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What bothers me about this epidemic is how easy it could be for authorities to stop. Fentanyl isn't created in the back of a motor home. It is a manufactured

What bothers me about this epidemic is how easy it could be for authorities to stop. Fentanyl isn't created in the back of a motor home. It is a manufactured and controlled narcotic. How controlled - just see the link below. All that needs to happen is for the DEA (et al) to stop raiding homes and torturing people and to pay a visit to these out of control doctors. Why a "Nurse Practitioner" is allowed to prescribe opioids 21937 times - wtf? Opioid prescribing is totally open and public - they aren't hiding it. Here I have a list of the highest prescribing opioid doctors (sunday with beer project): https://www.opendoctor.io/opioid/highest https://www.opendoctor.io/opioid/highest (let me know if you want the sql or whatever).

marcoperaza 9y ago
I remember that about a decade ago, doctors and others were criticizing the DEA for being draconian in their regulations surrounding opiate prescriptions. They were complaining that doctors often felt that they couldn't prescribe even when there was legitimate need. I don't know what happened in the interim, whether or how the DEA's policies changed, but if only we had draconian DEA policies aggressively stopping overprescription now. As someone who used to naively believe in legalizing all drugs for recreational use, this addiction epidemic has opened my eyes to why that's a horrible idea.
- DanBC 9y ago
  > I don't know what happened in the interim The VA noticed a lot of people had untreated pain. They pushed a campaign to make pain the fifth vital sign. Every time someone went into a hospital they'd be asked about pain. Pain was seen as something that absolutely must be treated. They also said that opioids are not addictive if prescribed for pain. It turns out that both of these are mostly wrong. If someone is in pain they'll tell you, you don't need to ask. And if someone has chronic pain they can become addicted to opioids. The VA withdrew that document. Here's a Google cache: https://webcache.googleusercontent.com/search?q=cache:pUQ-mcAJtGwJ:https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf+&cd=1&hl=en&ct=clnk&gl=uk https://webcache.googleusercontent.com/search?q=cache:pUQ-mc... We knew some time ago that it didn't help. Here's a report from 2006: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/
  - mjevans 9y ago
    Actually I agree with asking about pain. If someone's REALLY in pain they'll tell you, but if it's "minor suffering" some are predisposed to tough it out. I can't remember having ever been in 'real pain', maybe for that the addictive drugs should be considered under a monitored regime. For lesser pain something lighter should be used.
- mgkimsal 9y ago
  > but if only we had draconian DEA policies aggressively stopping overprescription now. Not sure what the policies are now, but around me, I can not go get any prescription for any back pain (have really needed it twice in the past 3 years). "Nope, go see your GP" (vs going to a walk-in clinic). The walk-ins around here all have signs on the front door saying "no prescriptions for oxycontin, etc" Now... yes, I could try to "see my GP", which generally means waiting a few days. (and, I don't really have a GP anymore, because I can never get in to see him). What's strange is that about... 6 years ago, going to one of the same clinics, my wife went with an eye problem. Specifically, she'd had a small piece of sand get in her eye, and it was really sort/irritated. Home flushing wasn't working, so we went to the clinic. As she was leaving, they asked if she felt she needed any pain medication. "Well, not really, but it's a bit sore, and I do have a headache". They gave her a script for 14 oxycontin on the spot. Same place last year would not even talk to me about pain medication ("go see your GP").
  - nxc18 9y ago
    Those practices (handing out oxy) are a major contributor to the current epidemic, if not the root cause. I've gotten opiate prescriptions I had no business having without asking. I get that some people need pain medication or will suffer, but there's a whole lot of suffering that opiate addiction causes and that is not really factored into the 'do no harm' calculation doctors are supposed to be doing. It really is a great thing to see legitimate restrictions on these prescriptions, as that should cut down on new addicts at the very least.
    - thearn4 9y ago
      I guess part of this is doctors overprescribing to prevent patient complaints, based on how much patient satisfaction surveys are used to rate their year over year performance. I don't know if its the AMA to blame for that or not, but everyone in the system seems to think its an upstream problem.
    - pkaye 9y ago
      I'm hearing on the one side that these legal prescriptions are causing the problems but on the other had others say that these drugs being illegal is causing the problem and if we made them legal that people will use them in a safe manner. If people get addicted them when prescribed legally then how can making them legal have any hope?
- WalterBright 9y ago
  > why that's a horrible idea Making drugs that people want illegal has never worked. Why should it work now? Besides, the drugs being illegal increases the death rate from them, because users now have little idea of what they are taking, and overdose easily.
  - sp332 9y ago
    Prohibition worked pretty well from a public health perspective. https://en.wikipedia.org/wiki/Prohibition_in_the_United_States#Rates_of_consumption_during_Prohibition https://en.wikipedia.org/wiki/Prohibition_in_the_United_Stat... It was the organized crime that was the problem.
    - nsgi 9y ago
      Organised crime is bad for public health
      - sp332 9y ago
        On balance it's still a win. Alcoholism kills a lot of people.
        koolba 9y ago
        Depends on what you're measuring. If it's pure death rates sure but throw in quality of life and it's not as clear cut. I personally wouldn't want to live in a world where I can't enjoy a glass of whiskey.
        sp332 9y ago
        That's not going to offset fetal alcohol syndrome or people raised by drunk parents or recovered alcoholics living with health issues for the rest of their lives.
        koolba 9y ago
- notadoc 9y ago
  > As someone who used to naively believe in legalizing all drugs for recreational use, this addiction epidemic has opened my eyes to why that's a horrible idea. You may be surprised to learn that opium and cocaine used to be sold widely at pharmacies over the counter. Curiously, there was not a widespread "epidemic" of addiction. Why is that? Alcohol and nicotine are legal and ubiquitous, where are the epidemics of their addiction? Curiously, smoking has been declining despite it being widely available and very addictive. Blaming the existence of a substance for addiction, and then harassing doctors and patients as a result, is nearing the height of absurdity.
  - maxerickson 9y ago
    Don't both alcohol and nicotine have far more dependent users than opioids? What is the comparison meant to illustrate? That easy availability will increase use and that the effects of the drug are the more important matter?
sndean 9y ago
> Fentanyl isn't created in the back of a motor home. But it probably could be, if there's a market for it. There are trained chemists making meth [0]. The sale of the precursors of fentanyl is controlled, but so are the precursors to meth. If fentanyl (or an analog) stays popular we'll have people making their own. Edit: I'm not saying it would be as obtaining PSE, but if you're a member of a chem lab, the only thing between you and an order to Sigma is ~two signatures? There's too much money involved for it to not happen. [0] http://news.sky.com/story/inside-the-cartels-cooking-crack-in-mexico-city-10353129 http://news.sky.com/story/inside-the-cartels-cooking-crack-i... (I know, Sky News..)
- deleted 9y ago
  [deleted]
- tomjen3 9y ago
  My brother studies Chemistry. One of the first things they told them was that they could make Meth (I think) with a street value of about 1000 times the cost of the materials, but the police would know where to start looking as soon as they got their hands on some, because it would be too pure, too well made. Mind you, this was told to incoming (freshmen) students, presumably the professors would be able to make the precursors in such a way that the authorities wouldn't know.
  - archgoon 9y ago
    So is the idea that the school tells them they could totally do this, and they'd get caught, so as to preempt students from coming up with the idea on their own?
    - vzcx 9y ago
      Eh, it sounds like the teacher is just trying to get their class excited about the chemistry. Come for the very pure drugs, stay for the molecular orbital theory and the love of the lab.
      - 9y ago
dpc59 9y ago
A lot of the fentanyl in Canada comes from china and was ordered over the dark web.
- hackermailman 9y ago
  Fentanyl and other opioid synthetics were legal to export in China until very recently, so ordering it was as simple as going on Alibaba or other wholesaler chemical sites and just bringing in enough of it that customs would miss a few shipments. Now that there are regulations involved on the Chinese side the price of Fentanyl smuggling has risen and it's no longer an attractive synthetic to maximize profits for dealers so they are importing other synthetics or Fentanyl from countries who still don't have export laws. Realistically the only way to stop this problem besides legalization is labs for testing pills and powders like they have in Spain and Netherlands, and mobile Suboxone clinics[1] which were proven here (Vancouver, Canada) to be the best solution for addict recovery as they can pick up the phone and have somebody quietly prescribe them Suboxone treatment without having to queue up at the methodone clinics everyday. Suboxone was described to me as satisfying the 'fiend' cravings while not making you high, so you can function sober and no longer need to chase daily money to satisfy a drug addiction and can actually plan things. It also ensures you won't use again since the antagonist ingredients makes it more difficult or impossible to use other opioids at the same time, making relapse less likely. The safe injection sites here are a double edged sword. On one hand they are helpful for street addicts but on the other hand they are more likely to take risks, knowing there's a nurse there so aren't afraid of mystery powders like they used to be, according to anecdotes of people I've talked to who frequent them. The city handed out overdose kits to street users who demanded a peer to peer type safe injection network but the junkies stole the needles out of the kits to shoot up with basically rendering them useless and wasting the hundreds of thousands it cost to distribute them. There's some data here about the Netherlands success in drug use reduction, they put a lot of funds into prevention instead of just treatment. http://www.emcdda.europa.eu/publications/country-drug-reports/2017/netherlands http://www.emcdda.europa.eu/publications/country-drug-report... [1] https://www.theglobeandmail.com/news/british-columbia/a-bc-clinic-is-showing-how-quick-treatment-can-get-patients-offopioids/article33815291/ https://www.theglobeandmail.com/news/british-columbia/a-bc-c...
opportune 9y ago
You're right that doctors can prescribe fentanyl, but I'm not so sure about your (implied) claim that prescribed fentanyl is contributing to the opioid epidemic. To my knowledge, fentanyl is safe to take when done in proper doses (as are most painkillers). The problem with fentanyl is that since it is so much more potent than drugs like heroin, when the two are mixed people can overdose much more easily since they won't know that the fentanyl. And the fentanyl being mixed in with heroin isn't coming from Dilaudid prescriptions, it's coming from China: http://securepackages.org/wp-content/uploads/2017/02/USCC-Staff-Report_Fentanyl-China’s-Deadly-Export-to-the-United-States020117.pdf http://securepackages.org/wp-content/uploads/2017/02/USCC-St... So unless you can figure out a way to stop the drug trafficking industry, fentanyl+heroin aren't going away. Perhaps we will see fentanyl produced less if China cracks down / increases regulations on their pharmaceutical industry. Unfortunately the opioid epidemic is going to have to be stopped by moving away from the casual prescription of opioids, which is what creates opioid addiction in the first place. I think your open doctor project is really cool and is a good way to start: shame doctors who are essentially operating as pill mills for their "patients." My hope is that people so obviously abusing the system like the doctors at the top of your list end up losing their license to practice medicine, or behind bars.
- hammock 9y ago
  A lot of fentanyl is coming from Mexico, where they easily synthesize it, and it's introduced into the heroin supply as a cutting agent. Whether or not it's "contributing to the opioid epidemic" depends on how you interpret that phrase. In other words, people are getting HOOKED on opioids because of the 12hr dosing of oxy etc that has been discussed on HN in the past. But people are DYING OF OVERDOSES because they cannot afford/lose access to pills and switch to heroin from the street (adulterated with fentanyl).
  - opportune 9y ago
    The source I linked mentions that the primary route fentanyl takes is from labs in China to Mexico, then to the US. Yes, we are in agreement then. I just don't think the epidemic (or the deaths) is as easy to stop as ransom1538 thinks, because the fentanyl problem by itself stems from trafficking instead of prescriptions. AndYou can't really stop the drug trafficking part of things very efficiently, see the DEA for proof. Personally I believe that the deaths are secondary to the addiction anyway. Of course, it's very, very bad that people are dying due to adulterated heroin, but the most effective way to lower deaths is probably to prescribe less of those 12hr oxies.
chrshawkes 9y ago
Fentanyl even killed Prince
notadoc 9y ago
Have you ever considered that perhaps there are just a lot of people with various levels of chronic pain, and, shockingly, some of them may want to manage their pain and see a doctor and end up with medication? > "an estimated 25.3 million adults (11.2 percent) experience chronic pain—that is, they had pain every day for the preceding 3 months. Nearly 40 million adults (17.6 percent) experience severe levels of pain." https://nccih.nih.gov/news/press/08112015 https://nccih.nih.gov/news/press/08112015
- ekianjo 9y ago
  Yes but opoids has many risks and should only be prescribed to a minority. This is not what is happening.
  - notadoc 9y ago
    Are you a doctor, anesthesiologist, or other clinical pain management specialist?
    - ekianjo 9y ago
      Not a doctor but working on a daily basis with them.
  - krageon 9y ago
    Leaving aside the question of competence, what alternatives would you suggest?

marcoperaza 9y ago

I remember that about a decade ago, doctors and others were criticizing the DEA for being draconian in their regulations surrounding opiate prescriptions. They were complaining that doctors often felt that they couldn't prescribe even when there was legitimate need. I don't know what happened in the interim, whether or how the DEA's policies changed, but if only we had draconian DEA policies aggressively stopping overprescription now. As someone who used to naively believe in legalizing all drugs for recreational use, this addiction epidemic has opened my eyes to why that's a horrible idea.

DanBC 9y ago
> I don't know what happened in the interim The VA noticed a lot of people had untreated pain. They pushed a campaign to make pain the fifth vital sign. Every time someone went into a hospital they'd be asked about pain. Pain was seen as something that absolutely must be treated. They also said that opioids are not addictive if prescribed for pain. It turns out that both of these are mostly wrong. If someone is in pain they'll tell you, you don't need to ask. And if someone has chronic pain they can become addicted to opioids. The VA withdrew that document. Here's a Google cache: https://webcache.googleusercontent.com/search?q=cache:pUQ-mcAJtGwJ:https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf+&cd=1&hl=en&ct=clnk&gl=uk https://webcache.googleusercontent.com/search?q=cache:pUQ-mc... We knew some time ago that it didn't help. Here's a report from 2006: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/
- mjevans 9y ago
  Actually I agree with asking about pain. If someone's REALLY in pain they'll tell you, but if it's "minor suffering" some are predisposed to tough it out. I can't remember having ever been in 'real pain', maybe for that the addictive drugs should be considered under a monitored regime. For lesser pain something lighter should be used.
mgkimsal 9y ago
> but if only we had draconian DEA policies aggressively stopping overprescription now. Not sure what the policies are now, but around me, I can not go get any prescription for any back pain (have really needed it twice in the past 3 years). "Nope, go see your GP" (vs going to a walk-in clinic). The walk-ins around here all have signs on the front door saying "no prescriptions for oxycontin, etc" Now... yes, I could try to "see my GP", which generally means waiting a few days. (and, I don't really have a GP anymore, because I can never get in to see him). What's strange is that about... 6 years ago, going to one of the same clinics, my wife went with an eye problem. Specifically, she'd had a small piece of sand get in her eye, and it was really sort/irritated. Home flushing wasn't working, so we went to the clinic. As she was leaving, they asked if she felt she needed any pain medication. "Well, not really, but it's a bit sore, and I do have a headache". They gave her a script for 14 oxycontin on the spot. Same place last year would not even talk to me about pain medication ("go see your GP").
- nxc18 9y ago
  Those practices (handing out oxy) are a major contributor to the current epidemic, if not the root cause. I've gotten opiate prescriptions I had no business having without asking. I get that some people need pain medication or will suffer, but there's a whole lot of suffering that opiate addiction causes and that is not really factored into the 'do no harm' calculation doctors are supposed to be doing. It really is a great thing to see legitimate restrictions on these prescriptions, as that should cut down on new addicts at the very least.
  - thearn4 9y ago
    I guess part of this is doctors overprescribing to prevent patient complaints, based on how much patient satisfaction surveys are used to rate their year over year performance. I don't know if its the AMA to blame for that or not, but everyone in the system seems to think its an upstream problem.
  - pkaye 9y ago
    I'm hearing on the one side that these legal prescriptions are causing the problems but on the other had others say that these drugs being illegal is causing the problem and if we made them legal that people will use them in a safe manner. If people get addicted them when prescribed legally then how can making them legal have any hope?
WalterBright 9y ago
> why that's a horrible idea Making drugs that people want illegal has never worked. Why should it work now? Besides, the drugs being illegal increases the death rate from them, because users now have little idea of what they are taking, and overdose easily.
- sp332 9y ago
  Prohibition worked pretty well from a public health perspective. https://en.wikipedia.org/wiki/Prohibition_in_the_United_States#Rates_of_consumption_during_Prohibition https://en.wikipedia.org/wiki/Prohibition_in_the_United_Stat... It was the organized crime that was the problem.
  - nsgi 9y ago
    Organised crime is bad for public health
    - sp332 9y ago
      On balance it's still a win. Alcoholism kills a lot of people.
      - koolba 9y ago
        Depends on what you're measuring. If it's pure death rates sure but throw in quality of life and it's not as clear cut. I personally wouldn't want to live in a world where I can't enjoy a glass of whiskey.
        sp332 9y ago
        That's not going to offset fetal alcohol syndrome or people raised by drunk parents or recovered alcoholics living with health issues for the rest of their lives.
        koolba 9y ago
notadoc 9y ago
> As someone who used to naively believe in legalizing all drugs for recreational use, this addiction epidemic has opened my eyes to why that's a horrible idea. You may be surprised to learn that opium and cocaine used to be sold widely at pharmacies over the counter. Curiously, there was not a widespread "epidemic" of addiction. Why is that? Alcohol and nicotine are legal and ubiquitous, where are the epidemics of their addiction? Curiously, smoking has been declining despite it being widely available and very addictive. Blaming the existence of a substance for addiction, and then harassing doctors and patients as a result, is nearing the height of absurdity.
- maxerickson 9y ago
  Don't both alcohol and nicotine have far more dependent users than opioids? What is the comparison meant to illustrate? That easy availability will increase use and that the effects of the drug are the more important matter?

sndean 9y ago

> Fentanyl isn't created in the back of a motor home. But it probably could be, if there's a market for it. There are trained chemists making meth [0]. The sale of the precursors of fentanyl is controlled, but so are the precursors to meth. If fentanyl (or an analog) stays popular we'll have people making their own. Edit: I'm not saying it would be as obtaining PSE, but if you're a member of a chem lab, the only thing between you and an order to Sigma is ~two signatures? There's too much money involved for it to not happen. [0] http://news.sky.com/story/inside-the-cartels-cooking-crack-in-mexico-city-10353129 http://news.sky.com/story/inside-the-cartels-cooking-crack-i... (I know, Sky News..)

deleted 9y ago
[deleted]
tomjen3 9y ago
My brother studies Chemistry. One of the first things they told them was that they could make Meth (I think) with a street value of about 1000 times the cost of the materials, but the police would know where to start looking as soon as they got their hands on some, because it would be too pure, too well made. Mind you, this was told to incoming (freshmen) students, presumably the professors would be able to make the precursors in such a way that the authorities wouldn't know.
- archgoon 9y ago
  So is the idea that the school tells them they could totally do this, and they'd get caught, so as to preempt students from coming up with the idea on their own?
  - vzcx 9y ago
    Eh, it sounds like the teacher is just trying to get their class excited about the chemistry. Come for the very pure drugs, stay for the molecular orbital theory and the love of the lab.
    - 9y ago

dpc59 9y ago

A lot of the fentanyl in Canada comes from china and was ordered over the dark web.

hackermailman 9y ago
Fentanyl and other opioid synthetics were legal to export in China until very recently, so ordering it was as simple as going on Alibaba or other wholesaler chemical sites and just bringing in enough of it that customs would miss a few shipments. Now that there are regulations involved on the Chinese side the price of Fentanyl smuggling has risen and it's no longer an attractive synthetic to maximize profits for dealers so they are importing other synthetics or Fentanyl from countries who still don't have export laws. Realistically the only way to stop this problem besides legalization is labs for testing pills and powders like they have in Spain and Netherlands, and mobile Suboxone clinics[1] which were proven here (Vancouver, Canada) to be the best solution for addict recovery as they can pick up the phone and have somebody quietly prescribe them Suboxone treatment without having to queue up at the methodone clinics everyday. Suboxone was described to me as satisfying the 'fiend' cravings while not making you high, so you can function sober and no longer need to chase daily money to satisfy a drug addiction and can actually plan things. It also ensures you won't use again since the antagonist ingredients makes it more difficult or impossible to use other opioids at the same time, making relapse less likely. The safe injection sites here are a double edged sword. On one hand they are helpful for street addicts but on the other hand they are more likely to take risks, knowing there's a nurse there so aren't afraid of mystery powders like they used to be, according to anecdotes of people I've talked to who frequent them. The city handed out overdose kits to street users who demanded a peer to peer type safe injection network but the junkies stole the needles out of the kits to shoot up with basically rendering them useless and wasting the hundreds of thousands it cost to distribute them. There's some data here about the Netherlands success in drug use reduction, they put a lot of funds into prevention instead of just treatment. http://www.emcdda.europa.eu/publications/country-drug-reports/2017/netherlands http://www.emcdda.europa.eu/publications/country-drug-report... [1] https://www.theglobeandmail.com/news/british-columbia/a-bc-clinic-is-showing-how-quick-treatment-can-get-patients-offopioids/article33815291/ https://www.theglobeandmail.com/news/british-columbia/a-bc-c...

opportune 9y ago

You're right that doctors can prescribe fentanyl, but I'm not so sure about your (implied) claim that prescribed fentanyl is contributing to the opioid epidemic. To my knowledge, fentanyl is safe to take when done in proper doses (as are most painkillers). The problem with fentanyl is that since it is so much more potent than drugs like heroin, when the two are mixed people can overdose much more easily since they won't know that the fentanyl. And the fentanyl being mixed in with heroin isn't coming from Dilaudid prescriptions, it's coming from China: http://securepackages.org/wp-content/uploads/2017/02/USCC-Staff-Report_Fentanyl-China’s-Deadly-Export-to-the-United-States020117.pdf http://securepackages.org/wp-content/uploads/2017/02/USCC-St... So unless you can figure out a way to stop the drug trafficking industry, fentanyl+heroin aren't going away. Perhaps we will see fentanyl produced less if China cracks down / increases regulations on their pharmaceutical industry. Unfortunately the opioid epidemic is going to have to be stopped by moving away from the casual prescription of opioids, which is what creates opioid addiction in the first place. I think your open doctor project is really cool and is a good way to start: shame doctors who are essentially operating as pill mills for their "patients." My hope is that people so obviously abusing the system like the doctors at the top of your list end up losing their license to practice medicine, or behind bars.

hammock 9y ago
A lot of fentanyl is coming from Mexico, where they easily synthesize it, and it's introduced into the heroin supply as a cutting agent. Whether or not it's "contributing to the opioid epidemic" depends on how you interpret that phrase. In other words, people are getting HOOKED on opioids because of the 12hr dosing of oxy etc that has been discussed on HN in the past. But people are DYING OF OVERDOSES because they cannot afford/lose access to pills and switch to heroin from the street (adulterated with fentanyl).
- opportune 9y ago
  The source I linked mentions that the primary route fentanyl takes is from labs in China to Mexico, then to the US. Yes, we are in agreement then. I just don't think the epidemic (or the deaths) is as easy to stop as ransom1538 thinks, because the fentanyl problem by itself stems from trafficking instead of prescriptions. AndYou can't really stop the drug trafficking part of things very efficiently, see the DEA for proof. Personally I believe that the deaths are secondary to the addiction anyway. Of course, it's very, very bad that people are dying due to adulterated heroin, but the most effective way to lower deaths is probably to prescribe less of those 12hr oxies.

chrshawkes 9y ago

Fentanyl even killed Prince

notadoc 9y ago

Have you ever considered that perhaps there are just a lot of people with various levels of chronic pain, and, shockingly, some of them may want to manage their pain and see a doctor and end up with medication? > "an estimated 25.3 million adults (11.2 percent) experience chronic pain—that is, they had pain every day for the preceding 3 months. Nearly 40 million adults (17.6 percent) experience severe levels of pain." https://nccih.nih.gov/news/press/08112015 https://nccih.nih.gov/news/press/08112015

ekianjo 9y ago
Yes but opoids has many risks and should only be prescribed to a minority. This is not what is happening.
- notadoc 9y ago
  Are you a doctor, anesthesiologist, or other clinical pain management specialist?
  - ekianjo 9y ago
    Not a doctor but working on a daily basis with them.
- krageon 9y ago
  Leaving aside the question of competence, what alternatives would you suggest?