[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