A reporter recently told me she thought there is a national trend toward hospitals issuing more bonds. I tried to verify this and found it surprising hard to do with publicly available data. But once I had to spend an hour digging through private Compustat data to find the answer, I figured I should share some results. Here’s the average debt in millions of companies by sector:
Source: My graph made from Compustat North American Fundamentals Annual data collapsed by Standard Industrial Classification code into the Fama-French 10 sectors
This shows that health care is actually the least-indebted sector, and telecommunications the most indebted, followed by utilities and “other” (a broad category that actually covers most firms in the Fama-French 10). But are health care firms really more conservative about debt, or are they just smaller? Let’s scale the debt by showing it as a share of revenue:
My graph made from Compustat North American Fundamentals Annual data collapsed by SIC code into the Fama-French 10 sectors(dltt/revt).
It appears that health care firms are the most indebted relative to revenue since 2023. But which parts of health care are driving this?
Hospitals in 2023 followed by specialty outpatient in 2024. However, seeing how much the numbers bounce around from year to year, I suspect they are driven by small numbers of outlier firms. This could be because Compustat North America data only covers publicly traded firms, but many sectors of health care are dominated by private corporations or non-profits.
I welcome suggestions for datasets on the bond-market side of things that are able to do industry splits including private companies, or suggestions for other breakdowns you’d like to see me do with Compustat.
The United Healthcare Group (UNH) is a gigantic ($260 B market cap, even after recent dip) health plan provider, which until recently seemed to be the bluest of blue-chip companies. It is a purveyor of essential medical services with a wide moat, largely unaffected by tariff posturing, and considered too big to fail. The ten-year stock price chart shows it steadily grinding up and up, shrugging off market tantrums like 2020 and 2022, and even the tragic gunning down of one of its division presidents in December.
But things really unraveled in the past month. Let’s look at the charts, and then get into the underlying causes.
The year-to-date chart above shows the price hanging around $500, then rising to nearly $600 as the April 17 quarterly earnings report approached. Presumably the market was licking its chops in anticipation of the usual UNH earnings beat. The actual report was OK by most corporate standards, but it failed to match expectations. Revenue growth was a hearty +9.8% Y/Y, but this was $2.02B “miss”. Earnings were up 4% over year-ago Q1, but they missed expectation (by a mere 1%). What was probably much more disturbing was guidance on 2025 total adjusted earnings down to $26 to $26.50 per share, compared to $29.74 consensus.
That took the stock down from $600 to around $450 immediately, and then it drifted below $400 in the following month as investors looked for and failed to find better news on the company. But then two things happened last week. The effects are seen in the 1-month chart below:
On May 13 (blue arrow) the company came out with a stunning dual announcement. It noted that the recently-appointed CEO, Andrew Witty, had suddenly resigned “for personal reasons.” The blogosphere speculated (perhaps unfairly) that you don’t suddenly resign from a $25 million/year job unless your “personal reasons” involve things like not going to prison for corporate fraud. The other stunner was that the company completely yanked 2025 financial guidance, due to an unexpected rise in health care costs (i.e., what they must pay out to their participants). Over the next day or two, the stock fell to about 50% of its value in early April.
Then on May 14 the Wall Street Journal came out with an article claiming that the U.S. Department of Justice is carrying out a criminal investigation into UNH for possible Medicare fraud, focusing on the company’s Medicare Advantage business practices. The WSJ said that while the exact nature of the allegations is unclear, it has been an active probe since at least last summer.
UNH promptly fired back a curt response to the “deeply irresponsible” reporting of the WSJ:
We have not been notified by the Department of Justice of the supposed criminal investigation reported, without official attribution, in the Wall Street Journal today.
The WSJ’s reporting is deeply irresponsible, as even it admits that the “exact nature of the potential criminal allegations is unclear.” We stand by the integrity of our Medicare Advantage program.
The stock nose-dived again (red arrow, above), touching 251, as investors completely panicked over “Medicare fraud.” Cooler heads promptly started buying back in, leading to substantial recovery. That includes the new CEO, Steven Hemsley, who was the highly-paid CEO from 2009 to 2017, and since then has been the highly-compensated “executive chairman of the board”, a role created just for him. Pundits were impressed that he stepped in to buy some $25 million of UNH stock near its lows, saying wow, he is really putting some skin in the game. Well, not really: the dude is worth over $1 billion (did I mention high compensation of health care execs?), so $25 mill is hardly heroic. He is already up some 12% or a cool $3 million on this purchase, a tidy little example of how the rich become richer.
The US Department of Health and Human Services has announced it is cutting 10,000 of its 82,000 jobs and restructuring:
As part of the restructuring, the department’s 10 regional offices will be cut to five and its 28 divisions consolidated into 15, including a new Administration for a Healthy America, or AHA, which will combine offices that address addiction, toxic substances and occupational safety into one central office.
AHA will include the Office of the Assistant Secretary for Health, the Health Resources and Services Administration, the Substance Abuse and Mental Health Services Administration, Agency for Toxic Substances and Disease Registry, and the National Institute for Occupational Safety and Health.
These divisions do many different jobs, but as usual what stands out to me is their data- both because it is what I have found directly useful in the past, and because it is what I still have some control over now. Writing your Representatives or writing an op-ed has a minuscule chance of changing Federal policy, but if you download data, you definitely have that data.
What worries me here is that some of the agencies being consolidated might discontinue some of their data products going forward, or even pull some of what they have already created offline. I don’t think this is farfetched given what has happened so far, and given that even in good times these agencies pull down data they painstakingly prepared. For instance, HRSA only publicly posts the State- and County-level Area Health Resources File back to 2019, even though they have annual data going back to 2001.
Probably all 13 of the reorganizing divisions have data worth looking into, and given the staff cuts, even data products in the other divisions could be at risk. But my plan is to focus on the two reorganizing divisions whose data I have previously found useful- HRSA and SAMHSA. HRSA has a nice data download page with 16 different datasets, including the Area Health Resources File, which offers detailed information on the health care workers and facilities in each US county. SAMHSA offers the National Substance Use and Mental Health Services Survey, the Treatment Episode Data Set, and the National Survey of Drug Use and Health. I have previously cleaned and archived the state-level version of the NSDUH, but not the individual-level version that is for now still available from SAMHSA.
All of these datasets are easy to download now, and some will probably become very hard to access later, so now is a good time to take a few minutes and save whatever you think you might need.
Certificate of Need laws require many types of health care providers to obtain the permission of a state board before they are allowed to open or expand in many US states. But there is a lot of variation from state to state in which types of providers are covered by these laws. I put together this map to show the 15 states that require new home health care agencies to obtain a Certificate of Need:
CON states see reduced competition, which tends to be bad news for patients and new entrants, but good for existing providers and the private equity firms consideringbuying them.
But some CON states like Rhode Island have proposed reforms that would exempt home health agencies from the CON process, putting them in line with the majority of states that put new entrants on an even footing with incumbent providers.
A number of weeds growing around your house are edible. Chickweed (Stellaria media) is found in lawns and random areas in cooler climates. It pops out ahead of most other plants in the spring, though it also grows year-round.
It can grow low, hiding in the grass, but it is easier to harvest as a taller standalone clump. Here is a clump from my yard, with the roots and tougher lower parts cut off:
People eat it raw, but I prefer to blanch it first to reduce any bitterness and to get rid of any critters or contaminants. To do that, I got two cups of water boiling in a Pyrex measuring cup, then dropped the chickweed in and stirred it around for a minute, followed by a cool water quench in a colander. The chickweed was then in a wilted state, but still green and crunchy and (as I understand) retaining nearly all its nutrients.
For me, chickweed functions like arugula or cilantro or Italian parsley, as an interesting and worthwhile addition to a salad or sandwich. I would not relish a whole plate of it.
Speaking of nutrients, in folk medicine chickweed is credited with amazing powers. Eat The Planet tells us that:
Chickweed is full of vitamins A, B1, B2, and C as well as fiber and protein. Due to its nutritional contents and numerous medicinal properties, this cold-weather herb has been used in folk medicine for hundreds of years. It can treat many different conditions, such as constipation, bowel problems, iron-deficiency anemia, asthma, bronchitis, joint pains, and blood disorders. It can also aid weight loss by making you feel fuller for longer.
You can also apply the herb directly onto the skin to treat itchiness, bruises, boils, ulcers, and psoriasis. To do this, you can either bruise the leaves or steep the stems in hot water before applying them directly onto the affected areas.
There is no indication that any of the plant’s constituents possess therapeutic activity. Its vitamin content is too low to be of therapeutic value.
Verywellhealth stakes out a middle ground, noting that chickweed has demonstrated significant anti-inflammatory and anti-viral activity in lab experiments with animals, but also noting that these results may or may not translate to efficacy in humans:
Juice or extracts made from chickweed have been studied in test tubes or mice models for the following conditions:
Hepatitis B. Chickweed was shown to have anti-hepatitis B virus activity in a test tube study.
Obesity. Chickweed extract given to overweight mice decreased the amount of food they consumed and their absorption of fats.
Diabetes. Chickweed leaf extract demonstrated antidiabetic effects, such as lowering blood sugar and hemoglobin A1c in mouse models.
Heart problems in people with diabetes. Chickweed tea given to diabetic rats did not improve their blood sugar levels but did seem to protect against cardiomyopathy.
Anxiety. Chickweed given to mice showed similar activity as diazepam, a classic anxiety medication in the benzodiazepine family.
Here I’ll outline a model of the optimal protein consumption bundle. What does this mean? This means consuming the quantities of protein sources that satisfy the recommended daily intake (RDI) of the essential amino acids and doing so at the lowest possible expenditure. Clearly, this post includes a mix of both nutrition and economics. Since a comprehensive evaluation that includes all possible foods would be a heavy lift, here I’ll just outline the method with a small application.
Consider a list of prices for 100 grams of Beef, Eggs, and Pork.* We can also consider a list that identifies the quantity that we purchase in terms of hundreds of grams. Therefore, the product of the two yields the total that we spend on our proteins.
Of course, not all proteins are identical. We need some characteristics by which to compare beef, eggs, and pork. Here, I’ll use the grams of essential amino acids in 100 grams of each protein source. Because there are different RDIs for each amino acid, I express each amino acid content as a proportion of the RDI (represented by the standard molecular letter).
Then, we can describe how much of the RDI of each amino acid that a person consumes by multiplying the amino acid contents by the quantities of proteins consumed.
Our goal is to find the minimum expenditure, B, by varying the quantities consumed, Q, such that the minimum of C is equal to one. If the minimum element of C is greater than one, then a person could consume less and spend less while still satisfying their essential amino acid RDI. If the minimum element is less than one, then they aren’t getting the minimum RDI.
How do we find such a thing? Well, not algebraically, that’s for sure. I’ll use some linear programming (which is kind of like magic, there’s no process to show here).
The solution results in consuming only 116.28 grams of Pork and spending $1.093 per day. The optimal amino acid consumption is also below. Clearly, prices change. So, if eggs or beef became cheaper relative to pork, then we’d get different answers.
In fact, we have the price of these protein sources going back almost every month to 1998. While pork is exceptionally nutritious, it hasn’t always been most cost effective. Below are the prices for 1998-2025. See how the optimal consumption bundle has changed over time – after the jump.
Since I have posted on the recreational drugs/painkillers kava and kratom for the past two weeks (here and here), I figured I would round it out with a look at the various active compounds that can be derived from the cannabis plant. I knew of THC (the main psychoactive ingredient in weed) and CBD (very tame), but there are many others. When I visited that head shop/kava bar in Florida last month, I noted that they sold a lot of products containing THC-A, THC-P, and HHC, since THC sale is illegal there:
“Super Looper” Vapes, Containing Cannabinoids
The stork clerk showed me the following road-map (with its color-coded “Measure Your Mellow” legend) of various cannabinoids, taking you from innocuous CBD (“Non-psychoactive, soothes anxiety, anti-inflammatory; calming, relaxing”) to THC-P (“Very psychoactive, best entourage effect; energizing, euphoric, total head and body high”) and HHC-P (“Strongest and longest-lasting psychoactive effect; energizing, sativa-like effect”):
Road-Map of Cannabinoids, with putative effects.
On this roadmap, the main “THC” ingredient in weed is shown as Delta-9 or trans-delta-9-Tetrahydrocannabinol (rated as “Very Psychoactive”).
I don’t want to go too far down this rabbit-hole, but out of curiosity I looked up a few articles to try to understand this zoo of mind-altering compounds. Out of sheer laziness, I’ll start with Wikipedia’s take on the pharmacology, focusing on THC itself:
When THC enters the blood stream and reaches the brain, it binds to cannabinoid receptors. The endogenous ligand of these receptors is anandamide, the effects of which THC emulates. This agonism of the cannabinoid receptors results in changes in the levels of various neurotransmitters, especially dopamine and norepinephrine, which are closely associated with the acute effects of cannabis ingestion, such as euphoria and anxiety. Some effects may include a general altered state of consciousness, euphoria, relaxation or stress reduction, increased appreciation of the arts, including humor and music, joviality, metacognition and introspection, enhanced recollection (episodic memory), and increased sensuality, sensory awareness, libido, and creativity. Abstract or philosophical thinking, disruption of linear memory and paranoia or anxiety are also typical. Anxiety is cannabis’s most commonly reported adverse side effect. Up to 30 percent of recreational users experience intense anxiety and/or panic attacks after smoking cannabis….Cannabidiol (CBD), another cannabinoid found in cannabis, has been shown to mitigate THC’s adverse effects, including anxiety.
Cannabis produces many other subjective effects, including increased enjoyment of food taste and aroma, and marked distortions in the perception of time. At higher doses, effects can include altered body image, auditory or visual illusions, pseudohallucinations, and ataxia from selective impairment of polysynaptic reflexes. In some cases, cannabis can lead to acute psychosis and dissociative states such as depersonalization and derealization.
Regarding some other cannabinoids:
There are similar compounds in cannabis that do not exhibit psychoactive response but are obligatory for functionality: cannabidiol (CBD), an isomer of THC; cannabivarin (CBV), an analog of cannabinol (CBN) with a different side chain, cannabidivarin (CBDV), an analog of CBD with a different side chain, and cannabinolic acid. CBD is believed to regulate the metabolism of THC by inactivating cytochrome P450 enzymes that metabolize drugs; one such mechanism is via generation of carbon monoxide (a pharmacologically active neurotransmitter) by upon metabolism of CBD.[14] THC is converted rapidly to 11-hydroxy-THC, which is also pharmacologically active, so the euphoria outlasts measurable THC levels in blood.
Almost none of these psychoactive compounds are present in the raw cannabis plant. The raw plant contains THC-A, which is then converted to THC and CBD, etc., by heating (e.g. by the heat of burning the dried leaves in a joint, or by baking in brownies). THC-A itself seems to have some attractive anti-inflammatory properties. This NIH article has a listing of the major classes of cannabinoids along with a description of their chemistries. Various synthetic cannabinoids have also been created, with some them now included in pharmaceutical preparations. I have not dug into all the research, but it seems likely to me that some combination of these other cannabinoids might have more favorable effects than plain old THC.
Although CBD is not itself psychoactive, it appears to helpfully modulate the effects of THC, and to have its own useful properties. It is used to treat seizures, and possibly anxiety and chronic pain. It can be eaten (think: gummy bears) or applied in skin patches (for longest-lasting, controlled exposure) or oils or lotions. Some varieties (e.g. “Full-Spectrum”) of CBD contain traces of THC, and so act more strongly.
Taking cannabinoids via a tincture under the tongue (where it can cross a mucous membrane, into the bloodstream) takes longer than smoking to show effects, but they last longer. It also gives a more precise dosage, and avoids smoke inhalation, so this seems like a preferable route if it is available. I recall reading some months back that a mixture of THC and CBD taken sublingually was effective in controlling pain. Eating cannabis, as in “Colorado” brownies, can be problematic: it often takes several hours to take effect (via liver metabolism), so users get impatient and start eating more brownies, and then end up way higher than intended.
Long-term adverse effects of cannabis are controversial. Some researchers claim there are none, but:
There is evidence that long-term use of cannabis increases the risk of psychosis, regardless of confounding factors, and particularly for people who have genetic risk factors. A 2019 meta-analysis found that 34% of people with cannabis-induced psychosis transitioned to schizophrenia. This was found to be comparatively higher than hallucinogens (26%) and amphetamines (22%).
Long-term cannabis users are at risk for developing cannabinoid hyperemesis syndrome (CHS), characterized by recurrent bouts of intense vomiting and abdominal cramping during or within 48 hours of heavy cannabis use.
Also, a very recent large study found that 63% of long-term heavy cannabis users had significantly reduced brain function for working memory tasks. (I’ll add that I know someone whose trajectory very strongly suggests that exposure to weed in early teens put a permanent crimp in her mental and emotional functioning).
It seems that habitual use of cannabis can result in general “chill” lassitude, which lowers productivity. As one counselor told a friend of mine, “It is true that with weed ‘nothing happens.’ That is just the problem.”
Weed has long been touted as an alternative pain-killer. I know of people who claim benefits here. Most states allow “medical marijuana” for conditions such as chronic pain or nausea. However, its use is still unlawful at the federal level, so weed must be grown in-state and not transported across state lines.
This NIH site summarizes many studies on cannabis for pain. The evidence is very mixed. Often a significant fraction of subjects report improvements, but so do those on placebos.
My totally amateur takeaway from this flyover: THC and related cannabinoids have a variety of effects on the mind, mostly pleasant but sometimes bad or very bad. There seems little evidence for adverse effects of weed on the body (outside of the brain), but real dangers of messing up your brain with heavy or extended use. As usual with these recreational drugs, harmful interactions are very likely if other substances are used at the same time.
As for pain treatment, it’s effectiveness seems to vary a lot among individuals. Weed may be worth a try as an alternative to opioids, but it still carries significant dangers
If I had to pick a poison for myself as alternative painkiller, at this point it would be a tie between weed (which messes with your brain, not so much your body), and kava (whose side effects mainly show in body parts like the liver and the skin, plus brief nausea). I would experiment to see what worked for me. But first I would make every effort to treat pain through some other means. There are many possible treatments for pain which may be safer than cannabis, and new treatments keep coming. For instance, a friend with neuropathy told me that he experienced relief with a new medicine called Neuropaway.
Huge Disclaimer: I have no expert knowledge here. Don’t act on anything here. All I have done is summarize a few articles. Consult your doctor before doing anything.
P.S.
I could not resist taking a look at the side-effects of drinking alcohol. After all, we all do it, and we have all seen headlines claiming health benefits of drinking a glass of red wine a day. Well, the medical community is pretty down on drinking, saying the proven harms far outweigh the few, slight proven benefits. Even “moderate” consumption can overtax the liver, which really damages it, per this.
Whenever researchers are conducting studies using state- or county-level data, we usually want some standard demographic variables to serve as controls; things like the total population, average age, and gender and race breakdowns. If the dataset for our main variables of interest doesn’t already have this, we go looking for a new dataset of demographic controls to merge in; but it has always been surprisingly hard to find a clean, easy-to-use dataset for this. For states, I’ve found the University of Kentucky’s National Welfare Database to be the best bet. But what about counties?
I had no good answer, and the best suggestion I got from others was the CDC SEER data. As so often, the government collected this impressively comprehensive dataset, but only releases it in an unusable format- in this case only as txt files that look like this:
I cleaned and reformatted the CDC SEER data into a neat panel of county demographics that look like this:
I posted my code and data files (CSV, XLSX, and DTA) on OSF and my data page as usual. I also posted the data files on Kaggle, which seems to be more user-friendly and turns up better on searches; I welcome suggestions for any other data repositories or file formats you would like to see me post.
This article was updated on March 1 with additional information on kava side effects.
This is a follow-up to my post last week, describing my visit to a shop purveying beverages laced with kava and with kratom, two substances I had not heard of previously. As a service to readers who may deal with someone who is using these materials, here is what I have found out about what they do to people.
Upfront disclaimer: I have no expertise in this area, these are just the observations of an amateur who has read a few articles. Do not make any decisions based on this article.
Primary Effects of Kava
Kava is made from the roots of a plant in the pepper family, which is native to the Pacific Islands. There are two main classes of kava plants. The “noble” cultivars are what has traditionally been used for human consumption, via water extraction of the roots to make a beverage. The non-noble (two-day or “tudei”) cultivars grow faster (so they are cheaper for production), but are more likely to have adverse side effects. Also, the above-ground parts of the plants are known to contain toxic alkaloids.
The Wikipedia summary of effects is, “Systematic reviews and meta-analyses conducted in the last decade have typically indicated a modest positive effect of kava on anxiety and generalized anxiety disorder, though the evidence is mixed and further research is frequently recommended.”
I found a 2020 memo by a FDA toxicologist, titled “Review of the published literature pertaining to the safety of Kava for use in conventional foods”, which covers both the positive effects and the extensive side-effects. The memo notes: “The major physiological action in humans is consistently reported as a pleasant, mild, centrally acting relaxant property which induces a generalized muscle relaxation and, ultimately, a deep natural sleep. A minor property of kava is its local anesthetic properties which are experienced as numbing of the mucous membranes of the mouth and tongue when the beverage is consumed.” That all sounds pretty nice.
The main active compounds in cava are called kavalactones. Known effects of the six major kavalactones are:
For the biochemists among us: “The psychotropic effects of kava are achieved by the modulation of gamma‐amino‐butyric acid (GABA) receptors. Although the exact mechanisms are not known, studies suggest that the effects are mediated via different mechanisms such as upregulation of GABA‐A receptor function, blockade of voltage‐gated sodium ion channels, enhanced ligand binding across GABA‐A receptor subtypes, and reduced excitatory neurotransmitter release.” GABA is the primary inhibitory neurotransmitter in the central nervous system, so it is commonly targeted by tranquilizers such as benzodiazepines (e.g. Valium). Hence, the calming effect. Research suggests that kava components also inhibit the re-uptake of norepinephrine (a chemical that makes you feel alert) and of dopamine (a feel-good hormone).
Side Effects of Kava
The most controversial issue is liver damage. There were a number of very severe cases (complete liver failure) in the late 1990s/early 2000s in Europe, which led to a ban of kava in a number of countries there starting around 2002. It was not banned in the U.S., but the FDA issued an advisory letter expressing concern about liver damage.
Kava advocates were unconvinced, and further research seems to indicate that nearly all of those liver damage cases were due to use of the non-noble cultivars and/or the use of stems instead of just the roots and/or the extraction being done with some alcoholic solvent rather than water (probably due to greedy/ignorant kava suppliers). Most European countries have relaxed their outright bans, although in many cases kava sales are still restricted or regulated. Because their main market got shut off due to the liver problems, Pacific island nations scrambled to rebuild kava credibility. They now try to ensure that only proper kava is exported to the West.
Kava advocates claim that if kava is extracted the traditional way from traditional cultivars, there are no appreciable severe bad side-effects. On the other hand, the 2020 FDA memo document claimed there was a wide range of serious adverse effects of kava use among traditional kava users in the eastern Pacific, especially liver damage, among heavy kava drinkers: “Several studies show a clear association of increased level of liver enzymes GGT, ALP, and moderate to heavy kava beverage consumption as shown in Table 2…..Hepatic injury due to traditional aqueous extracts of kava root was reported in a study of 27 heavy kava drinkers in New Caledonia (Russmann et al. 2003).”
On closer examination, however, it seems that the FDA document gave an overly negative view of kava liver effects. The Russman 2003 study did not actually show “heptatic injury” among the 27 heavy kava drinkers. All it showed was elevated levels of the liver-related enzymes. It is true that there were pretty consistent observations of elevated levels of enzymes such as GGT (gamma-glutamyl transpeptidase) and ALP (alanine aminotransferase) in blood samples. Most of the studies of Polynesian subjects cited in the FDA memo lacked controls, but Brown (2007) included kava users and nonusers in its survey of Tongans living in Hawaii. This study showed high levels of GGT and ALP among the kava users, yet without any clinical indications of liver malfunction. Also, other liver-related markers in the blood such as AST, ALT, bilirubin, and ferritin were normal in the kava users. The significance of the partial abnormalities in enzymes is not clear. My guess is that the liver is somewhat stressed but not to the point of malfunction.
So it seems true that moderate consumption of kava prepared the traditional way (water extraction from roots of noble cultivars) shows no general tendency for observable liver damage. That said, the elevated liver-related enzymes are grounds for at least a little caution, and there have been a (very) few cases of genuine liver damage from traditionally extracted kava. Russman (2003) reported two women in New Caledonia who developed symptoms of liver distress from kava; these symptoms resolved after cessation of kava use. And Becker (2019) documented the case of an otherwise healthy woman in Brazil who experienced complete liver failure following 52 days of using an approved kava pill at approved dosage; her life was saved by a liver transplant. However, people die every year from eating peanuts, so I don’t know how much to read into these isolated cases of liver damage from kava.
A common effect of kava use is dermatitis, presenting as dry skin, rashes, and eruptions. (This strikes me as an allergic-type reaction). Other common side-effects can be nausea and headaches. These effects typically resolve quickly if kava use is discontinued. In the plus column, there is some sketchy evidence for anti-cancer activity by kava. In general, cognition is not impaired.
I read about sixty reviews on Amazon from purchasers of kava root powders, and more discussions on Reddit. Most were quite happy with the kava products, but emphasized that preparing the drink from the root takes some time and effort to squeeze and then filter; the brew tastes terrible, like dirt (you have to gulp it down, not sip it), and some temporary nausea is common. However, there were a nontrivial minority that reported very ugly experiences, and one man who with his first dose went comatose and nearly died. The general opinion is that kava beverage made fresh (by you or at a kava bar) from the ground root is better than capsules or packaged drinks made from kava extracts.
The exact effects may depend on your genome – some folks may get whacked, while others escape unscathed. And there may be systemic differences between how Caucasians and Polynesians react to kava. Apparently you must chug it down on an empty stomach to get the full effects. It is best to drink it in multiple small increments, rather than one giant glass. Some users chase each “shell” with a swish of some other beverage to clear the taste out, and/or eat a tiny snack like a few chips to calm the queasy stomach.
Side effects seem to be greatly amplified when kava is consumed with other substances, especially alcohol. That makes chemical sense, since kava acts on many of the same metabolic pathways as alcohol and antianxiety meds like benzodiazepines and barbiturates. This is significant, since in the West kava is often consumed in a social context which includes alcohol.
For further reading on kava effects: see an objective 2022 review by Soarez, and many pro-kava articles such as this on the kava promotion site kavacoalition.org. That site includes testimonials of people using kava instead of opioids for coping with chronic pain from injuries. Although its main function is to reduce anxiety, that in turn may mitigate the sensations of pain. A number of participants in a Reddit thread stated that kava has helped them overcome alcoholism.
One source estimated that there are about 200 kava bars in the U.S., with about half of them in Florida. After a court battle with the state, a kava bar opened in Virginia in 2024. The state has so far has not approved serving of kratom.
My takeaway on kava: It seems to me to be somewhat similar to cannabis or alcohol – light, occasional use can give a good feeling, especially pleasant as a shared experience with friends. For some, it might be helpful in coping with pain. Unlike alcohol, there seems to be no obvious tendency towards addiction. However, as with alcohol and cannabis, there is some possibility of serious adverse effects, especially with heavy use and if it is consumed with other substances. Therefore, it would seem wise to start slow with kava and monitor your body’s reactions.
Also, it is essential to make sure you are getting kava made the right way, as discussed above. At a kava bar, you can talk with the server. If you are taking capsules, I’d suggest contacting the manufacturer. Or you can buy plain kava root, and steep your own brew.
Effects of Kratom
I will spend less time on kratom effects, since it acts largely like an opioid. Need we say more.
Kratom is extracted from the leaves of an evergreen plant native to southeast Asia. We discussed some of the varieties of kratom earlier. Quotations here are all from the Wikipedia article; they mesh with what I have read elsewhere.
The active compounds are a mix of dozens of alkaloid compounds. The key ones seem to interact with opioid receptors in the brain. But the interactions are complex and poorly-understood. On the plus side, “These compounds display functional selectivity and do not activate the β-arrestin pathway partly responsible for the respiratory depression, constipation, and sedation associated with traditional opioids.”
For recreational use, “At low doses, kratom produces euphoric effects comparable to those of coca. At higher doses, kratom produces opioid-like effects.” Much of kratom use is for more serious issues, such as managing chronic pain or helping with opioid withdrawal.
There are many documented adverse side effects, resulting in many visits to hospitals:
Common side-effects include appetite loss, erectile dysfunction, nausea and constipation. More severe side-effects may include respiratory depression (decreased breathing), seizure, psychosis, elevated heart rate and blood pressure, trouble sleeping, and, rarely, liver toxicity. Addiction is a possible risk with regular use: when use is stopped, withdrawal symptoms may occur. A number of deaths have been attributed to the use of kratom, both by itself and mixed with other substances.
…Long-term use of high doses of kratom may lead to development of tolerance, dependence, and withdrawal symptoms, including loss of appetite, weight loss, decreased libido, insomnia, muscle spasms, muscle and bone pain, increased yawning and/or sneezing, myoclonus, watery eyes, hot flashes, fever, diarrhea, restlessness, anger, and sadness. This may lead to resumption of use. Frequent use of high doses of kratom may cause tremors, anorexia, weight loss, seizures, psychosis and other mental health conditions.
Perhaps the biggest concern with kratom is the high propensity for addiction and the need to increase dosage to obtain the desired effects:
Kratom is a botanical with a known addiction liability and, in vulnerable individuals, dependence may develop rather quickly with tolerance noted at three months and four- to ten-fold dose escalations required within the first few weeks…Kratom addiction carries a relapse risk as high as 78% to 89% at three months post-cessation.
In 2017 the FDA stated that “There is no reliable evidence to support the use of kratom as a treatment for opioid use disorder; there are currently no FDA-approved therapeutic uses of kratom… and the FDA has evidence to show that there are significant safety issues associated with its use.”
Some advice here on Reddit on how with kratom “less is more” — due to complex biochemical interactions, upping your dose or making it more frequent can actually diminish the desired effects, and start down the road of diminishing returns and then using higher and higher doses. And this Reddit where users describe their problems with kratom addiction:
i suggest you stop while you are still able to walk away relatively unscathed. addiction is a very disgusting thing that can happen to a person. you will absolutely feel worse than you ever thought you could feel, save for losing a child or something insane happening IRL.
some drugs will actually cause a physical addiction, like kratom. this means your body adjusts to it & stops doing its job in order to let the drug do it. now when you stop using, your body & mind are without their own processes & they are also without the drug. this leaves you empty, sick, wide awake but exhausted, sweaty but cold, aching pain. for alcohol, withdrawal can actually lead to seizures, extreme hallucinations & delusions, & even will just straight up kill you bc you need a drink so bad.
My takeaway on kratom: This one seems like playing with fire, due to its addictive properties. Also, street doses of kratom are sometimes spiked with horrible drugs like fentanyl. Thus, I see little case for promoting it for recreational use, given that there are safer alternatives such as weed, booze, and kava. (And in general, there are more fruitful ways to rise above anxiety than drinking or smoking something – – change your thinking patterns, or even use flashing lights to put your brain into alpha waves. )
It is possible that kratom could be useful to someone dealing with chronic pain, as an alternative to opioids with their known addition danger. I have deep sympathy for anyone in that position. I would hope that they would work with a medical professional or at least a trustworthy friend to monitor their usage (keeping it low, no matter what), since in these matters it is easy to deceive oneself as to what is really going on.
ADDENDUM
In case someone is tempted to try kratom out of curiosity, I will share the cautionary observation an acquaintance emailed me after reading the original version of this article:
You know, I met some heroin addicts who said that they always told themselves they wouldn’t do it, they had seen it destroy people. But they ended up one day just caving to curiosity. One day, they just shrugged and said “screw it, I wanna see what this is about.” And their life was ruined by the immediate addiction. It’s a very sad story.
The average hospital is now 3/4 full- more full than during much of the worst of the Covid pandemic, and well above the 2/3 occupancy rate that prevailed during the 2010s. This is according to a study out yesterday in JAMA Open:
This seems to be due to a reduction in bed supply, rather than an increase in demand:
The number of staffed hospital beds declined from a prepandemic steady state of 802 000 (2009-2019 mean) to a post-PHE steady state of 674 000, whereas the mean daily census steady state remained at approximately 510 000
To me this is one more reason to reform Certificate of Need laws that put barriers in the way of hospitals opening or adding beds. Luckily I see a lot of momentum for CON reform this legislative season, including the highest-occupancy state, Rhode Island:
Economist Writing Every Day 
