[darawk]

Yes of course there are realistic ways to prescribe opioids routine and safely. Purdue did not invent opioids, what they did is patent a particularly strong formulation, and then work to undermine the cultural taboo in medicine around their use. That last thing was their crime.

There isn't, at this time, any other way to treat serious pain (in all cases). Opioid prescriptions will continue to be an unfortunately necessary feature of our medical system until we invent painkillers strong/good enough to replace them. I say this as someone who was personally addicted to opioids in general and Oxycontin in particular and feel very lucky to have only one dead friend as a result.

Opioids can't be banned until we can replace them with something equally generally effective. But what we should do is reinstate the taboo around prescribing them, and probably stop offering take home fentanyl prescriptions at all (it's still useful for anaesthesia, in hospitals). Perhaps more importantly, I think the cat is kind of out of the bag on prescriptions. I haven't been around that world for a long time, but it seems to me like pharmaceuticals aren't the primary entrypoint to opioid addiction anymore - people just start with fentanyl.

Dealing with fentanyl seems to me to be basically impossible. One kilogram of pure fentanyl is ~2,000,000 doses, for someone without a tolerance. This is impossible to interdict at the border. It is also fully synthetic, with no great choke point on synthesis routes. I have heard that there are other, even more dangerous, compounds like https://en.wikipedia.org/wiki/Etonitazene that are also even easier to synthesize. I don't really know if there is a good way out of this other than doing the slightly less impossible thing, which is curing addiction.

[shawndrost]

Thank you for the reply! I am honestly not informed about this stuff and not asking to covertly push an agenda.

Follow-up Q for you. What is the realistic way to prescribe opioids routinely and safely? Are there certain formulations that have been or should be removed from the market? How do we reinstate the taboo on prescribing them?

For EG: I got a vasectomy recently and was told to expect a day or two of pain. I was prescribed a month's supply of opioids without a single comment from the doctor on their addictive nature. My understanding is that this is how people get introduced to opioids; the pathway goes "legal scrip -> addiction -> illegal supply -> fentanyl -> death" and that's the engine of the epidemic.

Should it be legal for the doctor to prescribe pain meds like this? (Or, should it be legal but discouraged? Is there a well-understood way to do this?) If it should be legal, should we expect the epidemic to continue? And if so, is post-bankruptcy Purdue a good thing or a bad thing?

(My instinctive answers here are that we should make opioids illegal for much of their current use pattern, and that post-bankruptcy Purdue is approximately as gross as Sackler-era Purdue, for what it's worth.)

[doctorpangloss]

> I was prescribed a month's supply of opioids without a single comment from the doctor on their addictive nature.

Is this really what the question was about? Reflections on a personal experience? Those are perfectly valid concerns. Nobody is stopping you from asking any of the professionals you interacted with about addiction, if you are worried, go and ask!

[shawndrost]

No, my question is about how people judge our opioid status quo: a medical system that prescribes addictive opioids for routine and low-grade pain.

[sneak]

Correcting in the other direction is way worse. I had a huge surgery last year in Germany and 8 days later when released from the hospital, bones still not yet fused, I was given no industrial-grade painkillers whatsoever.

I had to cop on the black market to keep from going insane from insomnia and screaming, until I could check myself into an inpatient clinic that would dispense them legally.

There is more harm in making them difficult to get.

[doctorpangloss]

I just wonder why random people would know better about this than your highly educated providers. Go ahead and ask. You can say those exact words. They will give better answers!

If you want a poll, this court case was a poll. A majority of victims who had ample time to participate in litigation agreed to the settlement terms. They told you that addiction is bad, the new Purdue would help, and that money from its owners was sufficient justice. That some agitator basically played the Yogg-Sauron of this meta, the Supreme Court, and cast 5 fireballs against his opponent versus 4 fireballs on himself, isn't super material to the seeming success of the hard political work of this bankruptcy judge.

[darawk]

Oxycontin was, and still is, a prescription drug. I'm not sure if you're aware, but at least in the United States (where this court judgment was), it is doctors that write prescriptions. Listening to them is how the first opioid crisis happened. McKinsey dangled some shiny slides in front of Purdue, Purdue dangled them in front of doctors, and then doctors prescribed them en masse. This has, arguably, not gone well.

[jacobgkau]

> I just wonder why random people would know better about this than your highly educated providers. Go ahead and ask. You can say those exact words. They will give better answers!

Are you sure they'll give "better answers" when they're the ones prescribing like that?

[ninetyninenine]

its easier to ask random people from home then go to a provider when I have no such problem or need to physically introduce myself to a highly educated provider. it's like a google search.

What I wonder is why someone like you wouldn't know this?

[shawndrost]

My question is specifically about the judgements that uninvolved people have formed. I can't learn about this from my doctor, or from the victims' decision in the context of a highly-constrained kabuki dance.

It seems most commenters here are fine with a settlement that clears Purdue to sell opioids (for the benefit of victims), but not with a settlement that lets the Sacklers off with a fine. That is exactly the opposite of my moral intuitions. What gives?

Some questions are message board questions.

[jemmyw]

> I got a vasectomy recently and was told to expect a day or two of pain

I didn't get anything after mine. I nearly fainted outside the clinic waiting to be picked up when the feelings all suddenly caught up with me.

[circlefavshape]

Neither did I. "If you have pain then take ibuprofen"

[darawk]

np,

> Follow-up Q for you. What is the realistic way to prescribe opioids routinely and safely?

The simple answer is "less and with better monitoring". The first half of that was the equilibrium that Purdue intentionally shifted in the medical establishment. The cascading effects of that are what caused the modern day opioid crisis. Unfortunately, the modern-day opioid crisis as I understand it is mostly no longer related to pharmaceutical availability. So, while we should improve and lock down that supply chain route, unfortunately I don't expect it to make a large dent in the overall problem.

> Are there certain formulations that have been or should be removed from the market?

Take-home fentanyl is probably unnecessary, but again, I wouldn't really expect this to be a silver bullet. The DEA/FDA has gotten much tighter on their prescribing rules for powerful opioids, but their doing so has largely coincided with the expansion of the illegal heroin, and then fentanyl markets. It is now too late to fix by choking off supply, because the market has mostly moved outside of the regulatory regime (though we should still do that, to the extent we can).

> How do we reinstate the taboo on prescribing them?

These answers keep getting worse but we largely already have. We could probably do more, but if you are an MD and you are not "opioids are dangerous actually"-pilled, I think you need to go back to medical school. There was a short period in the mid 2000s where doctors were convinced otherwise by Purdue among others. Doctors who "think otherwise" today are almost without exception just outright criminals.

> For EG: I got a vasectomy recently and was told to expect a day or two of pain. I was prescribed a month's supply of opioids without a single comment from the doctor on their addictive nature. My understanding is that this is how people get introduced to opioids; the pathway goes "legal scrip -> addiction -> illegal supply -> fentanyl -> death" and that's the engine of the epidemic.

Overprescription like that (which that definitely is) is bad and unfortunately common. It's hard to say exactly how much addiction is caused by that variety, though. Most serious opioid addictions that I am aware of didn't get that way from a one time moderate overprescription of things like Vicodin or Percocet. It is possible to get "mildly" addicted from a month's supply of that and when you run out you might have a slightly unpleasant day or two, but not worse than that. If the illicit market wasn't there, that 30 day supply would be the end of any binge, and that would be "mostly fine", as such. That is not an endorsement or to say that it is at all a safe thing to do, but the risk comes primarily from not wanting to quit when you run out, and having other options available.

Two things changed with the introduction of Oxycontin:

1. It started being prescribed for chronic, not acute pain. This meant that people had permanent, ongoing prescriptions for them. Which meant that people built up a very large tolerance, which led to..

2. Oxycontin is pure oxycodone, it is not formulated with an NSAID (like Percocet is). The presence of an NSAID limits the amount you can take before you get sick, and prevents you from (straightforwardly) consuming it via non-oral routes of administration, which is exponentially more addictive.

> Should it be legal for the doctor to prescribe pain meds like this? (Or, should it be legal but discouraged? Is there a well-understood way to do this?) If it should be legal, should we expect the epidemic to continue? And if so, is post-bankruptcy Purdue a good thing or a bad thing?

Legal but discouraged, definitely. They are an important tool in the treatment of acute pain. They can, more rarely, be an important tool in the treatment of chronic pain (cancer / chemotherapy being a good example of a sufficiently serious condition). And finally, they are absolutely worthwhile for palliative care. For these reasons and what is now the magnitude of the illicit market, I don't think there is a lot of value in a total restriction.

[tialaramex]

> Take-home fentanyl is probably unnecessary

Nah, a friend and colleague needed fentanyl lollipops at one point. You'd be at lunch and he's like "Oh I can't eat food, they had to remove my entire stomach" sucking on the lollipop, and he'd calmly explain that you mustn't touch his weird lollipop because while he can suck on it for a normal person the dose from doing so would be fatal, he'd just used so many strong painkillers for so long that it was now necessary because the painkillers they give regular people did nothing.

Weaned himself off eventually too. Amazing willpower, probably related to why he's not dead.

[Nasrudith]

I don't know if it is genetic, a side effect of chronic or acute pain, or just plain luck but I've seen family wind up not addicted at all despite heavier doses. If it is genetic it might be linked to not finding painkillers enjoyable at all.

I know from my wisdom teeth removal getting a few days of oxycontin while it helped with the pain it mostly made me feel weak not only while taking it but for about a week or so after discontinuing it. And this is from someone with a low pain tolerance.

[darawk]

Fentanyl lollipops/patches are useful in rare circumstances where someone can't swallow pills for some reason, like this one. There are other ways of achieving similar effects but its possible fentanyl is the best way to go in this situation. It is a fairly rare situation though.

[worik]

> Opioids can't be banned until we can replace them with something equally generally effective.

Opioids should not be banned

Opioid addiction (I have seen a lot of it, not had it) is a social problem and is best managed with, opioids

The problems stem from putting unreasonable obstacles between adicts amd their appropriate treatment. Practical legal and financial obstacles, sadistic legal obstacles, and bizarre moral obstacles

Great Britain for many y4ars managed Opioid addiction with opioids, principally methadone and heroin

Nineteenth century society managed it with laudinum

We westerners in the twenty first century are failing to manage it with cruelty

The Sacklers are, were, parasites profiting from that social malaise and bad things will finally happen to them. But the cause of the malaise is our irrational attitude to drugs

[darawk]

> Opioid addiction (I have seen a lot of it, not had it) is a social problem and is best managed with, opioids

I don't entirely disagree with you, but I have also seen enough people stop, who probably wouldn't have if that were the typical treatment, to be pretty cautious about that. There are a number of promising addiction treatments in the wings at the moment, in particular Ozempic and the general GLP-1 agonist class.

Transitional opioids like Buprenorphine are fine as a detox strategy, and maybe even fine for the medium term, but committing to them for life I think is a mistake (in most cases).

> The problems stem from putting unreasonable obstacles between adicts amd their appropriate treatment. Practical legal and financial obstacles, sadistic legal obstacles, and bizarre moral obstacles

There is a lot of truth to this. It is, in fact, what I used to say when I used them. And it is and remains true. It is also true that prolonged opioid use is mostly physiologically harmless (overdoses notwithstanding). However, there are psychological elements that come with long term use that these measures do not capture, and are not fully internalized by the transaction costs (or literal costs) associated with obtaining them.

> Nineteenth century society managed it with laudinum

Ask China why they fought that opium war, and how they feel about such things lately. They are still mad about it.

> The Sacklers are, were, parasites profiting from that social malaise and bad things will finally happen to them. But the cause of the malaise is our irrational attitude to drugs

Agree on the Sacklers although personally I'd place more blame on the McKinsey consultants that wrote the original deck that proposed the strategy. I don't know how much the Sackler individuals personally made these decisions, but those people certainly did.

Re: irrational attitudes to drugs, I agree, but the situation is substantially more nuanced than it might superficially appear. Laudanum did used to be over the counter, as did cocaine among other things. However, these things were not criminalized for no reason - heroin wasn't criminalized in the 60s/70s anti-hippie craze, or for racist reasons in the 1930s (like marijuana).

Heroin was first criminalized for over the counter sale in 1910 - 15 years after Bayer first marketed it. Easily the fastest criminalization of a novel pharmaceutical compound in the history of the world. This is not an accident or a product of some temporary social hysteria. And unfortunately, it was also not criminalized because all of its harms were due to its being illegal.

If criminality were the problem we would expect things to get better, not worse, with the introduction of fentanyl which is far cheaper and more readily available. I could be misreading the data, but that does not seem to be working out.

[worik]

An agree fest ensues

I am not advocating pure herion (ironically quite a safe drug aside from addiction) or cocaine powder as modern consumer products.

Opium caused upheavals when used as a wedge by Westerners in China, but remember it had been present, and used for millenia in Arabia.

The same, roughly, with cocaine and coca

It is not a choice between continued sadism or free reign herion and cocaine dealing.

We can do better

And I think the "psychological elements that come with long term use" is largely confusing cause and effect.

From my experience people having drug problems recover when the problems recede. Hence advocating treating drug addiction with drugs

One size does not fit all, and some halt and are abstinent. Good on them, I know no-one like that

[darawk]

I mostly agree!

I'll quibble on two points. "used as a wedge issue by foreigners", while perhaps true in some moral sense, it does not really make much sense, on closer scrutiny. To reduce things down to being some foreign imposition is to suggest that it could have been any product. But it couldn't - only opium has the special properties necessary to become this kind of product. Nobody fought a war over tobacco, or even cocaine.

It is also true that Arabia, and even the ancient Greeks ('land of the lotus eaters') were aware of and could obtain Opium. However, I'd inquire as to how it is that the primary opium growing regions of Arabia are doing lately, or say, ever.

It is true that Opium has been available to varying degrees, at various times, in various places without a total social breakdown. However, widespread, sustained, cheap availability of pure Opium without total social breakdown is, as far as I know, unheard of. The over the counter stuff in Europe and the early US were mixed with other things, as in Laudanum. Almost all of high society at the time was addicted anyway, and this was the mild form.

The Chinese discovered that they could smoke it, and changing ROA from oral to smoking is a radical step change in addictiveness. I'm not entirely sure why this didn't catch on elsewhere at the time, but the fact of the matter is it didn't, and the difference between these things is a difference in kind, not degree.

> It is not a choice between continued sadism or free reign herion and cocaine dealing

I hope you're right! But I don't observe anything in the world that would support it, unfortunately. I quit because I was arrested, for instance. I want to be careful about causal meaning here, I didn't stay off because I was arrested, but it was the excipient that proximately caused and also facilitated it. It was a structural break that allowed other things to change around it.

That's not to say that the judicial system is a good way to deal with things - it's not. But the credible threat of the judicial system cannot really be done away with here without courting disaster. When dealing with highly physically addictive substances, shaping short term behavior by force is often a necessary ingredient in having any hope of shaping medium or long term behavior via therapy, life circumstance changes, or anything else.

[worik]

> opium growing regions of Arabia

The centre of civilisation for centuries

[darawk]

That was a very long time ago. I don't think the middle east was a significant producer of Opium during that time.

[worik]

> without courting disaster

Too late?

weeping...

[worik]

> But I don't observe anything in the world that would support it,

Portugal

Legalisation of capabilities across the globe

Coca in Bolivia (I am on thin ice, I know too little, but they elected a coca grower as president)

I think there is plenty of evidence that a considered thoughtful approach to drugs is better

But the psychopaths and sociopaths that make up the bulk of our governments (here in Aotearoa and in the USA) refuse to pay attention

[darawk]

> Portugal

Portugal is not the ringing endorsement that it is sometimes touted as. Some indicators have improved, some have worsened substantially:

https://en.wikipedia.org/wiki/Drug_policy_of_Portugal#Observ...

Causality is hard to tease out here, but more importantly, all they're doing is decriminalizing it and offering methadone/buprenorphine maintenance treatments. And the effect on number of addicts has not been good:

https://www.washingtonpost.com/world/2023/07/07/portugal-dru...

> Coca in Bolivia (I am on thin ice, I know too little, but they elected a coca grower as president)

Coca is really not anything. If you've ever chewed coca leaves, they're mildly stimulating. They're nothing like cocaine.

> I think there is plenty of evidence that a considered thoughtful approach to drugs is better

Considered, thoughtful approaches are always better! The question is, what are you considering and being thoughtful about. And the fact of the matter is that the most drug-liberal cities in the US have the worst drug problems, and so do the most drug liberal countries (like Portugal).

The countries that have the fewest problems with addiction are the harshest: Singapore, China, Japan. These things are not an accident. I'm not necessarily advocating adopting policies that harsh, just pointing out that they do actually work, whereas the liberal policies fail disastrously everywhere they're implemented. I'm in favor of criminalization, but only as a tool to force people into deferral/treatment programs. I don't want to see anyone actually put in jail for using drugs, unless they fail to complete their deferral program.

[seanmcdirmid]

> Ask China why they fought that opium war, and how they feel about such things lately. They are still mad about it.

Was this meant to be ironic? Most of the illicit fent precursors comes from China now, I would guess it’s only a matter of time until Chinese producers look inward rather than just at export, which is why I’m surprised the Chinese government isn’t taking a harder line stance on illicit fent production and export.

[jnovek]

“Opioids can't be banned until we can replace them with something equally generally effective.”

If only doctors took this advice! When the CDC made its first recommendation against using opioids there was a chilling effect and thousands of chronic pain patients who desperately in need of opioids to function were cut off. There were suicides.

It wasn’t until 2022 that the CDC loosened its recommendations and, in my experience, only a few doctors have caught up.

[BobbyJo]

I could not agree more. Fentanyl enforcement is obviously not feasible to anyone that has been, or known, an addict. Its incredibly cheap to buy, and you can store enough to kill 1000 people in a bag in your pocket.

You might as well have cops trying to arrest the pollen in the air.

[thegrimmest]

> That last thing was their crime

Taboos are bullshit. Either something is a clearly articulated, written, rule with an enforcement mechanism, or it's fair game.

Prescribing doctors are responsible for the opioid epidemic. Doctors failed in their duty of care to patients. Doctors massively overprescribed, failed to track their patient's medication usage, and failed to spot addictive behaviour. Why aren't we holding them responsible? Simply because that's hard to do?

[mcguire]

Purdue aggressively marketed OxyContin as having a very small rate of addiction to doctors who weren't pain specialists and thus had little experience with controlled medications, while providing a dosing regime that was almost designed to cause addiction. (It's sole advantage was as a timed-release medication; if pain returned before time for the next dose, doctors were instructed (strongly) to raise the dosage rather than increase the number of doses per day.)

"The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/)

"The Family That Built an Empire of Pain" (https://www.newyorker.com/magazine/2017/10/30/the-family-tha...)

[com2kid]

> . (It's sole advantage was as a timed-release medication; if pain returned before time for the next dose, doctors were instructed (strongly) to raise the dosage rather than increase the number of doses per day.)

The same thing happens with ADHD medications, the timed release dosages are supposed to last 12+ hours, but in reality they vary from 8 to 16.

Thankfully most doctors will willingly prescribe a small after lunch short acting dose.

There is a large delta between the average response curve and an individual's response curve!

[darawk]

> The same thing happens with ADHD medications, the timed release dosages are supposed to last 12+ hours, but in reality they vary from 8 to 16.

Modern ADHD meds are really not comparable to powerful opioids. They are both dopaminergic, but they are night and day in terms of addictiveness. Even weak opioids vs strong opioids is night and day.

> There is a large delta between the average response curve and an individual's response curve!

True! But the word "average" is actually not, itself, precise. It has at least three typical meanings: mean, median, mode. These all have quite large deltas to each other when talking about dose-response curves, and since they are curves, you would also have to pick a norm first.

There are a lot of sources of variability, but variation does not actually make it very difficult to detect improper opioid prescribing behavior. Just like the variation in people's weights would not tell you much about the strength of asphalt roads. These things are not measured in the same scale.

The majority of the pharmaceutical problem came from a very small number of people who churned out prescriptions like a literal mill. Like 5 minute appointments all day every day - not random doctors overprescribing their patients by accident. What is true is that the random doctors overprescribing provided a certain amount of cover for the corrupt doctors, for a while.

[com2kid]

> Modern ADHD meds are really not comparable to powerful opioids. They are both dopaminergic, but they are night and day in terms of addictiveness. Even weak opioids vs strong opioids is night and day.

True, my point more was that false advertising about "duration of extended release action" is a problem across multiple types of prescription drugs.

> True! But the word "average" is actually not, itself, precise. It has at least three typical meanings: mean, median, mode. These all have quite large deltas to each other when talking about dose-response curves, and since they are curves, you would also have to pick a norm first.

The marketing material doesn't care. "All day", "24 hour", "12 hour" are the phrases that get used.

Meanwhile reality is that every person who takes a drug is different and doctors need to be aware of this and just ask the patient how well things are working out.

> The majority of the pharmaceutical problem came from a very small number of people who churned out prescriptions like a literal mill. Like 5 minute appointments all day every day - not random doctors overprescribing their patients by accident. What is true is that the random doctors overprescribing provided a certain amount of cover for the corrupt doctors, for a while.

Yeah it got out of hand, but I'd imagine that this wasn't happening from day 1.

Also when we talk about preventative measures, people going to a pill mill doctors to get a refill are already addicted, but what can have a long term impact is putting in the effort to prevent people from becoming addicted in the first place, which means understanding how so many people who did not want to get addicted to opioids ended up that way.

[darawk]

> Also when we talk about preventative measures, people going to a pill mill doctors to get a refill are already addicted, but what can have a long term impact is putting in the effort to prevent people from becoming addicted in the first place, which means understanding how so many people who did not want to get addicted to opioids ended up that way.

This has changed over time. At first it was the pharmaceutical route, largely due to the shift in medical norms to prescribe opioids for chronic, not just acute, pain. Prescribing them for chronic pain is a near guaranteed recipe for addiction. However, I think things have changed in the past decade or so, with people largely moving straight to fentanyl and/or other illicit opioids. I don't think the pipeline is largely pharmaceutical in nature anymore.

[thegrimmest]

Blindly listening to a company trying to sell you something has never been a good idea. Doctors doing just that despite the clear, obvious, conflict of interest is their failure, not Purdue's.

Thinking that an individual or organization with a vested interest will not bullshit you at every turn is absurdly naive. This is why third-party testing, accreditation, certification, and audits are a thing.

> doctors who weren't pain specialists

Then they should have insisted on third party, board approved, usage guidelines; especially when it became obvious that OxyContin is highly addictive. It doesn't take that long. Doctors have not however been held responsible for their abject failure towards their patients, and continue to prescribe a month's worth of Oxy for minor issues. This will continue until doctors start losing their licenses.

[mcguire]

Everyone in every industry that I know about relies on true information from their suppliers, from software to produce. They're the ones who know about the products, after all. In fact, pharmaceuticals are the one industry most likely to treat suppliers at adversaries, with FDA regulations continually attacked as too stringent.

Purdue was actively lying about their drugs.

"Purdue trained its sales representatives to carry the message that the risk of addiction was “less than one percent.”50(p99) The company cited studies by Porter and Jick,51 who found iatrogenic addiction in only 4 of 11 882 patients using opioids and by Perry and Heidrich,52 who found no addiction among 10 000 burn patients treated with opioids. Both of these studies, although shedding some light on the risk of addiction for acute pain, do not help establish the risk of iatrogenic addiction when opioids are used daily for a prolonged time in treating chronic pain. There are a number of studies, however, that demonstrate that in the treatment of chronic non–cancer-related pain with opioids, there is a high incidence of prescription drug abuse. Prescription drug abuse in a substantial minority of chronic-pain patients has been demonstrated in studies by Fishbain et al. (3%–18% of patients),53 Hoffman et al. (23%),54 Kouyanou et al. (12%),55 Chabal et al. (34%),56 Katz et al. (43%),57 Reid et al. (24%–31%),58 and Michna et al. (45%).59 A recent literature review showed that the prevalence of addiction in patients with long-term opioid treatment for chronic non–cancer-related pain varied from 0% to 50%, depending on the criteria used and the subpopulation studied.60"

"The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/)

"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.

"When many doctors began prescribing OxyContin at shorter intervals in the late 1990s, Purdue executives mobilized hundreds of sales reps to “refocus” physicians on 12-hour dosing. Anything shorter “needs to be nipped in the bud. NOW!!” one manager wrote to her staff."

"‘You want a description of hell?’ OxyContin’s 12-hour problem" (https://www.latimes.com/projects/oxycontin-part1/)

From what I've seen (women sent home days after a c-section with Ibuprofen as the only pain medication; all of the doctors near me displaying signs saying they will not treat chronic pain), pain medication may well be under-prescribed at this point.

[darawk]

> Prescribing doctors are responsible for the opioid epidemic. Doctors failed in their duty of care to patients. Doctors failed to track their patient's medication usage, and failed to spot addictive behaviour. Why aren't we holding them responsible? Simply because that's hard to do?

This is a nice idea, but most Oxycontin is not prescribed by someone's doctor (it is prescribed by a doctor, but it is power-law distributed, most of it is sold by dealers). There are a small number of doctors in the country at any given time that prescribe almost all of the supply. This is not something you can readily fix with responsibility at the doctor level. It may seem like you can, because you could just prosecute "those doctors", but the problem is that the incentives are too concentrated.

That isn't to absolve these individuals of responsibility. They are responsible, and we should prosecute them legally. The problem is that we already do and always have. We should keep doing it, but I don't expect it to fix anything.

EDIT: To be clear I'm not necessarily for or against this settlement. There was a time that we might have stopped the opioid crisis at the corporate or pharmaceutical level, but that time has long since past. We could criminalize all opioids tomorrow and it would make almost no difference. Most opioid addicts use fentanyl now, and most fentanyl is produced/sold illegally. Heroin, for instance, has been Schedule I forever - the only thing that reduced its popularity was a cheaper substitute in fentanyl.

If we are going to bother prosecuting or civilly charging Purdue or its principals, it would have to be for purely punitive reasons. Corporate behavior unfortunately does not matter anymore.

[thegrimmest]

The on-ramp from minor pain or surgery; to a massive, blindly-renewed, over-prescription of Oxy; to an opioid addiction that spirals into street drugs is still mediated by doctors. Until these doctors start losing their licenses for their clear and obvious breaches in their duty of care, this on-ramp will remain open.

> a small number of doctors in the country at any given time that prescribe almost all of the supply

The fact that medical boards allow these doctors to retain their licenses is the core of the issue.

> we already do and always have

I am only aware of a handful of the most obvious, blatant, and egregious pill mill operators being prosecuted. Regular doctors who simply cannot be fucked to care for their patients, and prescribe them pills so they leave their office, have yet to be held accountable.

[darawk]

> The on-ramp from minor pain or surgery to a massive, blindly-renewed, over-prescription of Oxy to an opioid addiction that spirals into street drugs

This is mostly not a thing. I have known hundreds of current and former opioid addicts. I don't think I know a single one that was "on-ramped" from Vicodin or Percocet in any truly meaningful sense. It is the case that people almost always use these first. But it is relatively rare to become an opioid addict as the result of a one-off, acute vicodin prescription, per se.

> is still mediated by doctors. Until these doctors start losing their licenses for their clear and obvious breaches in their duty of care, this on-ramp will remain open.

I hope that is true! It doesn't seem like that to me, but I admit to not having carefully studied the data. Casually, there are 1.6 million opioid addictions currently in the US [1]. There were ~50,000 overdose deaths in 2019. That is, 1/1600 opioid addicts died in 2019 alone. To a first approximation, 0 people overdose annually from vicodin/percocet and other short term acute pain treatments.

It would be fairly surprising to me if (much) more than 1/1000 strong opioid users (per year) dies from an overdose. If the numbers were substantially higher than this, the epidemic would burn itself out in the population rather quickly. We can infer from this that most active opioid addicts are users of strong opioids, which are basically never prescribed for acute use. Hence, the overwhelming majority of current addicts are users of strong, non-acute opioids.

This doesn't mean there can't be some gateway effect (I do in fact think there is), but it does mean that "the problem" is mostly the presence of the strong opioids, not the Vicodin prescription for your wisdom teeth.

I'd be open to contrary data on the matter, though.

> The fact that medical boards allow these doctors to retain their licenses is the core of the issue

It is an issue, and we should absolutely try to improve it. It's just unlikely to materially dent the larger issue.

> I am only aware of a handful of the most obvious, blatant, and egregious pill mill operators being prosecuted. Regular doctors who simply cannot be fucked to care for their patients, and prescribe them pills so they leave their office, have yet to be held accountable.

I can personally attest to this being false. It was really quite annoying - I had to find new doctors on a number of occasions as a result, and that was ~15 years ago. Things have gotten much, much tighter on the pharmaceutical side since then. Every doctor who wrote me something was in prison or dead (from suicide, in prison) within 2-3 years of the last time I saw them, and I didn't even turn them in.

It is true that at any given time the Oxycontin prescriptions are power-law distributed, with most of the scripts being written by a small number of doctors. But this is a little bit like looking at the profits in the high frequency trading industry, or the cartels in Mexico (not to morally equate these things). Yes, there are a small number of them and they seem to make a lot of excess profits, but that does not mean you can knock them off and change anything. Nature abhors a vacuum, as they say.

1. https://www.hhs.gov/opioids/statistics/index.html

[burnished]

Taboos are part of how a society functions. Taboos can prevent the 'tragedy of the commons' in a way that rules and laws cannot. Think about it - people break the law all the time. They rarely break taboos.

[worik]

> Either something is a clearly articulated, written, rule with an enforcement mechanism, or it's fair game.

No. There are many legal and bad things.

Laws are a boundary, that few of us need.

Laws are not a target

[jjk166]

Taboos are not simply undesirable things, they are rules which carry severe penalties if you break them. The difference is that rather than going through the effort of getting society on the same page and agreeing what is okay and what isn't, you instead leave ambiguity that harms the well meaning and benefits the malicious. If something is bad enough that it should be banned by an unwritten rule, it's bad enough to be banned by a written rule. If you aren't willing to ban something by law, then it ought to be permissible.

[worik]

I am not a lawyer. I am from a legal family (three generations) and I understand jurisprudence

> you instead leave ambiguity that harms the well meaning and benefits the malicious.

Two points

1. Law advantages those with access, and often benefits the malicious and harms the good. Case in point: Drug law. Another is IP law

2. Law is not objective. The words that form it are in black and white, but there are courts and judges because the application of the law is subjective. The boundary cases are numerous and important

More generally....

> If something is bad enough that it should be banned by an unwritten rule, it's bad enough to be banned by a written rule.

Sotp, just stop! This is the idea that we must punish and scantion people into being good.

I think of things that are good (like treating drug addicts as ill, not criminal or imoral). I think not of "bans". They accomplish little.

Permissible, impermissible, these are blunt concepts that are not very useful. We can be, and should be, aspirational and collegial not judgemental and competitive

[jjk166]

> Sotp, just stop! This is the idea that we must punish and scantion people into being good.

You're not understanding what this conversation is about. Taboos punish and sanction people into being good. We are in full agreement that this is undesirable. There are some things that should be banned, and if they should be banned, they should be banned explicitly. There are many other things that should not be banned, and if it should not be banned it should not be a taboo, which is a form of ban.

You give a perfect example for my argument - treating drug addiction as an illness that should be treated instead of a moral failure to be punished. Where drug use is a taboo, you can't treat it; eliminating the taboo and accepting that these are people in need of help is, in my and many other people's opinion, the correct course of action. Most would agree that making drug use legal but ostracizing drug users would be an absurd strategy.

Taboos are fundamentally about what is permissible and impermissible, there is no other framework in which to talk about them.

[worik]

> There are some things that should be banned, and if they should be banned, they should be banned explicitly.

What about the things that are missed? Are you going to make an explicit rule for every bad thing?

Is the only way to be good, to be punished?

The creative bad folks, they are free to do their bad stuff, so long as they are more creative than the rule makers?

I do not want to live in the world where the only reason good things happen, is because all the options for being bad are outlawed

I want to live in a world, li,e the one I mostly live in, where we cooperate and love one another.

I am not advocating taboos. I am advocating the literal opposite

[thegrimmest]

I would argue that fiduciary responsibility mandates that corporate leaders do everything right up to the legal boundary in pursuit of their shareholders interests. In fact profitably violating regulations would also be the right thing to do in this case. Certainly most shareholders seem to appoint executives that do exactly that.

[worik]

> corporate leaders do everything right up to the legal boundary in pursuit of their shareholders interests.

Yes, that happens

Those are evil, short sighted people, sociopaths, who should not be emulated

[thegrimmest]

Sociopaths and other dark triad types have been the driving force in unifying and leading people since prehistory. It takes exactly that kind of person to unite tribes of strangers in order to go conquer, subjugate, and murder your neighbours.

"Evil" is immaterial. Markets and society are ecosystems, and the optimal patterns of behaviour in ecosystems are as ruthless as they are predictable.

[worik]

> "Evil" is immaterial.

No. Never

[doctorpangloss]

Nobody is forcing you to see any doctors for any of your problems.

That's pretty reductive, right? Well so is what you are saying.