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This probably isn’t quite what you’re asking, but of all the weird medication scams out there, I think the scammiest might be Silenor.

It works like this: doxepin (brand name: Sinequan) is an antidepressant from the 1970s, rarely used these days. A typical dose would have been about 100 mg. Some people noticed that very low doses of doxepin (maybe 10 mg) would put people to sleep. So even though as an antidepressant it’s been mostly replaced by SSRIs and stuff, for the past 40 years psychiatrists have used very low doses off-label as a sleeping pill. Not all psychiatrists did this, because you have to open a pharmacology textbook to realize that this sort of odd way of using an obsolete medication is even an option, but enough psychiatrists that it was a reasonably common practice. And a cheap one too - a supply of the 10 mg dose costs about $10 per month.

In 2010, Somaxon Pharmaceuticals rebranded low-dose doxepin as a new sleeping pill, Silenor. They spent $170 million to get it approved by the FDA at a dose of 6 mg (this non-round number will be important), with a nice FDA label saying “THIS PILL IS APPROVED FOR SLEEP”. Now they are selling it for about $450 per month.

You might ask: if you can get a month’s supply of 10 mg pills of a certain drug for $10, and a month’s supply of 6 mg pills of the exact same drug for $450, surely everyone will just buy the $10 version, right? Well, some people do, other people don’t; sales of Silenor are about $5 - $10 million/year.

Why? Well, about half of doctors don’t realize Silenor is just doxepin. The other half realize it, but have no incentive to prescribe the cheaper pill and can’t be bothered to do so. Part of this is that the official FDA studies showing doxepin promotes sleep were only done on the 6 mg dose. Everyone knows from personal experience that the 10 mg dose also makes you sleepy, there’s no pharmacological reason to believe the 10 mg dose is much different from the 6 mg dose, but if you prescribe the 10 mg dose then annoying people might say “Oh, you’re just EXTRAPOLATING from a study done on the 6 mg and your own anecdotal experience? Guess you must HATE EVIDENCE-BASED MEDICINE.”

(the blog Thought Broadcast does a good job looking into some of the actual pharmacology here - see https://thoughtbroadcast.com/2011/03/18/thank-you-somaxon-pharmaceuticals/ )

The good news is that even $10 million/year sales of Silenor aren’t enough to recoup the company’s initial investment in getting it through the FDA, so they’re going to make a huge loss from the whole affair and maybe this will discourage other people from trying the same thing. In the future, I expect pharma companies will stick to their usual strategy of at least taking a stereoisomer or a metabolite of an old medication before claiming that they’ve found something new and exciting we should all pay ten times as much for.

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I really wanted to link to this Jacobite article (via Left Conservative which I’m pretty sure is @bambamramfan?) with the description “This article explains why IKEA is awesome, as a metaphor for why liberalism is great.”

Rather, they have no concept of foreignness at all, because they have no native traditions against which to compare. Indeed, the very idea of a life shaped by inherited custom is alien to our young couple. When Jennifer and Jason try to choose a restaurant for dinner, one of them invariably complains, “I don’t want Italian, because I had Italian last night.” It does not occur to them that in Italy, most people have Italian every night. For Jennifer and Jason, cuisines, musical styles, meditative practices, and other long-developed customs are not threads in a comprehensive or enduring way of life, but accessories like cheap sunglasses, to be casually picked up and discarded from day to day. Unmoored, undefined, and unaware of any other way of being…

Like, isn’t that obviously the goal and the good life?

But he said too many things I substantively disagree with for that joke to land comfortably, especially in the second half. Including the next part of that quote! “Unmoored, undefined, and unaware of any other way of being, Jennifer and Jason are no one.” But the great thing about unmooring is that it allows you to recreate yourself, as you wish yourself. It makes you someone much more thoroughly than slotting into a pre-existing community would.

Basically, this bit is utterly baffling to me:

If one is not attached to a way of life structured by inherited values and customs, then one is unlikely to be attached to anything at all. Jennifer and Jason illustrate this: life choices follow arbitrary taste, friends come and go, ties with family are thin, and superficial interactions (largely online) with peers fill the gap.

The fact that my values and relationships aren’t inherited doesn’t have to make them shallow.

…it is not especially difficult to square this circle.

Short-short-short version: it’s much better to be a real self-created person with a real unique identity than to be a prefab generic traditional-model person, but it’s also much better to be a prefab generic traditional-model person than to be Jennifer/Jason.  And, at this stage in our cultural development, it’s not wrong to recognize that the world contains a lot more Jennifers and Jasons than real self-created persons.

Which is to say –

Constructing yourself takes work.  It takes work to go out and comb through a whole bunch of possible self-bits (interests styles philosophies mannerisms books movies etc.), so that when you’re trying to figure out what you want to take up into yourself, you have a reasonably-sized array of things from which to choose.  It takes work to reject the conformist identity pressures, both great and subtle, being imposed by everyone around you – and to keep on rejecting them, over and over and over.  It takes work to keep on investing in things even when they’re not immediately rewarding.  It takes work to say I AM FOO AND NOT BAR to a world that is almost certainly indifferent, and quite probably hostile, to such choices. 

Certain people do that work instinctively, usually because they started doing it at a very young age, which is usually because they kind of had to.  When you’re more interested in things than in social acceptance / social status, of course you’re going spend your time and effort checking out a whole bunch of things.  When it’s forcibly made clear to you that you’re Not Like Everyone Else, it’s an obvious next step to go and think about what you are like.  If you’re reading this, the odds are pretty good that you are such a person, and you can take comfort in knowing that this silly IKEA article is not about you.  Yay, weirdo pride, rah rah sis-boom-bah. 

But it doesn’t actually work that way for most people, most of the time. 

Most people aren’t pushed into forging identities for themselves, either by circumstance (which does it only for a few oddballs) or by culture (which at this point doesn’t do it for anyone).  They adopt whatever’s lying around.  They follow the lead of the people they see surrounding them; they walk the path of least resistance, which is usually some kind of general-purpose life behavior script; they adopt the prevailing values, and try to live up to the prevailing standards (because acceptance! and status!). 

The nice thing about traditional communities with well-defined norms is that they allow this strategy to work, mostly.  There’s actually a script for you to follow, and if you follow it, you get rewarded and you fit in.  You won’t blaze like a star or anything, and maybe there’ll be some strange inchoate yearnings deep in your soul that never get answered, but…if you can keep on the straight and narrow (whatever the local version of that may be), you’ll be more or less fine.  People will look upon you with respect and approval.  You will be given the satisfaction of knowing that you did a Good Job.  Even stupid things like “we eat This Dish all the fucking time because it is Our Dish, goddammit” can be sources of identity and pride.  After all – you’re one of Us, right?      

Anomic liberal bourgeois society got rid of the scripts, but didn’t actually teach people how to replace them with properly-crafted individual identities.  So instead you get…Jennifer and Jason. 

They haven’t been trained to do the self-construction thing that weirdos have been doing since early childhood.  (Sometimes they try it out, in desperation or just on a lark, but usually they find that it feels ridiculous and affected. Why am I going through this phase like a teenager, trying to care about this arbitrary thing?  So it doesn’t stick.)  They’re expecting to take their cues from everyone else.  So they watch everyone else, but because there’s no widely-accepted vision of the Good Life in which to ground themselves, all they see is –

– fads.  Fashions.  Petty status competitions and virtue-signaling.  Punishment for doing the wrong thing, for being uncool or unaware, but never any real reward for doing the right thing because there is no right thing.

So they try their hardest to be cool and aware, and they watch the TV shows that everyone they know is watching and they parrot the political opinions that everyone they know is parroting, and surprise! they are wretched, empty, unhappy people. 

You had me until the last line. How is parroting other people’s political opinions and cultural consumption in our society any worse than parroting people’s political opinions and cultural consumption in a traditional society? When a medieval Christian believes that Jesus Is Lord, reads Pilgrim’s Progress, and has a traditional Byzantine icon in his house - how is that interestingly different from or better than all the people who believe that Black Lives Matter, watch John Oliver, and have Ikea furniture?

We have a cultural script. We have well-defined norms and ready-made cookie-cutter identities. You might find them distasteful or silly, but Biblical literalism wasn’t super-great either.

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In Defense of Unreliability, on Thing of Things and LW

I primarily get places through public transit and Uberpool. The Bay Area’s public transit system is really really good compared to public transit in most of the rest of the country (for one thing, it is possible to get places on it). However, our public transit is certainly inferior to, say, New York City’s. One of the ways this works is that sometimes, based on the Inscrutable Whim of the Train Gods, the train will choose to show up fourteen minutes late. Uberpool also has high variance in time estimates, because they have to pick up and drop off other people. What this means is that when I say “I will get there at such-and-such a time”, I mean “there is a bimodal distribution of times when I could show up which is centered around this time and probably has a standard deviation of like five to ten minutes.”

I’m in the same position, except my arrival times are normally distributed with a mean of about “five minutes early”. Also, getting places is sufficiently hard that the whole thing is pretty costly in time.

However, I think I count my time as less expensive than Ozy counts theirs, so if people tell me in advance whether earliness or lateness is a better tradeoff for them, I’ll go with that. (I’ve found people prefer lateness to earliness for multi-person social events, so my arrival time has a mean of 5 mins late then, unless they specify otherwise. Meanwhile, individual hangouts in public places are like 10 mins early, while I try to avoid showing up early to people’s houses.)

I flake less than 10% of the time (maybe about 5%?) for things that I actually agree on a date and time for, though I’m sometimes hesitant to do that until I’m sure, because I very much don’t want to cancel after that. I’m OK with other people being flaky about showing up to my house, but I care far more if I have to head out, because going out is costly enough that I don’t want to turn back partway through. I don’t like lateness, but I mind it far less than cancellation.

I think it would be good if how flaky people were was information they shared publicly so that we could plan around that, along with what their arrival time distributions were. However, I understand why people aren’t incentivised to publicise that. :(

I think this breaks down when more than two people are involved.

When I went to school in Ireland, there was a culture there of not worrying much about being on time. Since only a fraction of the class would be there at the supposed starting time, the professor would wait until ten minutes after the supposed starting time when they could be pretty sure most people would be there. Well, soon enough we all realized it was stupid to come on time since we’d just be sitting ten minutes for no reason. So everyone would come ten minutes after the official starting time. But we couldn’t make that *official*, because then everyone would just come ten minutes after the new starting time, and so on.

So what we ended up with was a weird equilibrium where everyone trickled in at different times, and the professor would start at some unpredictable time in a distribution centered around ten minutes after the official starting time, and then inevitably be interrupted by a couple of people slamming the door as they entered. And if you tried to guess when the starting time would be, then sometimes you would guess wrong and be late, and other times you would guess wrong and be really early and have to sit around, and if you were a scrupulous person who felt bad about arriving ten minutes late. or an autistic-ish person who takes written rules seriously, then you were always going to waste about ten minutes of every day.

Also, we switched lecturers a lot, and every so often we would get a lecturer who was really strict, and who started exactly on time and locked the doors as soon as she started teaching, and then something like 75% of the class would miss the lecture. So you had to be okay with either missing some fraction of the lectures (and maybe getting yelled at later) or wasting ten minutes every day sitting around doing nothing.

I see this at parties too. Everyone assumes everyone else will be late to the party, but nobody knows how late, so unless you have some sort of weird social sixth sense that lets you predict this, you either miss the party or end up showing up super-awkwardly when no one else is there and having to just sort of sit quietly and stare at the host for an hour or so.

On the other hand, I’ve also lived in places where things that say they’re going to start at 8 actually start at 8, and it’s great. For the cost of giving the rare person who arrives at 8:05 slightly dirty looks, I can know exactly when to get to a place and have them be respectful of my time.

But in order for this to work, there has to be a culture of trying to arrive at the time you said you would. And I’m not sure you can have that culture for multi-person events without having at least some kind of relevant social norm as the default for two-person events.

Best medication for insomnia?

Sep. 23rd, 2017 01:36 am
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“Best” is a meaningless term here. Are we talking initial insomnia? Middle insomnia? Terminal insomnia? How old are you? What treatments have previously failed? Do you have a family or personal history of addiction? How bad for you would it be if the medication didn’t last long enough and made you wake up early, versus if it lasted too long and made you groggy during the day. How good is your insurance? What other conditions is your insomnia associated with?

There’s a reason why we do this whole “doctor” thing instead of just making a website saying “The best medication for insomnia is X, pass it on.”

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First of all, if you haven’t already, get a competent cardiologist’s opinion about whether your heart condition really prevents you from taking stimulants.

If so, look into guanfacine, atomoxetine, and clonidine. Your cardiologist may or may not approve modafinil; if they do, that’s also worth considering.

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I think this is another case of “thing you’re describing might exist, but the magnitude is nowhere near big enough to justify the importance you’re ascribing it.”

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The future may suck in unpredictable ways, and may have the same laws against suicide as the present, only better enforced. If you’re anything like a negative utilitarian, even a weak wishy-washy negative utilitarian, this should be a pretty big deal.

Also, it’s pretty hard to come up with a theory of identity strong enough to support cryonics, but weak enough to still need it. See http://lesswrong.com/lw/bg0/cryonics_without_freezers_resurrection/

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People who have tragic events happen to them often get depressed. I think of tragedy as a very strong risk factor for depression in the same way that smoking is a risk factor for lung cancer. Some people will suffer tragedy but not be depressed, other people will get depressed without tragedy, but overall the correlation is pretty impressive.

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The effect you mention sounds like the sort of thing that might exist, but I have no idea why you think the magnitude is that big. I think you are wrong about being 10 years from 100% unemployment. Remember that even if AI were perfect tomorrow, there would still be gigantic structural and regulatory barriers to using it.

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You mean like “dopamine deficiency disorder”?

If we’d used that naming system in the past, depression would have been “black bile excess disorder”, autism would have been “maternal closeness deficiency disorder”, and schizophrenia would have been “demonic possession disorder”. Let’s not start naming stuff after the etiology until we’re way more sure than we are now about what the etiology actually is.

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It seems to take a lot of work to make it happen, so my guess is nobody tries it, and if they did they would just stop concentrating-super-hard. You’d have to be a masochist to do it on purpose.

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I noticed something odd doing meditation earlier, where I felt like the object of meditation was unstable or fluctuating in a hard-to-describe way, and I figured it was just me personally being bad at meditating. I didn’t think of it as a “vibration” until I heard someone call it that.

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I don’t think people think these laws through or enforce them. I think it’s mostly just so that if they see someone carrying a ziploc bag full of Oxycontin to the local sketchy street corner, they have one more charge to pin on them.