it’s not true, as kind of weak and wimpy and –
Jason Myles: Ideological.
Chris Hedges: Yeah, and kind of clueless. Those are stereotypes, and the ruling elites perpetuate those stereotypes for a reason. This is what Gramsci writes about is cultural hegemony and the ability to shape the cultural narrative as an important source of power. That was why, as Glen Ford understood, Barack Obama was so destructive to Black radicalism. I remember speaking many times with Glen about how, up until Obama, Black Americans probably had, certainly proportionately, the best understanding of the evils of empire because, of course, empire is the external expression of white supremacy. They know quite intimately how white supremacy and institutional racism works. Obama was quite a powerful force in seducing many within the Black community to support empire. It’s interesting that August Wilson’s last play, Radio Golf – I don’t know if you know it – Is really about this Obama-like charismatic young Black politician who does the interests of – He sets it in Pittsburgh, like most of his plays – Who does the interests of the Pittsburgh real estate elite. That was Obama.
So you had figures like Cornel West, for instance, who held fast to that Black prophetic tradition. They were savaged, and especially savaged within Black media, which was complicit with the Obama administration. So those figures like Cornel who stood up publicly to defend that Black prophetic tradition were really crucified. That was the power of the corporate control of the media. Remember, Clinton deregulated the FCC, one of his many assaults against the American public and the American working class, along, of course, with the destruction of welfare, and that consolidated corporate control in the hands of about a half dozen corporations who control about 90% of what Americans listen to or watch. That has just narrowed the bandwidth of acceptable political debate. So there’s those erasures of history. I mean, as Black Americans, I’m sure you’re acutely aware of this, that the ruling elites always attempt to erase or silence the history of those they have oppressed and replace it with another history. This, again, is a –
Jason Myles: Martin Luther King.
Chris Hedges: Yeah. Well, you sanitize King. He becomes frozen and, “I have a dream.” Cornel published this great anthology called The Radical King that, essentially… But nobody reads books anymore. That’s another problem.
Jason Myles: He’s on the list after you. Cornel is on the list.
Chris Hedges: I mean, I think the cultural news, information, forces which have been seized by a half dozen corporations know what they’re doing. This hasn’t just affected Blacks in America, but it’s affected whites. I mean, the whole idea that undocumented workers are responsible for your economic free fall doesn’t make any sense.
Jason Myles: And not capitalism?
Chris Hedges: Yeah. First of all, there’s only 11 million of them and all of them are getting their wages stolen from them and they have no rights. This gets back to systems of information and education. So our real education, we had the bloodiest labor wars of any industrialized country. Hundreds, hundreds of American workers were murdered in the attempt to unionize. Thousands were blacklisted, probably tens of thousands blacklisted, thousands wounded by vigilante groups. We spoke about vigilante groups before, the Pinkertons, the gun thugs that were hired. There are recurring patterns and themes within American history, and those recurring patterns and themes in the hands of the ruling elite are meant to be silenced, which is why, for those who actually want to understand their own past, where they come from, how they got there, you have to be immensely proactive. You’re not going to get it, probably, off a screen too much. It’s there but it’s not taught. It’s not understood. That rootlessness, is actually a term Hannah Arendt uses, that rootlessness is quite effective in the hands of the ruling elite.
Jason Myles: Well, are they doubling down on that rootlessness that you speak of? Recently I just heard Kristi Noem, the governor of South Dakota, wants to eliminate teaching activism to children in schools. Did you see that, Pascal?
Pascal Robert: No. But I did see that the governor of the state of Florida is trying to make it illegal to make white people feel guilty about history in education, in public schools.
Jason Myles: So Black teachers can’t make them watch Roots anymore? [sad trombone noise]
Pascal Robert: I think this whole discourse, culture wars centered around education is absurd on all fronts, but I’m not surprised by what you’re telling me about the governor of South Dakota.
Jason Myles: It’s a reimagining of America.
Chris Hedges: Well, it’s mythology, and if you don’t know where you came from then you have no ability to self-critique or change. I mean, it becomes… I watched that. I covered the war in the former Yugoslavia. So with the breakdown of Yugoslavia had competing ethnic groups who were treated into their own mythologies about Serbs or Croats or Muslims and they couldn’t even communicate with each other because none of them were speaking about a history grounded in verifiable fact. That’s exactly what’s happening with the Christian right and this… Glen Ford used to call it Trump’s white man’s party.
So I was, a few years ago, down in Montgomery, Alabama, with Bryan Stevenson and Bryan was taking me through the city. Now half of Montgomery’s Black and there was just one Confederate memorial after another, including a gigantic Confederate flag that flies on the outskirts of Montgomery when you drive down from Birmingham. Bryan said these things have all gone up in the last 10 years. And Bryan, of course, has countered this with his markers to the victims of lynching. I said, Bryan, that’s exactly what happened in Yugoslavia. You strip people of their place within a society, those social bonds that give them meaning, a sense of purpose, that project the possibility of a future, and then they retreat into these mythical identities because it’s all they have left.
I see that happening, and you see it especially within the media, because the old media catered to the interests of the elites but went out of its way not to offend one demographic or another in its whole idea of objectivity and balance, which was a canard, but was used by them. Now that’s been replaced. Matt Taibbi wrote a good book on this called Hate Inc., which has a picture of Rachel Maddow on one side of the book and Sean Hannity on the other. Now you have media catering to a particular demographic and telling that demographic what it wants to hear, but then also demonizing the opposing demographic. The “left” or “liberal media,” MSNBC, CNN, The New York Times, Washington Post, are as guilty of this as the right-wing media. That, of course, mirrors what I watched in Yugoslavia as competing ethnic groups seized their own centers of media control. That’s very, very dangerous because there’s no ability to communicate. You constantly seek to stoke anger and rage, and, again, this is a parallel with Yugoslavia. You begin to speak in the language of violence, of assassinations, of taking people out, and it’s a very short step from there to actual violence. That’s kind of the road we’re on.
Pascal Robert: I wanted to ask you a question. This might be the 800-pound gorilla in the room, but I’m going to let you, as they say in hip hop, pop culture, freestyle with this question. What is your assessment of the Bernie Sanders presidential run and its effect on American politics overall, comprehensively?
Chris Hedges: I think Bernie’s responsible for emasculating the left. First of all, I mean, Bernie has always been a de facto member of the Democratic Party. He campaigned in 1996. This was after NAFTA, after the 1994 Omnibus Crime Bill. I teach in a prison. I’ve taught in the New Jersey prison system through Rutgers University and their college credit program for almost a decade. Most of my students wouldn’t be there but for Clinton, and Biden was a driving force behind this bill. I have a very hard time forgiving them for this. I certainly can’t vote for them. So Bernie… The Democratic Party always allows an outlier, Kucinich or someone like Sanders, there with the full knowledge that the quid quo pro is that when they anoint their selected candidate, whether that’s Hilary Clinton or Joe Biden, Bernie is going to then attempt to corral his supporters to back the Democrats.
We won’t build a serious political movement in that election cycle. We certainly won’t build it by capitulating to the Democratic Party. The Democratic Party have been full partners in the assault on the American working class and on the poor. Remember, 70% of the original recipients of welfare before Clinton destroyed the welfare system were children. We just had the governor of Maine, the legislature passed a bill allowing farm workers, it’s an agriculture state, to unionize, and the Democratic governor killed it.
So Bernie… I don’t dislike him. I certainly voted for him in the primaries. I think he does care about the working class, but he does not want to jeopardize his own political position. He’s not willing to defy the Democratic Party establishment. And that’s not conjecture, because in 2014 I was in an event in New York City with Kshama Sawant, a socialist city councilwoman from Seattle, and Bernie was one of the speakers with us, along with Bill McKibben and Naomi Klein. Before the event Kshama was really pushing Bernie to run as an independent. Bernie’s response was, I don’t want to end up like Ralph Nader. Now I thought that was really telling. I am a long supporter of Nader. I was Ralph’s speech writer. He understood that if he defied the Democratic Party establishment he would be turned into a pariah like Ralph Nader, and it was a cost he wasn’t willing to pay. So, therefore, I think Bernie is both politically and morally unfit at this point to lead the kind of resistance that is imperative if we are going to wrest back our, very flawed, but wrest back our democracy. Bernie isn’t going to do it.
Pascal Robert: Well, this is the thing. As you know, I’m a mentee of both Bruce Dixon and Glen Ford. Bruce Dixon, who was the original author of the Bernie Sanders is a sheepdog for the Democrats statement, that comes from Bruce Dixon. God rest the soul to the both of them. You don’t think – Hear me out on this – That Bernie Sanders running publicly as a democratic socialist within the Democratic Party and capturing about 30 to 34 percent of support within the Democratic Party, opening the political opening over to the window, to where actually people are identifying with socialism as a political option, having people talk about the legitimacy of policies like Medicare for all after people thought the Obama neoliberal Obamacare was some kind of great success story, things like universal health care, things like universal public education, higher education at the university level. You don’t think that the political discourse and ideological options that America has considered even rhetorically legitimate because of the rise of his campaign, you don’t find that to have been a net positive in terms of its effect on the American body politic?
Chris Hedges: That is a net positive. But we have to acknowledge the Democratic Party will never give it to us. It’s corporate controlled, and all you have to do is look at its major donors. So the Democratic Party freaked out with Bernie’s popularity in the primaries the second time around. Joe Biden’s campaign was going nowhere. They reached out for a Republican replacement, Michael Bloomberg. That didn’t go anywhere. Then Obama got on the phone and got everyone to drop out so we got Biden. What’s Biden done? Nothing. [crosstalk] minimum wage. He said everybody would get $2,000 checks. It’s all crap.
Jason Myles: Look here, Jack. He said you get two checks.
Pascal Robert: I want to pivot to the next question. This might be my last because I know Jason wants to jump in here. In that regard, and I want to let you freestyle on this one as well, Chris. We have this 50-year plus counter revolution we talked about where we had this bipartisan consensus, Democrat, Republican. They’re rooted in neoliberalism, which we define as a hyper fancy word for corporate privatization, for those who don’t understand what it is. Pretty much in the mind of the American consciousness, largely because of NAFTA and GATT, the Democrats were the worst stewards of the neoliberal turn or the hyper corporate, hyper privatization politics that brought us to this moment, in the consciousness of many Americans. I don’t want to argue whether that’s true or not.
But particularly because of NAFTA and GATT, and also in the minds of many Black Americans because of mass incarceration and the Clinton Crime Bill, the stain of the neoliberal turn and the corporate turn in American politics has been levied more adversely on Democrats. Usually when you say the word neoliberal, in the consciousnesses of most people they think Democrats and liberals now. Do you not think with the rhetoric and the posturing and the discourse in the Biden administration with things like the child tax credits, the Build Back Better, that – And I’m asking your thoughts – That the Democratic Party, though they may not be down with the Sanders agenda, because of the crisis of legitimacy they find themselves in, has no choice to either pivot to Keynesianism or social democracy or surrender to Trump-ism without any option.
Chris Hedges: They’ll never pivot to Keynesianism because they’ve been bought and paid for. So what has Biden presided over? He’s presided over the loss of extended unemployment benefits, rental assistance forbearance of student loans, emergency checks, the moratorium on evictions and foreclosures, and now the ending of the expansion of the child tax credits, all as the pandemic is surging. You have the Americans who are uninsured or those who are covered by Medicare who are often front line workers that can’t be reimbursed for over the counter COVID tests they buy. What did Glen Ford used to say? The Democrats aren’t the least worst, they’re the most effective worst, or he may have said the most effective [crosstalk].
Jason Myles: Evil.
Pascal Robert: The most effective evil.
Chris Hedges: He’s right, he’s right. So it’s rhetorical. I mean, you can get your corporate tyranny dished out to you by women and gays and people of color or you can get it served out by neoconfederate racists but you can’t vote against the interests of Goldman Sachs in the American political system. It’s impossible. [crosstalk]
Pascal Robert: You don’t believe the Democratic Party or any flank of American capital, the right flank or the left flank, is… Do you think that we are in a position where neoliberalism or the move to hyper corporate American politics and capitalism has been so deleterious that there’s going to be a need to pivot away from it? You do not believe that the pivot away from neoliberal capitalist American politics is happening in this current moment of crisis at all?
Chris Hedges: I do, but it’s happening with front line workers. It’s not happening within the Democratic Party. The power of figures like Biden or Schumer or Pelosi is that they’re the spigot. They get all the money and then they dole it out. It’s why they’ve domesticated AOC in the squad and everyone else. Without that money, that dark money, they wouldn’t hold political power. And they know it. They’re not going to give that up. They’d rather bring the whole thing down with them because even when they lose then they become lobbyists or they go to the Council on Foreign Relations. The elites all take care of themselves. But it isn’t going to come from the Democratic Party. I’m all for the overthrow of the corporate state. In fact, I think that’s an imperative. The Democratic Party does not function as a political party.
Jason Myles: Oh, we’re agreeing with you. We’re agreeing with you. We’re just saying, do you think that there is going to be a slight pivot, that their Overton window, as they say, has shifted?
Chris Hedges: No. Biden’s already pivoted to the right. He’s pivoted. To the right.
Jason Myles: I mean, he’s been that way since the mid ’70s.
Chris Hedges: Well, that’s why he was selected. I mean, Biden has assiduously served… They used to call him senator credit card. By the way the credit card companies even back then were employing his son Hunter Biden for staggering sums of money. That’s why he was selected. They will fight over that narrow tranche of undecided Trump voters. 80 million people in this country don’t even vote. You never hear that number used. They just go after Jill Stein or Ralph Nader or somebody, which is ridiculous because nobody votes for Ralph and nobody voted for Jill. They’ve pivoted. They’ve pivoted to the right.
Pascal Robert: So you don’t buy into the Joe Biden is the new FDR rhetoric? [sad trombone noise]
Chris Hedges: I think people are actually running around saying that stuff. I don’t own a TV, so I insulate myself from this kind of crap.
Jason Myles: Oh, you know what, we have your email now, so we’ll just send you –
Chris Hedges: [crosstalk] …You can send it to me.
Jason Myles: We’re coming up on an hour and I do want to end on this note. You are constantly, maybe, mischaracterized as the doom and gloom guy. You always have the predictions of doom and gloom. I want to ask you this question. We did a show some time ago with a gentleman named Michael Harris who wrote a book about Star Wars. I don’t know if you remember the Star Wars movies. He uses Star Wars as a grand narrative for the left, kind of capturing what Lucas was originally talking about when he made Star Wars, that the Evil Empire was the United States and the Rebels were the Viet Cong. It gets into all the politics that Lucas was trying to put into these movies that we didn’t see and how Lucas was actually part of the new left of the late ’60s. What is your message of hope for this young burgeoning left that we see here?
Chris Hedges: I mean, for me… I mean, I read climate reports and I don’t know how anyone can be particularly optimistic given the inability on the part of the ruling elites to respond in a rational way to the ecocide. My message is that resistance is a moral imperative. All great revolutionaries: Nelson Mandela, Che … Che was a kind of mixed figure, but let’s go with Che, Václav Havel, who I knew, it didn’t really matter whether you succeeded or not. You stand with what the great theologian James Cone used to call the crucified of the earth. I mean, I do, in the end, come out of this religious tradition and you have to be willing to pay the price.
I mean, every time you want to go into a booth and vote for a Democrat you should ask yourself, what would Malcolm X do? Really, no, seriously. I mean, our two greatest prophets, contemporary prophets Malcolm X and Martin Luther King were both deeply religious people. They understood that there was a moral imperative that may even end with a loss because they couldn’t be bought. They wouldn’t sell out. They wouldn’t be quiet. The state knows what to do with prophets like that. It’s what they did to Fred Hampton. They kill them. King and Malcolm were acutely aware of that, and I think we have to find that kind of political courage to defy these forces of radical evil and stop asking what’s practical. Revolutionaries never ask what’s practical; they ask what’s right.
Jason Myles: Pascal, do you have any parting words or questions [crosstalk]
Pascal Robert: I wanted to say that I really appreciate Chris Hedges coming on our show and laying down the gauntlet in terms of his position on the contemporary moment. I don’t want you to get into prognostications because, well, maybe you do. What do you see in the immediate – Maybe you are into prognostications. What do you see in [crosstalk]
Jason Myles: I will say this, Pascal. In reading America: The Farewell Tour, there’s a couple paragraphs I actually highlighted where he called out some of the stuff that we’re talking about today in 2018 when the book came out, probably 2017 [crosstalk]
Pascal Robert: Jason gave me an opportunity. We’re still in a moment where we have global reactionary right-wing what some would call fascism on the march all over the world. We have Viktor Orbán in Hungary who is now expanding his consensus to other European countries. We thought Marine Le Pen was the nightmare of the reactionary right in France, now we have someone even worse than her with Éric Zemmour. We have Boris Johnson who’s still governing over Europe. Britain is basically now a right-wing one-party state. I have said that I think America is going to move in that direction. The global reactionary right in terms of the failure of neoliberal capitalism is ascendant. Do you think that the left flank of capital, globally, is defeated beyond the capacity to make post World War II liberal democracy a factor anymore, and that we’re moving, literally, to a global reactionary right political reality?
Chris Hedges: Probably, but it doesn’t matter. We still have to resist, and that resistance allows us to assert ourselves as distinct individuals. It builds a community with people who have also embraced that moral imperative, and it tells those vulnerable, those people who are the most oppressed and the most demonized, whether that’s Muslims or Blacks or undocumented workers or anyone else, that we stand with them. That’s our job. It’s not our job to ask whether we’re going to succeed or not. You go back and read the early moments of any revolution anywhere and the odds are so stacked against the revolutionaries. I mean, Lenin, six weeks before the Bolshevik… Well, it wasn’t the Bolshevik, but before the Russian revolution that ended with the Bolshevik rise to power, six weeks before, gave a speech that said, those who are my age will not live to see the revolution. He was wrong. You can never tell how history will play out. You can never tell, what we talked about earlier, what convergence of forces will come together to trigger an uprising. We have to be there. We have to be ready. We can’t be passive. We can’t be complicit, because I’m going to go back to my religious roots. That’s spiritual and probably intellectual death.
Pascal Robert: I appreciate that, and I respect that answer. Chris Hedges, it’s been an honor and pleasure talking to you. I hope you enjoyed your time with us at This is Revolution podcast.
Chris Hedges: [crosstalk] yeah, you guys are great. I’ll go back and listen to the other podcasts.
Jason Myles: Well, don’t hang up just yet. We’ve got to play the outro music, but don’t hang up just yet. Thank you guys for watching the show. If you haven’t done it already, please hit the like and subscribe button so you can get more programing like this. Also, we’re going to try to convince Chris to hook us up with Cornel West so we can talk to Cornel West, because it’s really hard to get through to these people. If you only saw the amount of emails. Just to let you know, Chris, before we go, I want to say this on air, Joe Sacco even sent you a message for you to come on our show.
Chris Hedges: I love Joe. Joe is a genius. He’s amazing.
Jason Myles: He likes our show.
Chris Hedges: Oh, Joe’s great.
Jason Myles: So there you go. So don’t hang up. Everybody, we are out.
Tuesday, August 03, 2021
Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids
QuestionIn patients prescribed stable, long-term, high-dose opioid therapy, is dose tapering associated with an increased risk of overdose or mental health crisis?
FindingsIn this retrospective cohort study that included 113 618 patients prescribed stable, high-dose opioid therapy, patients in periods following dose tapering, compared with patients before or without tapering, had an adjusted incidence rate ratio of 1.68 for overdose and 2.28 for mental health crisis; both risks were statistically significant.
MeaningOpioid dose tapering was associated with increased risk for overdose and mental health crisis, but interpretation of these findings is limited by the study design.
Abstract
ImportanceOpioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis.
ObjectiveTo assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids.
Design, Setting, and ParticipantsRetrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion.
ExposuresOpioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period.
Main Outcomes and MeasuresEmergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity.
ResultsThe final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21).
Conclusions and RelevanceAmong patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.
Introduction
Amidst the ongoing US national crisis of opioid-related mortality and morbidity, heightened scrutiny and shifts in opioid prescribing trends have occurred in the US.1-3 Key guidelines released in 2016 by the Centers for Disease Control and Prevention (CDC)4 recommended against higher doses of opioids in managing chronic pain and recommended dose tapering when harms of continued therapy outweigh perceived benefits for individual patients. These and other widely disseminated recommendations have led to increased opioid tapering among patients prescribed long-term opioid therapy.5,6 However, opioid-related mortality has continued to rise.7
Subsequent US recommendations have advised caution in opioid de-prescribing.8,9 Studies suggest risks of suicidal ideation, transition to illicit opioids, and overdose after opioid tapering and discontinuation. The US Food and Drug Administration issued a prescriber warning about potential hazards of rapid dose reduction in patients prescribed long-term opioids.9 However, studies assessing harms of opioid dose reduction have been limited to smaller samples,10 veteran populations,11 or specific regions12 or have focused on discontinuation and not included sensitive indicators for tapering initiation.11,13,14 As clinicians and patients face difficult decisions about whether and how to de-prescribe opioids,15 there is a need to elucidate the potential harms of stopping or decreasing these medications.
It was hypothesized that tapering the dose of patients receiving stable, long-term, high-dose opioid therapy would be associated with increased risk for specific adverse events. Dose disruption among this population might trigger unhealthy substance use, withdrawal, depression, or anxiety, leading to increased acute care events related to drug toxicity and mental health. The objective of this study was to assess whether there are associations between opioid dose tapering among patients prescribed stable, long-term, higher-dose opioids and subsequent rates of overdose and mental health crisis. The potential risks associated with faster rate of opioid dose reduction were also assessed.
Methods
Study Data, Setting, and Participants
This retrospective cohort study used administrative claims data from the OptumLabs Data Warehouse from 2007 to 2019. The database contains deidentified retrospective administrative data, including medical and pharmacy claims (with associated diagnosis codes) and eligibility information as well as electronic health data for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on patients representing a diverse mix of ages, ethnicities, and US geographical regions (OptumLabs and OptumLabs Data Warehouse Descriptions and Citation. OptumLabs; 2020). The Institutional Review Board of the University of California determined this study to not be human subjects research because it involved analysis of preexisting, deidentified data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines.
We identified a cohort of patients prescribed stable, high doses of opioids for at least 12 months. Patients 18 years or older at the time of receiving an opioid prescription between January 1, 2008, and December 31, 2019, were eligible for inclusion if they had at least 14 months of continuous enrollment in medical, pharmacy, and mental health coverage and 12 months of continuous opioid prescriptions (operationalized as ≥90% of days filled), with mean daily dose of at least 50 morphine milligram equivalents (MME) that varied by no more than 10% above or below the mean monthly dose across the baseline year. We required at least 14 months of enrollment to allow for establishment of the stable baseline period and at least 2 months of follow-up to observe for tapering. We excluded patients with cancer, those receiving hospice or palliative care, and those prescribed buprenorphine (Figure 1).
Beginning the first day after the end of the baseline year of stable dosing, patients were followed up for up to 1 year for outcome events. Patients were censored if they died; their enrollment was disrupted; they developed a new diagnosis of cancer; or they entered hospice, palliative, or skilled nursing care for at least 90 days. We also censored patients during the first 7 months of follow-up if their mean daily dose increased by greater than or equal to 15% above their baseline dose and they had not previously initiated a taper; this censoring rule was adopted to allow comparison of outcomes among patients with continued opioid dose stability and those who underwent dose tapering. The study design allowed individual patients to contribute multiple baseline and follow-up periods during the study period, and the analysis plan accounted for time-varying covariates and variable follow-up duration.
Identifying Opioid Tapering
Following the 12-month baseline period, we computed 60-day moving mean daily doses during 6 overlapping windows spanning the 7 months following the baseline period. A taper was identified if the mean daily dose during one of these periods was greater than or equal to 15% below the mean daily dose in the baseline period. Tapering status was defined as a binary time-varying event history variable, specified as nontapered during all months prior to and during the 60-day period in which tapering was identified and tapered during all subsequent study months (eFigure 1 in the Supplement).5 The sensitivity and specificity of this measure has not been determined. However, the predictive validity of the measure was suggested by a longitudinal study in which 69.8% of patients identified as undergoing dose tapering showed sustained relative dose reduction of greater than or equal to 15% at least 9 months after tapering was identified.16
Dose Reduction Velocity
For all patients in the cohort, we used dosing data from the initial 6 overlapping 60-day periods of follow-up to identify the fastest monthly rate of dose reduction (velocity) occurring prior to the observation month. Detailed methods for specifying dose reduction velocities are included in the eMethods in the Supplement. For each follow-up month, we identified the maximum velocity of dose reduction that occurred in previous dosing intervals, and maximum velocity of dose reduction was a time-varying variable. Based on descriptive and graphical analyses of the distribution of tapering velocities, maximum velocity of dose reduction was then categorized as less than 10%, 10% to 19.9%, 20% to 49.9%, or at least 50%.
Outcome Variables
After each stable baseline period, we examined medical claims during the following 12 months to identify monthly (30-day) counts of 2 coprimary end points.
Overdose or withdrawal events were defined as emergency department visits or inpatient hospital admissions for any drug overdose, alcohol intoxication, or drug withdrawal. We identified International Classification of Diseases, Clinical Modification, Ninth Revision and International Classification of Diseases, Clinical Modification, Tenth Revision codes for this outcome by augmenting the definition for “all-drug overdose” specified in CDC drug overdose surveillance guidelines,17 with additional codes for alcohol intoxication and alcohol or drug withdrawal. In sensitivity analyses, we also assessed the “all-drug overdose,” as specified in the CDC guidance (without additional alcohol or withdrawal codes), and “opioid overdose.” In validation studies based on medical record reviews, diagnostic codes for opioid overdoses identified emergency or hospital events for opioid overdose with positive predictive values ranging from 67% to 84%.18,19
Mental health crisis events were defined as emergency department or inpatient hospital admissions with depression or anxiety diagnosis codes in the primary diagnosis position (to make the outcome more specific to acute episodes of depression or anxiety rather than prevalent depressive/anxiety disorders coded during an episode for a different medical issue) or suicide attempt or intentional self-harm in any diagnosis position. In addition to the main analysis using the composite outcome, we also examined each mental health crisis outcome separately (depression, anxiety, and suicide attempt). In a systematic review and validation study, diagnostic codes for depression had sensitivities of 29% to 36%, specificities of approximately 99%, and positive predictive values of approximately 90%.20 In a systematic review, diagnostic codes for suicide attempts or intention had positive predictive values between 55% and 100%.21 The list of diagnostic codes used to identify study outcomes is included in eTable 1 in the Supplement.
Covariates
We included covariates that might contribute to differences in rates of the outcomes of interest in populations prescribed opioids. Sociodemographic information included age, sex, education status, rurality of home address (dichotomized as metropolitan/micropolitan vs small town/rural using rural-urban commuting area codes 1-6 vs 7-10),22 and insurance status (commercial vs Medicare Advantage). Age was categorized as 18 to 34, 35 to 49, 50 to 64, and 65 years or older. Education was categorized based on median household education level for the patient’s zip code derived from US census data. A valid race variable was not available in the data set.
We included key clinical factors as covariates. Baseline opioid dose was calculated using pharmacy claims for all opioids during the baseline period and categorized as 50 to 89, 90 to 149, 150 to 299, and greater than or equal to 300 MME per day. To account for the increased risk of adverse outcomes conferred by co-prescribing benzodiazepines and opioids, we included a variable for whether the patient was concurrently prescribed a benzodiazepine (identified by National Drug Codes) on the final day of the baseline period. We included a count variable for the number of overdose events in the baseline year, specified by the same criteria as the overdose outcome variable. Baseline depression or anxiety was identified by either claims diagnoses23 or 1 or more pharmacy claim for a selective serotonin reuptake inhibitor prescription during the baseline year. Comorbidities were accounted for using 27 discrete indicator variables for noncancer conditions in the Elixhauser comorbidity index, which includes variables labeled drug abuse and alcohol abuse (hereafter referred to as drug use disorder and alcohol use disorder), as well as psychosis.24 Year of cohort entry was also included.
Statistical Analysis
Analyses were conducted using Stata MP, version 15.1 (StataCorp). We performed descriptive analyses to characterize the study population at baseline and identify bivariate differences between the tapered and nontapered samples.
We performed 2 key sets of analyses. First, we compared tapered and nontapered patient months and their associated risk of overdose and mental health crisis. To account for potential overdispersion of study outcomes, we used negative binomial regression to estimate adjusted incidence rates and incidence rate ratios (IRRs) for the 2 outcomes. We accounted for variable follow-up time by using a discrete time regression framework, with follow-up months nested in patients with eligible baseline periods. In adjusted analyses, models included the time-varying taper history variable and fixed patient-level covariates, including age, sex, education status, rurality, insurance status, Elixhauser comorbidities, baseline opioid dose, co-prescription of benzodiazepines, baseline overdose events, baseline depression/anxiety, and study year. In main analyses, a missing category was included for education (missing for 5.6% of patients), while the small percentage of patients with missing rurality data (0.2%) were grouped with the “small town/rural” category. We used postestimation commands to estimate adjusted incidence rates by tapering status. We used the same analytic approach in modeling associations between tapering and alternative specifications of the count outcomes (ie, all drug overdose; opioid-only overdose; or depression, anxiety, or suicide events). All analyses used cluster robust standard errors to account for clustering of multiple eligible baseline periods in individual patients. All tests were 2-sided with significance level of α = .05. Because of the potential for type I error due to multiple comparisons, findings for analyses of secondary end points should be interpreted as exploratory.
To examine whether tapering associations varied by covariates that we expected to be associated with overdose or mental health crisis, we assessed for meaningful 2-way interactions between tapering status and key covariates using Akaike’s information criterion and χ2 tests for the significance of interaction terms. Statistically significant interaction effects were displayed graphically.
In the second set of analyses, we used negative binomial regression to examine associations between maximum dose reduction velocity and overdose and mental health outcomes. We included the time-varying independent variable maximum velocity of dose reduction first as a continuous measure and then as categorized above. These models adjusted for the same covariates described above. Regression analyses of maximum velocity of dose reduction only included patients who accrued follow-up time in month 3 of follow-up or later, which was the first month when maximum velocity of dose reduction could be defined based entirely on prior dosing. Thus, 4395 patients were not included in maximum velocity of dose reduction analyses due to early censoring events (3.9% of total).
We conducted additional sensitivity analyses, as described in the eMethods in the Supplement. Briefly, these analyses assessed the effect of alternative specifications of the study outcomes or the tapering measure. For example, to account for the potential bias that could have arisen from censoring due to death, we repeated main analyses wherein death was counted as an overdose or a mental health crisis event in the respective models. In addition, to account for the potential endogeneity arising from a patient’s propensity to undergo dose tapering, we conducted analyses with inverse probability weighting by a propensity score for the likelihood of undergoing tapering.
Results
The study cohort consisted of 113 618 patients prescribed stable, long-term, higher-dose opioid therapy for at least 12 months who contributed a total of 203 920 baseline periods (mean per patient, 1.8; median per patient, 1.0). Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). A total of 18.2% of baseline periods were followed by tapering (37 170 tapering events), of which 7620 (20.5%) were discontinued at some point during follow-up (eg, prescribed 0 MME during a 60-day dosing period). The median (interquartile range) maximum velocity of dose reduction was 22.7% (15.0%-41.3%) per month for tapered periods and 3.2% (1.7%-5.9%) per month without tapering.
Table 1 compares the baseline characteristics of patients by tapering status during their most recent baseline period. Patients who underwent tapering had significantly higher baseline opioid doses; were more likely to be co-prescribed benzodiazepines; and had significantly higher baseline rates of overdose, drug use disorder, depression, and anxiety.
Table 2 shows the adjusted incidence rates for the study outcomes by tapering status. Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference [aIRD], 3.8 per 100 person-years [95% CI, 3.0-4.6]; adjusted incidence rate ratio [aIRR], 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (aIRD, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]).
Among patients who underwent tapering and had 1 or more outcome events during follow-up, the median time to first event was 6 months for both outcomes. In secondary analyses of the individual components of the mental health crisis outcome (depression, anxiety, and suicide attempt), tapering was associated with depression events (aIRR, 2.46 [95% CI, 2.05-2.96]), anxiety events (aIRR, 1.79 [95% CI, 1.48-2.15]), and suicide attempts (aIRR, 3.30 [95% CI, 2.19-4.98]). The full regression model for the analysis of main effects is provided in eTable 2 in the Supplement.
In analyses with interaction terms between tapering status and other key covariates, only interactions between baseline dose category and tapering status were found to be both informative (based on reductions in Akaike’s information criterion) and statistically significant, based on χ2 tests of significance of the dose category × tapering interaction terms (P < .01). For both outcomes, patients prescribed higher baseline doses had greater risks associated with tapering than patients prescribed lower baseline doses (Table 2; eFigure 2 in the Supplement).
In analyses of maximum monthly dose reduction velocity (n = 109 599 patients followed up for 139 941 person-years), an incremental increase in maximum monthly dose reduction velocity of 10% was associated with an increased aIRR for overdose (1.09 [95% CI, 1.07-1.11]) and mental health crisis (1.18 [95% CI, 1.14-1.21]) (eTable 3 in the Supplement). Higher maximum monthly dose reduction velocity categories (compared with maximum monthly dose reduction velocity <10%) were associated with higher event rates for overdose and mental health crisis (Figure 2; eTable 4 in the Supplement). The associations observed in the main analyses were robust to a series of sensitivity analyses (eTables 5-6 in the Supplement).
Discussion
In a large cohort of patients in the US prescribed stable, long-term, higher-dose opioids, undergoing opioid dose tapering was associated with statistically significant risk of subsequent overdose and mental health crisis, including suicidality.
Guidelines for opioid tapering published in 2019 by the US Department of Health and Human Services (HHS) cautioned about the potential hazards of rapid dose reduction, including withdrawal, transition to illicit opioids, and psychological distress.9 Qualitative studies suggest that many patients experience the tapering process as emotionally challenging,25,26 and both the HHS and CDC guidelines advise clinicians to monitor patients carefully during tapering and to provide psychosocial support. In the current study, tapering was associated with absolute differences in rates of overdose or mental health crisis events of approximately 3 to 4 events per 100 person-years compared with nontapering. These findings suggest that adverse events associated with tapering may be relatively common and support HHS recommendations for more gradual dose reductions when feasible and careful monitoring for withdrawal, substance use, and psychological distress.9
Previous research has examined adverse outcomes associated with discontinuing long-term opioids.10-14 This analysis demonstrated associations between adverse outcomes and a more sensitive indicator of opioid dose reduction (≥15% from baseline). The associations persisted in sensitivity analyses that excluded patients who discontinued opioids during follow-up, suggesting that the observed associations between tapering and overdose and mental health crisis are not entirely explained by events occurring in patients discontinuing opioids. Additionally, all categories of maximum dose reduction velocity demonstrated higher relative rates of outcomes compared with the lowest (<10% per month), suggesting that risks were not confined to patients undergoing rapid tapering.
Patients undergoing tapering from higher baseline opioid doses had higher associated risk for the study outcomes compared with patients undergoing tapering from lower baseline doses. Due to physiologic opioid tolerance,27 patients receiving higher doses may have heightened intolerance of opioid dose disruption, potentially warranting additional caution in patients tapering from higher doses.
The risks of long-term opioids are well-documented, particularly at higher doses and in the presence of other risk factors for opioid toxicity,4 and clinicians and patients must carefully weigh risks and benefits of both opioid continuation and tapering in decisions regarding ongoing opioid therapy.28 The risks associated with opioid tapering warrant further exploration to inform clinical guidelines regarding patient selection for tapering, optimal rates of dose reduction, and how best to monitor and support patients during periods of dose transition.
Limitations
This study has several limitations. First, although it included a number of key covariates, unmeasured factors may have contributed to increased risk for adverse events in the population who underwent tapering. Nevertheless, the findings are consistent with recent studies of opioid discontinuation10-15,29,30 and were robust to adjustment for baseline overdose, mental health conditions, and a range of sensitivity analyses. Second, the analyses could not assess tapering circumstances. Recent evidence has shown that the majority of opioid tapering and discontinuation is clinician-initiated,31 and risks may differ with voluntary vs involuntary tapering.32,33 Third, the study design considered any dose reduction of greater than or equal to 15% of the baseline dose as a taper initiation but did not account for subsequent dose trajectory. Fourth, the data set lacked an accurate measure of race, limiting the ability to account for the potential differential opioid prescribing and tapering trends between racial and ethnic groups. Fifth, the data set does not measure illicit opioid use or account for methadone administered in certified treatment programs. Sixth, administrative claims data have inherent measurement error. Seventh, these data were claims from commercially-insured and Medicare Advantage patients in the US, and the generalizability of these findings is uncertain.
Conclusions
Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.
Corresponding Author: Alicia Agnoli, MD, MPH, MHS, Department of Family and Community Medicine, University of California, Davis, 4860 Y St, Ste 2300, Sacramento, CA 95817 (aagnoli@ucdavis.edu).
Accepted for Publication: June 21, 2021.
Author Contributions: Drs Agnoli and Fenton had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Agnoli, Magnan, Jerant, Fenton.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Agnoli, Jerant, Fenton.
Critical revision of the manuscript for important intellectual content: All authors.
Administrative, technical, or material support: Agnoli, Magnan, Jerant.
Supervision: Agnoli, Magnan, Jerant, Fenton.
Conflict of Interest Disclosures: Dr Agnoli reported receiving grants from the University of California Davis School of Medicine Dean's Office (scholar in women's health research; BIRCWH/K12) during the conduct of the study. No other disclosures were reported.
Funding/Support: This study was supported by a University of California–OptumLabs Research Credit and the Department of Family and Community Medicine, University of California, Davis. Dr Agnoli was supported by the University of California, Davis School of Medicine Dean’s Office (Dean’s Scholarship in Women’s Health Research).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Jeffery MM, Hooten WM, Henk HJ, et al. Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study. BMJ. 2018;362:k2833. doi:10.1136/bmj.k2833PubMedGoogle Scholar
Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162(4):276-286. doi:10.7326/M14-2559PubMedGoogle ScholarCrossref
Bohnert ASB, Guy GPJ Jr, Losby JL. Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention’s 2016 opioid guideline. Ann Intern Med. 2018;169(6):367-375. doi:10.7326/M18-1243PubMedGoogle ScholarCrossref
Wilson N, Kariisa M, Seth P, Smith H IV, Davis NL. Drug and opioid-involved overdose deaths—United States, 2017-2018. MMWR Morb Mortal Wkly Rep. 2020;69(11):290-297. doi:10.15585/mmwr.mm6911a4PubMedGoogle ScholarCrossref
Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020;368:m283. doi:10.1136/bmj.m283PubMedGoogle Scholar
Binswanger IA, Glanz JM, Faul M, et al. The association between opioid discontinuation and heroin use: a nested case-control study. Drug Alcohol Depend. 2020;217:108248. doi:10.1016/j.drugalcdep.2020.108248PubMedGoogle Scholar
James JR, Scott JM, Klein JW, et al. Mortality after discontinuation of primary care-based chronic opioid therapy for pain: a retrospective cohort study. J Gen Intern Med. 2019;34(12):2749-2755. doi:10.1007/s11606-019-05301-2PubMedGoogle ScholarCrossref
Pitt AL, Humphreys K, Brandeau ML. Modeling health benefits and harms of public policy responses to the US opioid epidemic. Am J Public Health. 2018;108(10):1394-1400. doi:10.2105/AJPH.2018.304590PubMedGoogle ScholarCrossref
Vivolo-Kantor A, Pasalic E, Liu S, Martinez PD, Gladden RM; Overdose Morbidity Team. Defining indicators for drug overdose emergency department visits and hospitalisations in ICD-10-CM coded discharge data. Inj Prev. 2021;27(S1):i56-i61. doi:10.1136/injuryprev-2019-043521PubMedGoogle Scholar
Green CA, Perrin NA, Janoff SL, Campbell CI, Chilcoat HD, Coplan PM. Assessing the accuracy of opioid overdose and poisoning codes in diagnostic information from electronic health records, claims data, and death records. Pharmacoepidemiol Drug Saf. 2017;26(5):509-517. doi:10.1002/pds.4157PubMedGoogle ScholarCrossref
Slavova S, Quesinberry D, Costich JF, et al. ICD-10-CM-based definitions for emergency department opioid poisoning surveillance: electronic health record case confirmation study. Public Health Rep. 2020;135(2):262-269. doi:10.1177/0033354920904087PubMedGoogle ScholarCrossref
Fiest KM, Jette N, Quan H, et al. Systematic review and assessment of validated case definitions for depression in administrative data. BMC Psychiatry. 2014;14:289. doi:10.1186/s12888-014-0289-5PubMedGoogle ScholarCrossref
Swain RS, Taylor LG, Braver ER, Liu W, Pinheiro SP, Mosholder AD. A systematic review of validated suicide outcome classification in observational studies. Int J Epidemiol. 2019;48(5):1636-1649. doi:10.1093/ije/dyz038PubMedGoogle ScholarCrossref
Moore BJ, White S, Washington R, Coenen N, Elixhauser A. Identifying increased risk of readmission and in-hospital mortality using hospital administrative data: the AHRQ Elixhauser comorbidity index. Med Care. 2017;55(7):698-705. doi:10.1097/MLR.0000000000000735PubMedGoogle ScholarCrossref
Henry SG, Paterniti DA, Feng B, et al. Patients’ experience with opioid tapering: a conceptual model with recommendations for clinicians. J Pain. 2019;20(2):181-191. doi:10.1016/j.jpain.2018.09.001PubMedGoogle ScholarCrossref
Frank JW, Levy C, Matlock DD, et al. Patients’ perspectives on tapering of chronic opioid therapy: a qualitative study. Pain Med. 2016;17(10):1838-1847. doi:10.1093/pm/pnw078PubMedGoogle ScholarCrossref
Lovejoy TI, Morasco BJ, Demidenko MI, Meath THA, Frank JW, Dobscha SK. Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders. Pain. 2017;158(3):526-534. doi:10.1097/j.pain.0000000000000796PubMedGoogle ScholarCrossref
Frank JW, Lovejoy TI, Becker WC, et al. Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review. Ann Intern Med. 2017;167(3):181-191. doi:10.7326/M17-0598PubMedGoogle ScholarCrossref
