6 ms·

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 for

by darawk 2y ago

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 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.

thegrimmest 2y ago
> 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?
- doctorpangloss 2y ago
  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.
- worik 2y ago
  > 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
  - thegrimmest 2y ago
    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 2y ago
      > 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 2y ago
        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 2y ago
        > "Evil" is immaterial. No. Never
shawndrost 2y ago
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 2y ago
  > 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 2y ago
    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.
    - doctorpangloss 2y ago
      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.
worik 2y ago
> 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 2y ago
  > 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.
deleted 2y ago
[deleted]
jnovek 2y ago
“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 2y ago
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.

by darawk 2y ago

thegrimmest 2y ago

> 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?

doctorpangloss 2y ago
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.
worik 2y ago
> 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
- thegrimmest 2y ago
  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 2y ago
    > 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 2y ago
      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 2y ago
        > "Evil" is immaterial. No. Never

shawndrost 2y ago

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 2y ago
> 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 2y ago
  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.
  - doctorpangloss 2y ago
    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.

worik 2y ago

> 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 2y ago
> 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.

deleted 2y ago

[deleted]

jnovek 2y ago

“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 2y ago

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.