[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.