[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.