[announcerman]

The amount of responsibility laundering that's happening is staggering. Is it the fault of the doctors for prescribing strong painkillers or the responsibility of lobbyists for keeping the status quo as it is. Or is it the responsibility of patients to not seek strong opiates for the smallest aches? On whom falls the blame for this?

[pjc50]

My own preferred hypothesis is that this is the result of despair: https://www.theatlantic.com/health/archive/2017/04/joblessne...

Someone will no doubt reply that US unemployment is falling, and therefore so should the opiates crisis, but it's not a simple matter of economics and statistics, it's a question of what people believe about the world and their future in it. Someone who gets a bad, painful job with no agency or fulfilment will vanish from the unemployment stats but the despair remains.

(Mind you, both for-profit heathcare and a punitive, moralist approach to pain relief belong in the blame picture as well)

[Someguywhatever]

>My own preferred hypothesis is that this is the result of despair

I agree with you, I would also throw in nihilism and purposelessness, the general lack of vision for the future from government and elites.

[prolikewh0a]

It's an easy out to the reality a lot of people with no economic success or vision for their future because of economic circumstances. The country is really not great for a whole lot of people. 50% of the entire population is poor or low income [1].

[1] https://kairoscenter.org/wp-content/uploads/2017/02/Poverty-...

[adventured]

Manufacturing jobs are booming in the US. The very people that you're implying are hopeless, that specific demographic, have access to blue collar jobs in a way they haven't in nearly a generation. The US hasn't seen this kind of sustained manufacturing job growth since the mid 1990s.

The US has drug problems, and has for 50 years, that other first or second tier nations in worse structural condition never picked up. This goes all the way back to peak US economics of the 1960s and early 1970s, when the US had a standard of living that it has taken the best European nations 50 years to catch up to. The opioid crisis is the latest extension of the US being a drug abusing nation, which it has been for a very long time, even at the peak of US economic success when it had 1/2 of all global manufacturing. It has had multiple heroin waves, multiple cocaine craze waves, multiple pill abusing waves.

The people of Spain didn't overdose at 2x or 4x the rate of the US despite having a drastically worse economic situation. Their economic desperation is still far beyond that of the US.

The standard response to that is: yeah, but the US doesn't have a welfare state. Yes it does, it has a massive welfare state, and its welfare spending as a percentage of GDP is higher than Canada or Australia.

The opioid problem has particularly hit poorer Americans. Why aren't Bulgarians or Moldovans overdosing at far higher numbers? They're radically poorer. Part of this equation is access: Americans have massive, low cost, easy access to all the drugs. People in the US have an almost unique position in the world in regards to having enough money, easy access and combining it with the way drugs get pushed to Americans.

Some of this is in fact unique to the US and doesn't require there be a particular high level of stress.

Every economic metric indicates Americans are doing better today than they were seven years ago, and yet the opioid crisis isn't receding and it's far worse than it was seven years ago.

Japan has lost a minimum of 1/3 of its standard of living in 15-20 years. They're not overdosing on opioids like people in the US are. They've suffered far worse than people in the US have.

Every culture behaves differently under stress, there's no question about that. There's also zero evidence that the on-going opioid crisis is a result of active high level desperation. That's where it started; those are not the same things.

Do people in Sweden and Belgium commit suicide at higher rates than people in the US, because their standard of living is collapsing? Belgium's suicide rate is nearly 100% higher today than the US rate was in the year 2000. Does wealthy Europe have among the highest rates of suicide on earth because it's so terrible there and they're under incredible economic stress? Or is it more likely these cultural issue are in fact complex rather than simple.

[rgbrenner]

Manufacturing jobs are booming in the US. The very people that you're implying are hopeless, that specific demographic, have access to blue collar jobs in a way they haven't in nearly a generation.

It hasn't been a generation since the 2008 recession.. and there are still over 1 million fewer manufacturing jobs today than in 2008.

https://fred.stlouisfed.org/series/MANEMP

Since the low point, the industry has only added about 1 million jobs.. so they're only about 50% recovered by this stat.

[lazerpants]

>Japan has lost a minimum of 1/3 of its standard of living in 15-20 years. They're not overdosing on opioids like people in the US are. They've suffered far worse than people in the US have.

This seems patently false to me and strikes me as a way to bolster your "Americans are druggies" argument without any real evidence. FYI, GDP per capita in Japan is about the same as it has been for the past 20 years, despite a falling population.

[tafda]

Proof the claim Japan has lost 1/3 its standard of living in the past two decades is completely false:

https://fred.stlouisfed.org/series/NYGDPPCAPKDJPN

Visit Japan sometime. The Japanese clearly have a standard of living that is among the best in the world.

[jeffreyrogers]

If that GDP per capita isn't adjusted for inflation then living standards would probably have fallen by about 1/3.

[pjc50]

This is a reply to my "it's not a simple matter of economics and statistics"?

> Or is it more likely these cultural issue are in fact complex rather than simple

Yes, I'd agree with that. I said it was a "question of what people believe about the world and their future in it", which goes beyond the economic.

I don't think all these drug overdose deaths are counted in the plain definition of suicide, but they're clearly a manifestation of self-destructive behaviour.

[aedron]

A nitpick:

> Does wealthy Europe have among the highest rates of suicide on earth

Certainly not: https://en.wikipedia.org/wiki/List_of_countries_by_suicide_r...

Only your two examples are in the somewhat upper bound of that list, the rest of Europe are among the lowest suicide per capita countries in the world.

[freeflight]

> This goes all the way back to peak US economics of the 1960s and early 1970s, when the US had a standard of living that it has taken the best European nations 50 years to catch up to.

So the "best European nations" will have reached a living standard, like the US of 60/70s, by the year 2020?

I mean, I'm not even convinced the US currently is anywhere near the standard it had back then, so that claim sounds a bit bold.

Could you quantify that in any way? The UN's Human Development Index could be of great help for that, sadly they only started doing that since 1990. So how are you measuring "standard of living"?

[ams6110]

> US unemployment is falling, and therefore so should the opiates crisis

For most people, once addicted, it's very difficult to stop. It's no longer about numbing your despair, it's a physical dependency with very unpleasant withdrawal symptoms.

[netsharc]

I mean, Trump is here because of despair too. Hillary promised "more of Obama", and the desperate people not benefiting from the roaring markets thought "I've been in misery for the past x years, she's promising more of that, the other guy is saying 'change', he might be full of shit, but what if he strikes it lucky, who do I pick, more of the same, or a chance of my life improving?".

Which is also why it was ridiculous that Trump (and his base) celebrated the latest GDP numbers, when on the ground the people were still suffering. And then we have Amazon, Uber, etc, "jobs"...

[i_feel_great]

> I mean, Trump is here because of despair too. Hillary promised "more of Obama", and the desperate people not benefiting from the roaring markets thought "I've been in misery for the past x years, she's promising more of that, the other guy is saying 'change', he might be full of shit, but what if he strikes it lucky, who do I pick, more of the same, or a chance of my life improving?".

Damn this is a sad comment. You ruined my night tonight.

[stef25]

The doctors. Anyone who spends the better part of a decade studying medicine can't be ignorant about opioids and addiction, regardless of what the slimy Purdue representative tells them.

The only excuse they have for the blatant over prescribing of opioids (2 months worth of oxy for getting wisdom teeth pulled kind of thing) is that if they don't do it, the patient will just go to another doctor.

But how can you justify setting someone up with fistfuls of oxy (knowing full that heroin / fentanyl and a world of misery for them and their loved ones is just around the corner) just "to make money" ?

> Or is it the responsibility of patients to not seek strong opiates for the smallest aches?

What the patient seeks is irrelevant. The only one who decides what prescriptions a patient should take is a doctor.

Personally I suffered from lower back pain for about 10 years and went from one useless quack to the next. Eventually I found a physio who taught me how to strengthen my core, now I'm at the gym 2x a week and loving it, did couch25K (and beyond) and am pain free for 3 years.

All I sought was pain relief but pills is not what I needed. If I was in W-Virginia instead of the EU I guess I'd be shooting heroin by now.

The US health care system is broken in more ways than one, no doubt this is made worse by various societal factors like joblessness.

[umvi]

> What the patient seeks is irrelevant. The only one who decides what prescriptions a patient should take is a doctor.

That kind of rubs me the wrong way, but I'm not sure why. I like having the option of overriding the doctor if I disagree.

[toomanybeersies]

I understand where you're coming from.

I have a little stack of benzos (valium, xanax, some others) that I use on the odd occasion, despite not being prescribed. Obviously possessing them is illegal. I know that I'm sound enough to know when to use them and when not to, and they've saved me a lot of avoidable pain. I wouldn't go so far as to say they've saved my life, but they've come damn close.

I also use my fair share of recreational drugs, as I've mentioned in previous comments. I know I'm good for them, I practice harm reduction strategies and rave safe. However, I am aware that not everybody is me. There are people who have amphetamine habits, or benzo habits, or {{drug_of_choice}} habits. It's by luck,good planning, and good friends that I don't have a habit and manage to use drugs without causing excessive harm.

That's something that a lot of readers here seem to forget. The average HN reader is very intelligent and usually very capable of looking after themselves (although I am aware there is a fair share of HN readers who've had struggles with addiction). Not everyone is as switched on as the average HN reader though.

[amaccuish]

In the NHS, that isn't possible. You either take the doctor's treatment, or you get no treatment at all. You can go around, asking different doctors, or having a discussion with your doctor, but you will not be prescribed something you don't need. The incentive being, that with a tax payer funded system, money should go to those who actually need it. It is understood here I guess that the doctor is the expert, not you.

[toomuchtodo]

I can totally appreciate this. As an American though, I have gone around my doctor and ordered prescription medications online when they would not prescribe them (ivermectin, anti-parisital, non-controlled substances, almost zero risk to myself if my diagnosis was inaccurate).

[umvi]

Slightly related, sometimes I just want a new pair of glasses without the hassle of going to/paying the eye doctor. I can still see 20/20 with my current prescription, but since it's "expired", physical retailers won't sell me glasses nor will they use their refractometer to read off the prescription of my current pair. So I instead go online and order a pair from Zenni using my expired prescription that I wrote down.

[toomanybeersies]

That's an interestingly unique problem to the USA I think.

Here in Australia, I haven't been to an optometrist in 5 or 6 years. I just keep ordering new glasses for $60 a pair online, my vision hasn't changed enough that I feel that I need to go to an optometrist again. The optometrist is legally required to give me my prescription, which I can then use as I want.

I haven't bought glasses in a brick and mortar store for 5 or 6 years (last time I got an eye test), but I'm fairly sure they won't/can't refuse to make me a pair to my specifications. Actually, I did get a pair made in the shop in Vietnam 2 years ago, and they were more than happy to make them (overnight too, I might add), although they did laugh at how blind I was.

[cm2012]

Could you email me (in profile) which sites you've used? Would love to pick up non controlled stuff online but the sites are all shady.

[toomuchtodo]

Unfortunately, this was almost 6 years ago, and I don't recall the site I used. My apologies!

[skookumchuck]

> The incentive being, that with a tax payer funded system, money should go to those who actually need it.

The idea that people, absent the profit motive, will work solely to the benefit of society is not correct. They're always selfishly motivated - career advancement, risk aversion, corruption, etc.

For example, if the doctor gets punished for prescribing to junkies, he's going to reduce his risk by avoiding prescribing to legitimate pain patients, just to be on the safe side.

Pray you don't get into a situation where you've got painful, terminal cancer and the doctor won't prescribe opiates because you might get addicted.

[roenxi]

Maybe one of the following? These are a couple of takes of that attitude from a few slightly different viewpoints.

* Removal of agency from the patient in relation to how their body is treated; anti-individualism.

* Decision making power assigned to an agent who does not have skin in the game; anti-system-thinking.

* Attitude runs counter to having a strong sense of personal responsibility; anti-some-morality-systems.

* Imposition of doctors value system overrides patient values; not-sure.

[sangnoir]

> That kind of rubs me the wrong way, but I'm not sure why. I like having the option of overriding the doctor if I disagree.

If you're American - my guess is it is cultural: you don't want someone else making decisions for you, rather, they should be making suggestions and you have the final say. American culture extolls autonomy/individualism.

I think this is explains some of the differences between the US and other developed countries when it comes to drug abuse and over-prescription. In the US, the doctors tend to defer to the patient on what's good for them more than elsewhere, especially around pain management.

[stef25]

It would be fair to make choices in the sense of picking a longer treatment that doesn't force you to stay home from work, vs a shorter treatment that would. And of course "another round of chemo" or "I can't be f*cked anymore" are valid choices.

But really, when things like opiates are involved patient input is rarely useful.

[skookumchuck]

> But really, when things like opiates are involved patient input is rarely useful.

Since there is no method for determining the level of a patient's pain, and opiates are for pain management, how can you conclude that?

[stef25]

Yeah, I didn't phrase that properly. Of course patients should communicate how much pain they are in, but they shouldn't communicate the type of painkillers that are to be prescribed.

[ams6110]

> 2 months worth of oxy for getting wisdom teeth pulled kind of thing

Surely this is not the norm? My son had his wisdom teeth out a few years ago, they gave him about a day's worth of hydrocodone and told him to take Tylenol after that. And all the doctors my family has seen for the past couple of decades have been pretty conservative about prescribing anything narcotic for pain.

[akuji1993]

Here in the EU, the doctor didn't give me any strong opiod. They just pulled the tooth and sent me home. When the pain reached a score of 8 / 10 on my personal score card, I took one Tylenol and another 1/2 before bed that day and didn't take anything else the next day.

[maccard]

> When the pain reached a score of 8 / 10 on my personal score card, I took one Tylenol

What's a 10/10 on your personal score card, out of interest? I hope you understand that your 8/10 may be akin to a 2/10 for someone else.

[akuji1993]

It might also have been a 7/10. When I had surgery on my back, right above my buttocks, they dug a hole deep right onto my bone and then it had to heal on its own, took 4 months to close. The first two days were a solid 9.5/10.

[freeflight]

Yup same here in Germany, you can ask for something against the pain, but that will usually only get you a prescription for Ibuprofen 600/800 mg.

Took those way to long over jaw issues until I got stomach problems, asked the dentist for something else and he prescribed metamizole drops.

Didn't use many of those as they sometimes give me kidney pains.

[mrguyorama]

Both my sister and I received A few days worth of Hydros despite being particularly gentle wisdom teeth removals, in her case eating solid food hours later. I took one and probably didn't even need that. This was a very drug prone and poor area.

If they wanted to, they could have gotten away with "take extra strength Ibuprofen", but what is their incentive to do that? They don't want patients telling the next guy "It hurt a lot" after.

[toomanybeersies]

I'm from New Zealand. I had two molars pulled out when I was 15 to fix an overbite problem. It was a serious enough procedure that they gave me an IV anesthetic.

All they prescribed me afterwards was ibuprofen. The general rule around here seems to be that if they're not using a knife, they don't give you opioids. I had to get 6 stitches in my head a few years ago, and they refused to give me anything stronger than ibuprofen again.

[solean]

I had all 4 wisdom teeth pulled 8 years ago (USA). Was given 60 Lortab pills for pain. I only took 1 the day after the operation, the pain really was not bad at all. Insanity.

[LeifCarrotson]

Look for the root cause,not the proximal one.

You can certainly blame one bad doctor. You could probably blame a group of associated doctors, if the problem was associated with a certain hospital or medical school.

But when the problem is something that thousands and thousands of individual doctors mess up, it's hard to blame them all.

Personally, I blame the slimy Purdue salesmen and the idiot bureaucrats who let prescription drug companies advertise prescription drugs on TV, or give kickbacks to doctors who prescribe their medicine. Without these awful incentives, you wouldn't have this widespread failure.

[stef25]

This is like saying web developers aren't responsible for thousands of websites getting hacked through some plugin, because the authors of a plugin simply said it was cool, and they advertised it as such and the devs got some affiliate kickback every time they implemented it on a site.

The analogy doesn't work 100% but pretty close :)

[mercer]

To alter the analogy, perhaps these web developers might be implementing said plugin because their manager told them to, and once said plugin took off clients started demanding it.

Most web developers that I know who have this problem fit this description. they don't like doing any of this, but it's what they're told to do. Or alternatively they're barely 'developers' and care about other things instead (many designer-developers, for example).

[js2]

> The doctors.

Certainly training them to prescribe less is a place to start: Doctors trained at lower-ranked American medical schools prescribe more opioids

https://www.economist.com/graphic-detail/2017/08/23/doctors-...

[mtw]

> found a physio who taught me how to strengthen my core, now I'm at the gym 2x a week and loving it

Most other patients demand quick and effective pain relief. When most doctors operate within a system that promotes total customer satisfaction and when they know an opioid is going to make the pain go away right now, the opioid prescription is easier. Plus this will make extra dollars for the system.

Changing this would require mindset change for patients (I need to endure the pain and follow a clean diet/exercise), and having doctors look to 360 treatments, including diet, sleep and exercise recommendations, instead of opioids

[ce4]

Here's a discussion from 7 months ago about exactly that. US patient came to another country and was faced with a mindset change and subsequently wrote an article about it in the nyt titled "After Surgery in Germany, I Wanted Vicodin, Not Herbal Tea" [0].

[0]: https://news.ycombinator.com/item?id=16252372

[nonbel]

I have a friend who had brain surgeries as a child and then again a few years ago. He said even though he weighed 2-4x more for the recent surgery they gave him half the morphine dose he got when younger. Apparently that dose was only enough make his feet itchy without sufficient pain relief, but they said they couldn't give him any more for whatever reason (legal, hospital policy, etc).

If that story generalizes it may be that somehow outpatients are getting too much painkillers while inpatients are not getting enough. The latter group is, of course, much less likely to get addicted.

[village-idiot]

American doctors are persistently and openly reluctant to prescribe lifestyle changes for fear of patient anger and noncompliance. Even in cases where the medical advice is something along the lines of “get some exercise or start planning your own funeral”.

Obviously doctors continuing to hand out pills (opioids, statins, etc.) to patients who really need therapy, exercise, or dietary changes is helping to reinforce the problem.

[dominotw]

> 2 months worth of oxy for getting wisdom teeth pulled kind of thing

I saved mine after wisdom tooth/root canal combo and used them as mood enhancer later.

I am not sure I am addicted to them though. I find this theory hard to believe that opioid overdose is an end result of series of missteps starting from wisdom tooth oxy prescription.

[toomanybeersies]

Most of the population drinks alcohol. Most of the population are not alcoholics.

I haven't abused opioids for recreational purposes, but I know people who have saved their prescribed codeine and gotten fucked up on it. They aren't addicted. I also walk to the supermarket every day, past the safe injection centre filled with smackheads. I've seen dead heroin addicts wheeled into the ambulance.

Not everyone is as susceptible to addiction as others, but the more opioids/alcohol/other drugs you take, the more likely you are to get addicted.

[mercer]

that's a very important point. I've had a number of friends who struggle with addiction (whether alcohol, cigarettes, or other things), and a smaller number of friends who seemed almost entirely impervious to addiction. It's been quite frustrating to find that the latter would simply not understand the former. Some of them would suspend judgment, but others just concluded that those who were addicted simply "didn't try hard enough".

To some extent, I can understand this rather uncharitable conclusion. It's like explaining being in love to someone who hasn't been. Addiction is difficult to explain without having experienced it.

Nonetheless, what makes me side with the addicts, so to speak, and their helplessness, is that when I look at the 'whole' of their person, many of them clearly don't lack willpower or discipline in other areas of their lives. I've either seen the addiction infect the rest of their lives, or seen them being functional, even successful, in other areas despite the addiction. The only conclusion I can draw is that some (most?) people are just unusually susceptible to certain vices.

[nioesd]

Keep in mind that some people are at much higher risk for becoming addicted to opiates. You may have been able to take them recreationally without major issue, but the same behavior could have a much more severe consequence for someone in that at-risk group.

[dominotw]

> some people are at much higher risk

Why is that? Something in their genetic makeup? Wonder if its possible to identify these ppl preemptively.

[freeflight]

Genetics play a huge role [0], but so do social and environmental factors.

[0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442454/

[dwaltrip]

Possibly that, but life experiences and environmental factors (stress at work, etc) play a huge role.

[free652]

For wisdom teeth I got 25 tablets - that's like around a week worth. So other "patients" ask upfront for more tablets?

[zolthrowaway]

Yes, many people will take the largest script the doctor will prescribe. Insurance generally helps cover the cost of the prescription, so reselling them can be really lucrative. Even in your scenario, 25 pills seems like a lot. Many people will be totally pain free in 2-3 days. No one needs 8 pills a day for wisdom teeth. Let's say they take 4 a day for 3 days, that's still 13 pills leftover.

Go to any manual labor job (construction for example) in the Midwest. You will find people wanting to buy leftover prescriptions and people selling them. It's a pretty large black market. The vast, vast majority of people I know doing construction, laying asphalt, etc are all daily drinkers, potheads, or addicted to opiates. It's honestly super depressing.

[ensignavenger]

Since the insurance charges the same for a large prescription versus a small one, even if you aren't planning on selling them, it makes sense from a financial perspective to get the extra pills, just in case you do need them. (If there are complications, or if something else happens, etc.)

[matwood]

Wow. I had my ACL done and got 3 days worth of Oxycontin (6 tablets, 1 every 12 hours). I didn't want to finish taking them because they made me hallucinate. Looking back, I probably could have gotten by after the first day with only ibuprofen. The doctor was very concerned about staying ahead of any pain though.

[DanBC]

Have a look at the letter that started it all. This letter claimed that addiction is rare in patients treated in hospital with opioids for pain.

https://www.bbc.co.uk/news/world-us-canada-40136881

The US Veteran's Association noticed that many veterans were living with pain. They felt that this needed to be treated, and they believed that opioids were safe an effective to treat long term pain, and that the risk of addiction was low.

They introduced a thing called "pain as the fifth vital sign". They wanted healthcare professionals to i) always ask about pain and ii) always try to treat pain.

https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital...

This led to huge amounts of mostly unsuitable treatment for pain. People in pain tend to reject psychological treatment ("My pain is real, it's not in my head!") and access to good quality physiotherapy is more expensive than opioids.

[amanaplanacanal]

Yes! That became the common wisdom: If patients are taking opioids for pain relief, they won't become addicted. Of course that article was talking about opioids given to patients in a hospital setting, not patients being sent home with bottles of them. It was taken completely out of context.

The other half of it was somehow deciding that opioids were the proper treatment for chronic pain, rather than temporary pain relief after surgery. Which was never really studied. And the consensus seems now to be that was a terrible idea.

[baxtr]

Many say that big Pharma corporations have a large share of the responsibility because they began promoting strong pain killers heavily, starting in the 90s [1]. Now it has become part of American culture (doctors, patients, pharmacistse etc) to treat any pain with these pain killers. It’ll cost a lot and take a long time to reverse that [2]

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/ [2] https://www.vox.com/2017/6/5/15111936/opioid-crisis-pain-wes...

[cookiecaper]

At the same time, know that every time a politician gets a bullet point on his re-election flier for "fighting the opioid epidemic" or "keeping our streets clean", there are real people in real pain who get stranded without the medication they need to function.

After the birth of my youngest child, my wife spent the immediate recovery period blindsided by pain because new regulations meant the hospital was unwilling to prescribe opioid medication for "routine" things like an uncomplicated childbirth. She didn't have to deal with that for any of our other children, because back then, the hospital was willing to administer these medications.

Medicine is already over 8% of GDP, but the political complex is not satisfied with that -- every day it gets harder and more expensive to stay on the right side of the law while obtaining necessary medications.

In Florida, it is now unlawful for a physician to write for more than 3 days of narcotic painkillers (if there are extenuating circumstances, this can be pushed to a week, but the rationale must be documented and approved by at least one other physician, iirc). If your pain hasn't subsided in 3 days, you need to make another appointment -- which means paying another copay, or if uninsured, paying another out-of-pocket office visit -- to get a refill.

If you require pain medication for a chronic condition, you now, by law, have to acquire a separate doctor who specializes in "pain management"; your family doctor is legally not allowed to write for more. Good luck finding an appointment at a reputable pain management clinic within 3 months.

This is not a simple thing, and these medications continue to be prescribed because they help a great deal of people, relatively few of whom descend into addiction (and note that many who do go to the streets are driven there because their docs or pharmacists got spooked by the DEA and cut them off, leaving them in mind-numbing pain, or because they couldn't afford the substantial financial and social costs required to get controlled Rxs renewed and refilled on an ongoing basis).

[paulie_a]

I have a friend that went to med school and has a back issue. He basically needs some pain killers 2-3 days a year. At one point he literally considered going to one of those shady pill mill "pain clinics" just to have something on hand for the rare cases he needed it.

Ive honestly considered looking into dark web markets for a different (non opioid) drug I was taking for 10 years consistently. Multiple doctor's kept trying to have someone else deal with it due to DEA paperwork. I once had a doctor actually say "who sent you here, did someone tell you about me?"... My response was "my insurance company and you are 3 blocks away from my apartment.". It was very awkward considering I said I would release any necessary medical records etc.

[hansthehorse]

Floridian here - I was given 1 month morphine prescriptions for 6 months. I believe 1 month is the max. This was this year.

[cookiecaper]

New law went into effect July 1.

[ekianjo]

In the end of the day doctors are the only ones holding the pen to write prescriptions, no matter how you look at things.

[Retric]

Plenty of other people share responsibility.

The public often expects strong painkillers rather than dealing with extreme pain. You can request less extreme painkillers and use less than prescribed.

Doctors can’t directly measure pain so while the have an important role, they can’t do it alone.

On top of that drug companies had a strong incentive to change the culture around pain and succeeded.

The illegal drug market thrives via specific and changeable laws.

People doping illegal drugs have a direct moral responsibility to their customers, but frankly they are already breaking the law so you can only expect so much.

Illegal drug users often seek out stronger highs resulting in their deaths. Seeking treatment is a possibility for these users.

[bluecalm]

At the end of the day the patients are the only ones taking the pills, no matter how you look at things.

It's personal responsibility first of all. I don't want to live in a world where I need prescription or permission to do anything that is potentially risky to my health. What happened to the idea that you are responsible for your actions? We already have too much prohibition and government picking and choosing what is and what isn't allowed in your life.

[raverbashing]

Drug companies pushed for a higher dose "that lasts 12h/24h" (it didn't) instead of more moderate dosing that doctors wanted to do .

[baxtr]

That's somehow like saying: the guy in the store that sold the weapon is solely responsible for a killing with the same gun.

[ekianjo]

No, it's not the same thing at all. I'm not saying doctors are causing overdoses. I was answering the previous comment putting the blame on pharma companies mainly, which is ridiculous because doctors are the only ones who are able to prescribe anything. The fact that they let themselves be corrupted by pharma companies is totally THEIR responsibility.

[Broken_Hippo]

There is more responsibility than this, I think.

A lack of laws allowing for paid sick leave, for example. It is easier to sit at home and not take pain meds than it is to have to go to work. If people cannot afford to take time off, there might as well be no sick time.

There is a fault with doctors, but I truly think that for most doctors, they shouldn't have to be the gatekeeper for such things so long as they are prescribing for medically necessary conditions. The responsibility is that they should talk about addiction and symptoms of it with the patients and be prepared to work with patients if there is trouble. This should be without treating them like criminals 5 years later if they have a real reason to have medication (like surgery, for example).

To a lesser extent, yes, it lies with a few doctors for prescribing strong pain killers. But if they are the medical norm for the sort of pain you are dealing with, they aren't being irresponsible either. I'd much rather folks be able to manage their pain than to suffer.

Pain centers are horrible places and not convenient enough for everyone. The ones around where I lived (the first 30+years of my life) generally drug tested people, treating folks with chronic pain like criminals. They would treat folks like an addict for having pot in their system, for example, and were likely to kick folks off the program for such things.

A lack of medical based treatment centers for additiction and to an extent, for mental health. This falls squarely on insurances and government.

It would take government initiative and there would be some public pushback, but there could also be a national (or even state by state) digital medical system that includes prescriptions for these (and all) drugs. This would help doctors and pharmacists catch folks shopping around for different doctors. I hesitate to deny treatment to such folks, though, but instead refer the same folks to medical testing to see the cause of their woes and/or treatment for addiction.

[thedailymail]

You forgot to mention the drug manufacturers like Purdue, which aggressively promoted their opioids (e.g., Oxycontin) as presenting only a very low risk of addiction and abuse.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/

[ubernostrum]

As I understand it, a combination of a few things.

One was a change to quality-of-care measurements. Lots of entities in the US health care system are evaluated on metrics around patient outcomes, and some of those look at management of physical pain. Changes to metrics for pain effectively pushed doctors toward a target of zero pain, and doctors began prescribing more medication to achieve that target.

Another is the allegation that pharmaceutical companies downplayed the risks of their newer formulations for pain medication, or even outright lied. Purdue, Endo, Allergan, Johnson & Johnson, Teva and others all are facing or have faced lawsuits over this. To take an example: Purdue marketed OxyContin as a breakthrough long-acting drug -- they claimed 12 hours of effectiveness -- which would reduce the risk of addiction. In reality, patients reported the effects wore off after as little as 4 hours, and Purdue's marketing and sales arms pushed doctors to prescribe more and higher doses. This naturally led to... addiction and overdoses.

Still another factor is that pharmaceutical companies seem to have been perfectly willing to overlook obvious abuse in order to move product and make money. It's not terribly hard to spot the patterns; there were cases of small (couple thousand people) towns where the local pharmacy would handle millions of doses of hydrocodone or oxycodone. And there have been lawsuits over that, too, with the drug companies mostly trying to reach settlements and avoid trials.

[grecy]

How about if everyone stopped playing the blame game (because it's irrelevant) and spent all that effort and time working on a solution instead.

It feels like reality TV has crept into every day life, and now everything has to be turned into a drama. Stop pandering to the drama, start working on a solution already.

[DanBC]

You can't defeat something if you don't understand it.

[pjc50]

Understanding is very different from blame - that's the main lesson from air accident investigation.

In particular, when you want to assign blame, you create an incentive to destroy or conceal evidence about what's actually happening. For opiates there are criminal penalties as soon as someone steps across the grey boundary between "medically necessary" and "recreational", so obviously everyone involved is going to lie about what's happening.

[belorn]

Since the article talk exclusively about opioid use disorders, this not about using opiates for aches. It is a common replicated experiment that patient that use opiates exclusively for aches don't develop habits, and more control and choice by the patient usually result in lower doses.

However I have heard constantly during the last decade that stress and depression is on the rise and also spreading to younger age groups. I thus find it very questionable to view the problem from the drug supply perspective. Is it not a more logical conclusion that more people are self medicating and the problem is the social environment (stress, depression, looniness, and so on) and possible faults in the medical system in not helping those people as effective it could?

[base698]

"Dreamland" is a pretty amazing summary of the responsibility.

https://www.amazon.com/dp/B00U19DTS0

In short: pharma companies for misrepresenting an editorial in the 80s about addiction rates, medical industry calling pain the fifth vital sign, and enterprising drug dealers setting up Domino's like delivery services for heroin.

[amanaplanacanal]

Terrific book, highly recommended.

[MrFantastic]

These overdoses happen because society is not educated about the risks of combining opioids with alcohol and the illegal drug supply is unregulated. Imaging if beer all tasted the same but ranged from 2%-95%; 12 oz of pure alcohol would kill quit a few people.

[qudat]

None of these. Why should we look to blame someone? At the core of this issue as well as many in the US, we are in the midst of a mental health epidemic. The medical system in this country does not care about preventative care, the primary directive is triage.

Why are people using drugs at staggering quantities? Whether it is "recreational" or seemingly necessary, mind-altering substances are being used for a reason and I don't think this country has a good answer to why. We certainly do not have a good way to solve this problem.

[aaavl2821]

Some people have some back pain / other pain and, if they're out of a job (commonly factory jobs) they go on disability (almost as a form of welfare), and will often get meds for their pain (this is the fault of doctors, pharma companies, generally medical culture emphasizing quick fix Rx vs other methods of dealing with pain).

Obviously these drugs are addictive, and if you're already in a bad place bc you went from a great stable job in your 30s to pseudo-welfare in your 50s, you're more vulnerable to addiction

[freeflight]

Like most things, probably the combination of all of them.

It might be convenient to ask for that "one prime mover", but the reality is usually way too complex for that.

[merinowool]

It is mainly responsibility of voters who keep corrupt and evil people in charge. If you voted for a prohibition supporter you have blood on your hands.

[ryan-allen]

A few documentaries I've watched suggest that the dosages as recommended by the drug companies are designed to induce withdrawal symptoms before the next dose is due during treatment, I'd wager that's a good way to induce dependence during the course of treatment.

The hypocrisy of the law when it comes to this is insane, but given how large the profits are and the power that money commands with lobbying, I'm not really surprised.

[SquareWheel]

Honestly, that sounds very conspiratorial and baseless. It assumes doctors are idiots and drug producers are comic book villains. Reality is more nuanced.

[oldgradstudent]

Sadly, assuming by default (until proven otherwise) that doctors are idiots, and drug producers are comic book villans may be the smart thing to do.

http://www.latimes.com/projects/oxycontin-part1/

> Purdue has known about the problem for decades. Even before OxyContin went on the market, clinical trials showed many patients weren’t getting 12 hours of relief. Since the drug’s debut in 1996, the company has been confronted with additional evidence, including complaints from doctors, reports from its own sales reps and independent research.

Or

https://study329.org

[usrusr]

Comic book villainy quickly dissolves into nuanced realism when you distribute the elements of the "conspiracy" over the org chart. Then you end up with a lot of people who wanted to believe and mutually reassure each other that everything was fine, resulting in collective blindness to the evil they were doing.