As opioid overdoses exact a higher price, communities ponder who should be saved | Hacker News Reader

As opioid overdoses exact a higher price, communities ponder who should be saved

washingtonpost.com

72 pointsjseliger110 comments

(this article can be read by searching for the title on http://twitter.com/, then opening the link in a private window)

> Two doses of an injectable form of naloxone, Evzio, cost $4,500, up from $690 in 2014. The price of other forms of the drug, including the nasally administered Narcan, typically range from $70 to $150 per dose, officials say.

The cost of naloxone [1] is an insignificant part of the cost of reviving an addict. The rest of the costs mentioned in this article are pure profiteering.

[1] http://www.sigmaaldrich.com/catalog/product/sigma/n7758?lang....

If you buy 5 grams from Sigma Aldrich, a 2mg dose costs $0.588. Add a few more cents for salt, water and packaging brings the cost per dose to $2. An EMS supplier sells a single "kit" with an intranasal atomizer for <$48 [2]...

Someone on Reddit sent me 4 vials of naloxone. I sent them <$20 to cover postage. [Edit: these vials have .4mg naloxone. Needles were also included. I think the standard intranasal dose is 2mg.)

[2] http://www.dixieems.com/Economy-Naloxone-Kit.asp?pid=2086

Naltrexone is very similar to Naloxone. It is used to keep people from getting high on opiates. Big Pharma has found a way to jack the price of this generic drug too. 15 days ago I posted about the Naltrexone rip-off: https://news.ycombinator.com/item?id=14672338

I don't know how long this country can survive with this rampant corruption and profiteering. When do we hit a breaking point, and what does that look like?

I mean I read your response and think, "wow, that's horrible." Then realize absolutely nothing is going to be done about it.

I guess one way it could play out is that as the corruption becomes more and more obvious, together with increasing differences in political ideology between red and blue states, an appetite for seceding from the United States could develop in some states, and if that sentiment becomes common enough, it could become a reality?

It's IMO more likely than most people think. I really hope we don't see a civil war in our lifetime, but historically democracy's are highly unstable. This time it might be different, but then again it might not.

A Civil War today would look like Afghanistan or Iraq, not like the one we had before. It won't be pretty and will probably end in authoritarianism the likes we've never seen.

A civil war in a nuclear armed country could be considerable worse than that. Just consider what would happen if a faction of the army with control over nuclear weaponry took a non-neutral stance...

~50% of all US war casualties occurred during the Civil War. It was very nasty, even if only 3% of the total US population died in direct fighting.

Yes, it was a gruesome war. By Afghanistan and Iraq, I meant more insurgent type war rather than sanctioned armies fighting. Liberal states would have insurgent right wingers and Conservative states would have insurgent left wingers. Insurgents would be fighting the opposite faction of insurgent, and everyone will be armed to the teeth. We saw a glimpse of how that would play out in rural areas with the Oregon stand off. I suspect the cities would be something like we saw in Ukrane with their stand in the main square with the firewall, except a lot more shooting. There would be massive food shortages. It would be crazy and unpleasant and not a damn thing will have been resolved.

I realized I was being vague.

The problem is that the stratified cultures that form the arbitrary two sided political dichotomies (see Britain for another great example - given current norms it would make perfectly good sense for Scotland, London, and Northern Ireland to secede from the more conservative England and Wales).

But they are arbitrary. The talk radio in the rural conservative parts and the Internet circlejerks in the liberal ones have divided peoples way worse than they were a hundred years ago by putting the soft-reds and soft-blues into echo chambers of the most ardent idealogues and turning many into adherents that place their personal identity into their politics.

The other problem is those of us guilty of that - the framing of our identity on high-brow concepts like ideology - don't want to change. Who wants to revert back to ignorance on how you personally think the world is best ordered?

The rift will only grow until dissolution does happen unless all participants admit that they want to preserve solidarity in society. They will not be able to change themselves, but they can train future generations to not base themselves so heavily in politics such that they do not segregate themselves such. But it would take everyone agreeing on something nobody wants to have happen. So... yeah right.

100 years ago, politicians were tricked into trusting organized crime to tend to the health of people who are drawn to opiates. Those politicians are dead & gone, but we're still stuck with their mistake.

My mother broke her wrist 6 months ago, and was given opiates to deal with the pain of having a plate put in her wrist. She did not become an opiate addict. I presume she managed to avoid becoming a junky because she has a pretty stable day-to-day life.

By "organized crime," I assume you mean something other what's traditionally thought of as organized crime, e.g. the Mafia, but I can't tell what.

> I presume she managed to avoid becoming a junky because she has a pretty stable day-to-day life.

While circumstance and upbringing are factors for addition, I think it's accepted that there is also a biological component; your mom may be inherently less prone to becoming addicted to opiates.

> By "organized crime," I assume you mean something other what's traditionally thought of as organized crime, e.g. the Mafia, but I can't tell what.

The Mafia and other manifestations of "traditional" organized crime is exactly what I was referring to.

Two years ago, when a new friend was teaching me about her addictions, I bought Johann Hari's book, Chasing the Scream: The First and Last Days of the War on Drugs [2]. Hari says that after heroin was made very difficult to obtain (circa 1915), organized crime became the supplier for most addicts.

The Los Angeles Times Op-Ed A 1930s California story shows why the war on drugs is a failure also covers how the Mafia swooped in to supply the needs of addicts [2]. This is the primary article I was thinking of when I wrote the quip you responded to.

[1] http://chasingthescream.com/

[2] http://www.latimes.com/opinion/op-ed/la-oe-hari-california-d...

> > I presume she managed to avoid becoming a junky because she has a pretty stable day-to-day life.

> While circumstance and upbringing are factors for addition, I think it's accepted that there is also a biological component; your mom may be inherently less prone to becoming addicted to opiates.

My mother is inherently less prone to becoming an addict because she has meaningful things to do: job, family, friends, trips, etc. My friend who taught me about addictions (mentioned above) was vulnerable to the street pharmacy because she was exposed to meth amphetamine as a pre-teen, and her brain chemistry never fully recovered. She says she was very depressed as a child/teen, and was made suicidal by her doctor when he injected her with Depo-Provera around age 20 (this is a chemical castration drug used for 3 months of "birth control"). This friend is doing well now because I provided the "connection" that Johann Hari says is so important for helping addicts out of their pit.

Describing criminal drug peddlers as "tending to the health" of people is a very odd way of putting it. It's also rather beside the point when talking about today's epidemic.

Having meaningful things to do is not "inherent."

I never heard of Depo-Provera before but calling it "chemical castration" and putting "birth control" in scare quotes seems like hyperbole and inflammatory. The drug is a progestin, a synthetic hormone that is administered in a number of forms. Depression is one of the possible side effects of the shot, but that doesn't necessarily mean it would exacerbate an existing condition and you've not mentioned whether the doctor was also treating her depression.

https://www.plannedparenthood.org/learn/birth-control/birth-...

> Describing criminal drug peddlers as "tending to the health" of people is a very odd way of putting it.

The intention is to point out the absurdity of our situation, where much-desired plant-based substances can only be obtained with the assistance of organized crime.

> It's also rather beside the point when talking about today's epidemic.

The point is that the epidemic is entirely artificial. It is created and maintained by stupid politicians. It could be ended in a few months by implementing the same solution as is used in Switzerland.

> I never heard of Depo-Provera before but calling it "chemical castration" and putting "birth control" in scare quotes seems like hyperbole and inflammatory.

The same drug is given to male sex offenders [1] explicitly for the purpose of chemical castration. Many women lose their libido when they're put on this drug. No hyperbole is enough to warn about the dangers of this FDA-approved substance.

[1] https://en.wikipedia.org/wiki/Medroxyprogesterone_acetate#Ot...

You're ignoring the fact that the current situation has been created by prescription pill misuse (in proscribing and taking) and the death toll has exceed that of automobiles largely because of Fentanyl and other synthetic opioids. Of course, a lot of the attention being paid is not because of the relative scope but because the affected population is whiter and less poor.

But synthetic vs. plant-based doesn't mean shit, plenty of plants can kill you. I'm all for treatment over criminalization but you sound more like you're advocating for legalization of heroin.

> No hyperbole is enough to warn about the dangers of this FDA-approved substance.

Sure, if you're willing to ignore all the other information on that Wikipedia page. Every patient should be well-informed about possible side effects before starting a medication. The injection form is longer lasting so it may take longer for bad effects to subside but loss of libido for a few months is not the end of the world.

The worst thing about chemical castration of sex offenders is it's forced.

> You're ignoring the fact that the current situation has been created by prescription pill misuse (in proscribing and taking) and the death toll has exceed that of automobiles largely because of Fentanyl and other synthetic opioids.

My friend did not transfer her addiction from pills, she was a good old-fashioned heroin addict. The present body count stems from the synthetics. Many fewer people died when the street pharmacy's products were purer.

> I'm all for treatment over criminalization but you sound more like you're advocating for legalization of heroin.

I don't think legalization is necessary, just an acknowledgement that present policy is actually a make-work program for organized crime.

As for your comments about Provera, I say that doctors should not play Russian Roulette with women's health.

From what I understand, the current state of the epidemic was exacerbated by the crackdown on pills and the current deaths is from heroin more than anything. Heroin used by people who can no longer get pills of which they know the dosage of.

Yes, restrictions on prescriptions, meant to stop people from getting hooked and cut down on illegal distribution, plus some crackdowns on pill mills have driven people already addicted to cheaper, more available opioids.

"Heroin-related deaths more than tripled between 2010 and 2015, with 12,989 heroin deaths in 2015. The largest increase in overdose deaths from 2014 to 2015 was for those involving synthetic opioids (other than methadone), which rose from 5,544 deaths in 2014 to 9,580 deaths in 2015. One of these synthetic opioids, illegally-made fentanyl, drove the increase. It was often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge." [0]

But the rate of increase for death by prescription opioid has been greater than non-prescription so they are nearly half of all deaths.

[0] https://www.cdc.gov/drugoverdose/epidemic/index.html

Addiction is fundamentally about not being able to regulate ones nervous system and looking for external triggers for dopamine release.

This is almost always linked to developmental and shock trauma earlier in life.

That doesn't account for the genetic component.

You may have a person who is more sensitive in some ways, but you don't get addiction without some form of developmental or shock trauma - I've never seen it, and haven't met any professionals who have either.

> You may have a person who is more sensitive in some ways, but you don't get addiction without some form of developmental or shock trauma

I wish the justice system would consider this factor when deciding whether to send people for gratuitous punishment...

When the drug war started, politicians had a problem: banning someone from ingesting wasn't something the US government had the power to do. We were a free country after all. They had to bend the constitution by implementing a tax rather than a ban, and simply never issued tax stamps. Fast forward 100 years, the federal, state and local governments can ban anything they damn well please with little to no resistance, confiscate our property with no recourse and a myriad of other things we accept as normal.

Where would we be if they hadn't circumvented the constitution and just let people use the drugs they wanted? We would probably (maybe) have more drug deaths, but we wouldn't have this 1984 like society. I think I want a do-over.

Would there be more deaths? Surely legalisation/decriminalisation of some drugs gives a guide has to what happens when people can get what they want. Obviously the drugs that are becoming more freely available are of the safer variety but the scare mongers told us horror stories about what was going to happen, and it hasn't worked out as they stated.

> I don't know how long this country can survive with this rampant corruption and profiteering.

So far it has been 241 years.

Rather than a revolutionary movement you see mass implosion, addiction, suicide and people falling apart under the weight of triple time hours or being excluded from work altogether .

You mean unregulated Capitlism? It will wake up when we realize we need some middle ground between Capitalism and Socialism.

Most everybody already realizes this. We have exactly such a system in place. The argument is about exactly where the balance is to be found.

Furthermore, I'd imagine the cost of the naloxone alone is a small percentage of the total cost of the emergency responders + acute care given in life-threatening overdose. The article doesn't discuss a recurring theme in medicine: acute care is really, really expensive. It'd be far more cost-effective to reduce the need for acute care by providing access to addiction treatment before things get to this point. Easier said than done I suppose.

> It'd be far more cost-effective to reduce the need for acute care by providing access to addiction treatment before things get to this point. Easier said than done I suppose.

Johann Hari has pointed out that it's very effective to just give heroin addicts pure heroin and a safe place to inject it. Switzerland has 'essentially' [edit] eliminated opiate deaths with this strategy:

[edit: added 'essentially' in response to tptacek's comment below because the swiss probably haven't gotten rid of 100% of their opiate deaths]

https://www.irishtimes.com/news/health/johann-hari-heroin-in...

In reports about the Swiss strategy and in this story about Hari I see plausible claims that Switzerland has eliminated deaths due to needle-borne HIV, but no claims anywhere that prescribing heroin has eliminated all opiate fatalities. Can you cite a more rigorous source?

> but no claims anywhere that prescribing heroin has eliminated all opiate fatalities. Can you cite a more rigorous source?

I have edited the comment above to add a word.

The friend who taught me about her opiate addiction knew how to manage her dose pretty well. Then the mental health industry got her addicted to benzodiazepines, which changed her tolerance. She overdosed on me when trying to get off the benzos. The fire department revived her, then disappeared into the night. Those two doses of Naloxone stabilized her for about 2 weeks...

A lot of the deaths in the United States' present opiate overdose epidemic has to do with contamination of the heroin supply with more powerful synthetic opiates. When the supply includes elephant opiates, addicts don't know how much to use.

I see credible claims that Switzerland has reduced overdose deaths from opiates with this strategy, but none saying they've "effectively eliminated" them. I didn't look very hard, and you see familiar with the subject. Can you point me to a resource establishing this?

The thing I see reports saying Switzerland has effectively eliminated is deaths due to needle contamination. That's not hard to believe (but then, you could get that effect by giving addicts clean needles).

In the article you posted, I see Hari saying that Switzerland's practices have eliminated wounds and abscesses he attributes to drug contamination. That, too, is very plausible. But most opiate fatalities are not caused by injection site wounds; they're caused by overdose.

I think there might be some confusion. Switzerland itself claims that nobody has died from overdose of officially prescribed heroin. That, too, is totally plausible. But Switzerland still has a street opiate drug market problem!

> But Switzerland still has a street opiate drug market problem!

The planet's various governments created the street drug marketplace by making desired substances illegal. The United States government created the country's drug culture by lying to people about the actual hazards of these desired substances.

Perhaps Switzerland has not eliminated opiate deaths, as my comment originally indicated, but the Swiss are doing better than everyone else in making progress at helping people with opiate addictions.

  Results from the Swiss studies, however, show that 
  mortality among patients in heroin assisted 
  maintenance programmes is low, and lower than for 
  patients in other maintenance programmes.14 In 
  addition, the wider safety concerns could not be 
  empirically confirmed in Switzerland or the 
  Netherlands.15 Finally, the incidence of heroin 
  dependence has decreased greatly in Switzerland 
  since the start of the trials, and currently 
  heroin has a more negative image than it did 15 
  years ago.16

- http://www.bmj.com/content/336/7635/70?variant=full

ref #14 (above) says:

  CONCLUSION: Mortality in heroin-assisted treatment 
  was low compared to the mortality rate of Swiss 
  opioid users 1990s (estimated to be between 2.5 
  and 3%). It was also low compared to mortality 
  rates of opioid users in other maintenance 
  treatments in other countries as reported in the 
  literature. The SMR was also lower than that 
  reported in the only meta-analysis in the 
  literature: 13.2 (95% C.I. 12.3-14.1). The low 
  mortality rate is all the more noteworthy as 
  heroin-assisted treatment in Switzerland included 
  only refractory opioid addicts with existing 
  severe somatic and/or mental problems.

- https://www.ncbi.nlm.nih.gov/pubmed/16002023?access_num=1600...

Not quite "eliminated", and I don't have a source in English, but drug overdose deaths fell by about two thirds between 1995 (Heroin prescriptions started in about 1994) and 2012:

http://www.suchtmonitoring.ch/de/3/7.html?opioide-mortalitat

In 2015, there were about 10 cases of needle-borne HIV infections in Switzerland, out of a bit more than 500 overall.

Vancouver is doing this too:

http://www.cbc.ca/beta/news/canada/crosstown-clinic-heroin-a...

Hari is a self-admitted liar.

If you totally discount the good manufacturing practices and traceability that pharmaceuticals have to follow, sure you can hack together a cheap substitute that might not work when the chips are down

Except for biologics, many drugs are not that expensive to manufacture. The cost is in proving they will do what they say they do on the package.

It's clear enough that the manufacturer is enjoying their market position rather than having their costs spiral out of control as demand increases.

Do you really believe that it costs upwards of 4000 dollars to track a little box with medication in it? For that money I hope each box comes with a solar rechargeable smartphone that sends a gps beacon every half hour.

It's not the tracking, it's the super long and expensive regulatory process, and the cost of researching the drugs. Remember that for every successful drug, there are probably many that the company spent lots of money working on, and didn't end up working out. Someone has to pay for those failed ones as well.

How does that explain that the autoinjector was $690 in 2014 but $4500 today?

I don't know about the autoinjector, but for a lot of medication the list price is there simply so that when the insurance company negotiates a lower price, the manufacturer will get a reasonable amount. in many cases expensive drugs can even be free if your income is low enough.

This is a good point as well. List price doesn't mean the price that people end up paying. Some of these products are discounted 80-90%.

To actually put some numbers to the argument, literal aircraft grade bolts from spruce and specialties or spencer are super handwavy about twice the retail cost of similar low/single quantity bolts sold at home depot. I've done a couple ham radio antenna projects where I don't wanna climb up there again anytime soon nor do I want to clean up a failure and literal aircraft grade fasteners are surprisingly cheap and available and extremely reliable. Good enough for a 747, good enough to hold up my ham radio antenna.

With modern technology, trace ability and all that is really not that expensive for commodities. Returning to the topic, it would be predictable if OPs re-invention of the concept of generic drugs were maybe 1/10th the price of name brand. Oddly enough that's not unusual for generic pharma to be shockingly cheaper than name brand. The real question is why aren't generic overdose drugs incredibly cheap? I would guess profiteering, but who knows. Maybe they're not shelf stable, perhaps extremely temp or UV sensitive?

As noted by others, the cost of Evzio is up from $690 to $4500.

So, yes, there always is some reason. The pharma company needs to cover the costs to their whole business with the revenues from their whole business, and they'll play whatever games help them do that. The price for a drug does not correspond to the cost to produce (or develop or get approval for) that particular drug, the price corresponds to maximum revenue for that drug.

With all the max revenue from all drugs, they need to cover research for a bunch of drugs that won't work out, marketing, board of directors, and other expensive hires to power the rotating door between regulation and industry, etc.

It would obviously be better if prices paid for long-existing well-known drugs did not mostly go to cover inept big-business shenanigans. "Real competition" would fix this, but the health care industry is fucked up in 10 different ways and we can't agree which direction to go to fix it. (In this case I'd say the problem is that the end-user is not paying for it, so bureaucracy and politics decide how much of which brand to buy, and the result is so bad the end-user would never pay for it, so we're stuck - it's unfixable.)

After struggling with alcoholism for decades I used Naltrexone to stop drinking five or six years ago. It wasn't a simple taper but when I had my last drink it was easier to walk away from than anything I could have ever imagined before I did it.

Thank you for posting this; it'll help me help someone who is a self destructive alcoholic.

If it helps I used the treatment program outlined in the "sinclair method" which I found online and bought his book off Amazon. In the country I now live in, using Naltrexone in this way isn't exactly unheard of but it was definitely not the status quo treatment program.

The docs that I found to prescribe it for me really wanted me to subject myself to antabuse (Disulfiram) which is a profoundly sadistic strategy that creates a major sensitivity / negative reaction to even small amounts of alcohol that can be incredibly distressing and even life threatening.

Naltrexone on the other hand simply took away most of the euphoric experience I was getting from drinking and after a 4-6 weeks of using it every time I drank, I quit after a night of heavy drinking and morning of regret. After decades of quitting only to find myself drawn back to it, it was a profoundly liberating experience to actually be sober and not want a drink at all. It still is actually (though in a different sort of way).

I have to say that drinking while taking Naltrexone was a pretty weird experience because many of the signals I'd grown accustomed to for gauging my intoxication were muted... so I "felt" kinda sober but at the same time clearly was not. I think if there is a major risk in this it's possibility of deciding to drive because of "feeling sober". So that's the thing I think people need to be really cautious about.

Alternate access: https://outline.com/R36DZt

NB: I have no association with outline.com, nor do I even know who's running this, though if anyone has information on that, I'd like to know.

It is ... staggeringly useful.

Big Pharma has found a way to jack the price of this generic drug too.

Take a look at what companies make these generic drugs. It's not big Pharma at all. It's small companies. Most big pharma give up on a drug once it goes generic.

How can it be acceptable that you would declare people too expensive to save, rather than challenge the prices of a profit-making company that is bringing those costs in the first place? Shouldn't you be able to detect the sheer amount of corporate worship in such a statement before it leaves your mouth?

It breaks my heart to keep reading about this epidemic, with such a consistent reaction of hatred from so many people. This state of vulnerability should be met with support, but because opiates are nominally pleasurable, everything surrounding them must be a failure of personal responsibility - of people getting in over their heads.

This is what happens in the UK right now. The government decides when the life support machine gets turned off- they pay for it so it's their choice.

Not a common or planned outcome, but an unfortunate byproduct of nationalized healthcare.

http://www.bbc.com/news/uk-england-40423371

Not really comparable, that's a rare situation with no chance of recovery.

Commercial private medicine and commercial private medical insurance are legal in the UK and do exist although the markets are fairly small. If anything private medicine is less regulated in the UK than it is in the US (for example it's easier to call a doctor and get a price list, on enroll at any time in a plan). The legal basis of not allowing Charlie Gard's parents to take him to the US is not related to the existence of nationalized healthcare.

The Charlie case is not comparable - the question discussed by the court is not whether it should pay to keep him alive, but whether it's ethical to, given that he's constantly incurring brain damage and few people in the medical community believe he has any chance of survival at all. The justification used is that of "continued suffering", not cost.

>Not a planned outcome.

Sure, but the people responsible clearly don't care, as evidenced by the tone of the article.

Drug addiction is the result of the weak border [1], and a depressing job market [2], which is also the result of the weak border [3].

[1] http://www.businessinsider.com/us-heroin-coming-from-mexican...

[2] http://www.gallup.com/opinion/chairman/181469/big-lie-unempl...

[3] https://www.judiciary.senate.gov/imo/media/doc/03-16-16%20Bo...

The US prescribes far more opioids than any other country.

It's likely that some of the addiction problem in the US comes from this irresponsible prescribing.

https://www.dea.gov/divisions/hq/2015/hq110415.shtml

> Since 2002, prescription drug deaths have outpaced those of cocaine and heroin combined. Abuse of controlled prescription drugs is higher than that of cocaine, methamphetamine, heroin, MDMA, and PCP combined.

This is completely untrue.

"The government" has no say in life support. The government has given Charlie Gard world class medical treatment. The government has also paid for Charlie Gard to have his own legal representation - independent of his parents - to protect his legal rights.

You might want to learn more about the case because nothing in your comment is true.

Here's the GOSH statement which lays out the facts:

http://www.gosh.nhs.uk/news/latest-press-releases/latest-sta...

> 7. Charlie’s parents fundamentally believe that they alone have the right to decide what treatment Charlie has and does not have. They do not believe that Great Ormond Street should have had the right to apply to the Court for an independent, objective decision to be made. They do not believe that there is any role for a Judge or a court. They believe that only they can and should speak for Charlie and they have said many times that they feel they have been stripped of their rights as parents.

> 8. GOSH holds and is bound by different principles. A world where only parents speak and decide for children and where children have no separate identity or rights and no court to hear and protect them is far from the world in which GOSH treats its child patients.

> 9. Throughout this court process, Charlie has been represented by his Cafcass Guardian who has visited him in hospital, spoken to Charlie’s parents, nurses and doctors and written reports that ensure that as much as is possible for a desperately unwell baby, Charlies own viewpoint is articulated and given weight. When asked what happens to the role of the Guardian if their belief that only they have the right to decide on Charlie’s treatment is correct, Charlie’s parents answer that he does not need a Guardian because they will speak for him.

> 10. GOSH believes in its core that every patient is his or her own, unique and special person and that it owes a duty of care to each. The hospital’s mission statement is “The child first and always” and the hospital does not treat any child differently or as less of an individual because of the severity of illness or disability or because of infancy. If anything, special care is given to discover and work out with parents what is best for very vulnerable patients who cannot speak for themselves

Resources are finite.

For a less dire example, when people stop making progress in physical therapy, insurance stops paying for it. Not because there is no chance they will benefit from further therapy, but to control costs.

>Resources are finite.

But the important point is what exactly is making this drug scarce for local authorities. Opiod addicts are not rapidly consuming all the reserves of the drug on earth; companies have just set high prices and left the people to take the burden.

Accepthing that this resource is scarce for governments means inherently agreeing with the price set by the pharmaceutical company - and I don't think that's what we should do at all.

As someone pointed out in a sibling to my comment, the prices aren't high for generics.

So if they are spending for the branded version something else is going on.

Naloxone is already generic and basically free, government officials just like buying the branded version so they can get kickbacks while complaining about the cost.

Ugh. That is sickening. Since it seems like you have some expertise in the area, is this antipattern actually codified In regulations, or more of a de-facto/status quo thing?

> is this antipattern actually codified In regulations, or more of a de-facto/status quo thing?

A lot of drug purchasing things are codified. For example, Medicare is banned from negotiating drug pricing with manufactures. So even though they're buying billions of dollars worth of drugs in bulk, they're literally paying the retail price, which is just whatever the Pharma companies ask for.

In terms of why they're buying the branded version in the first place, not entirely sure what the exact situation is right now. I'm sure someone will write a great article on it in a few years though after all the money has already been siphoned off.

> why they're buying the branded version in the first place

Probably doesn't take a psychic to see its because the brand bought the right politicians at the right time.

Medicare does negotiate on drugs, just not in a direct way.

For injected drugs, Medicare pays no more than the average price that private insurers pay. They basically piggy back on the deals. If you look at heavily discounted drugs, Medicare is paying no where close to list price.

For peals, Medicare doesn't negotiate because they buy them. Private insurers adjudicate all claims and they certainly do negotiate drug prices. Those lower prices get passed to consumers who purchase their plans.

And this doesn't even include the 340B discount which is mandatory.

Medicare doesn't negotiate, it creates laws that lower it's drug costs.

"Medicare is banned from negotiating drug pricing with manufactures."

Where can I read more about this? I've heard the exact opposite.

Medicare Part D is the bit of law involved. Here is a randomly googled column with some history from a reputable paper: http://www.latimes.com/business/hiltzik/la-fi-hiltzik-medica...

A similar thing happened in Washington (but seems to be on the way out), that all ambulances were mandated to carry EpiPens. Not epinephrine, but an EpiPen. Even those that carry vials and syringes.

This absolutely blows my mind, the whole point of an epi-pen is it can be self-administered - what is the point of making paramedics have one in their vehicle when they've already got vials of epinephrine and syringes (and can be used for a lot more than anaphylaxis).

GoodRX shows the cash price for generic Naloxone for the general public shopping at retail pharmacies as ~$20 a dose ($13 at one pharmacy).

So yes, it is quite inexpensive.

Epidemic: "a widespread occurrence of an infectious disease in a community at a particular time." I can't see how drug addiction can fit in this definition. If one of them sneezes I don't immediately feel the urge to put some shit in my veins. I think that if someone doesn't want to be saved then maybe after a while it doesn't make much sense to try to save him.

In the UK, naloxone with an injector costs £20.58, plus £4.16 VAT and £4.95 shipping, in quantity 1. Total is about US$38. The price goes down if you order in bulk. The supplier notes "You may be able to get naloxone free of charge from your local drug service, or GP."

Note that this, like ephedrine, is an old drug, out of patent decades ago.

There's an opportunity here for a startup. The startup doesn't even have to make the drug; there are contract pharmaceutical manufacturers who can do that.[3] The startup just has to handle marketing, distribution, and FDA approvals. Here's a list of makers worldwide.[4] Auto-injectors are available from various suppliers.[5][6]

This project could be put together by a small team and would get very favorable publicity.

Then, on to replacing the Epi-Pen.

[1] http://www.exchangesupplies.org/shopdisp_prenoxad_naloxone_p... [2] https://www.fda.gov/downloads/Drugs/NewsEvents/UCM454757.pdf [3] http://www.contractpharma.com/csd/categories [4] http://naloxoneinfo.org/get-started/where-to-get-naloxone [5] http://www.medicalplasticsnews.com/news/autoinjector-landsca... [6] http://www.shl-group.com/products/shl-medical/

Why is ibogaine [1] still a fringe treatment for opiod addiction? It seems like a heroin -> methadone -> ibogaine treatment could get the vast majority of addicts cured. Instead, on one end of our medical system's pipeline we get people addicted to opiods, and on the other end we've created so many addicts we have to save them from overdosing. In this domain our "medical" pipeline is actually a disease-creating pipeline that's clogging itself up at the end... Research is still ongoing, but it seems likely that even the majority of opioid painkiller prescriptions can be replaced with cannabis.

It seems then, that we can empty the pipeline by adding less opiod addicts in, by prescribing cannabis when possible instead of opiods, and clear out the end by actually effectively treating addicts.

Unfortunately, our federal government is so out of touch with reality that it classifies both ibogaine and cannabis as Schedule I drugs, substances with "high potential for abuse", "no accepted medical use", and "lack of accepted safety for use under medical supervision". The irony is devastating, and it's ruining countless lives.

[1] http://ww.iceers.org/docs/science/iboga/Alper%20et%20al_1999...

[2] https://www.theatlantic.com/health/archive/2016/11/a-new-tes...

There is a big controversy about this in the area of Ohio I am from (overdose capital of the U.S., Coincidentally). A sheriff who presides over a country near my home is loudly deriding the use of Narcan, saying it will not be used by his deputies, due to moral and financial concerns.

Needless to say, I have lost 8 high school classmates to the epidemic at last count, and of those, 5 had been revived multiple times. So I can see both sides. There is no easy answer, and this problem will not go away on it's own.

While we are dealing with this severe public health crisis, Republicans in Congress are about to pass a healthcare bill that will, according to the non-partisan CBO, result in millions of people losing their health insurance.

There is really no word that adequately describes how disgusting it is.

Threaten to nationalize manufacturing of Naloxone, then do it if prices aren't brought down.

If there's an epidemic and private manufacturers can't respond to the demand without raising prices by a factor of 10, something needs to be done.

Annual overdose deaths have doubled over the last ten years. To bring a certain brand of hyperbole to the table, 2016 saw a loss of life equivalent to about thirty times that of 9/11.

Some see that as national crisis, others see it as an opportunity to gouge our people, towns and country.

Threaten to nationalize manufacturing of Naloxone, then do it if prices aren't brought down.

That should do wonders for R&D investment in the US!!

The majority of useful drug R&D (ie, not more penis enlargement pills) comes from research grants and university labs, not from private drug companies. It is a great meme Big Pharma has spread as a means to protect their lavish profit structure.

The US leads in pharma research because it has the best research universities, not because it has private drug companies and no universal healthcare.

The majority of useful drug R&D (ie, not more penis enlargement pills) comes from research grants and university labs

Absolutely false. Only 24% of new, innovative drugs come from academia. 76% come from biotech or pharma companies.[1]

And even if they were discovered by an academic center, someone still has to take it all the way to the finish line which is where most of the cost comes from.

[1]http://blogs.sciencemag.org/pipeline/archives/2010/11/04/whe...

The present drug R&D regime is remarkably ineffective.

There's been little advance in overall mortality rates since the 1920s / 1930s. Much of that comes from public-health measures, including preventive care, water and environmental quality, food quality, risk reductions (e.g., safety standards on electrical and mechanical equipment, automobiles, etc.), through removal and reduction in contaminants (especially of environmental lead in paints and motor-vehicle fuels), an through, apropos this thread, reduction in habitual consumption of drugs, notably alcohol, tobacco, and various narcotics.

What R&D exists has focused to a large extent on chronic conditions (far better treated through lifestyle changes), in specific high-value conditions (think impotence, though that's arguably a quality-of-life issue), and in treatments which offer often only very slight improvements in treatment.

A notable exception would be the introduction of artificial birth control, notably hormonal contraception, "The Pill". In 1960. Fifty-seven years ago.

(And yes, there've been incremental advances since.)

The cancer that killed my good friend nearly 30 years ago? Still effectively untreatable. And the therapies used then were the same as had been used two, and for the most part three, decades earlier.

Directed national policy sometimes is precisely the right tool to bring to bear. C.f., China. Or Friedrich List.

There's been little advance in overall mortality rates since the 1920s / 1930s.

Going to have to disagree with you. Penicillin wasn't discovered until the 1940's. That alone is a huge benefit to mankind.

Add on top of that the number of cancers who before were an immediate death sentence and are now chronic conditions (AML, HER2+ breast cancer, etc.)

Are there still cancers out there we can't treat? Sure, but that doesn't mean we haven't made massive strides in care.

See: https://ello.co/dredmorbius/post/MsQfdPAn_0XUdZUoReBfbg

Specificially 200 years of mortality data as compiled by the New York Department of Health & Mental Hygiene: https://assets2.ello.co/uploads/asset/attachment/1468664/ell...

Note that from 1940 to 1950 the mortality rate actually rose. Much of the improvement since 1970, if you dig into detailed statistics, comes from traditionally underserved communities, most especially black males. There's a lot more to be had for seeing those who get little or no treatment, get more, than in increasing treatment of the most privileged.

Laurie Garrett, author of The Coming Plague: “In all, 86 per cent of the increased life expectancy was due to decreases in infectious diseases. And the bulk of the decline in infectious disease deaths occurred prior to the age of antibiotics. Less than 4 per cent of the total improvement in life expectancy since 1700s can be credited to twentieth-century advances in medical care.”

https://www.goodreads.com/author/quotes/12627.Laurie_Garrett

I'd be quite interested to know what specific outcomes progress in cancer treatment you have in mind.

The Naloxone patent expired in the 80s. There is not some grand complication to its production - there are plenty of generic drug manufacturers who could be making Naloxone for $5 a bottle.

It seems obvious this is more a case of regulations mandating the use of brand name Naloxone by a specific company, thus eliminating any free market competition in the prices since only one entity can provide Naloxone to EMTs by law.

And, naturally, the politicians that signed such a law to mandate one singular company provide all of a specific drug probably got sizable benefits from said drug company for doing so.

Compare it to the money US spent on Afghanistan invasion and the explosion in opium production there. Where do you think the production goes and who is running the operations? Wouldn't it be fair to divert part of those budgets to help civilians in US to cope with the results?

The bitter thing is that even Trump will boost military budgets, not much change here from the previous regime.

I agree about the costs of war (though I think Iraq was a war of choice, to the detriment of the campaign in Afghanistan) but "nearly all of the heroin available in the United States comes from Mexico and South America." [0]

This problem was also started with prescription meds, due to deception by pharma companies and lack of attention and mismanagement by the medical professions and government.

This sheriff is an asshole. He says he doesn't want his deputies carrying Narcan playing paramedic, does he also not want them trained in administering CPR or basic first aid?

[0] http://www.politifact.com/truth-o-meter/statements/2016/sep/...

Why is the price increasing as volume has gone up? Is it FDA-type regulation that's preventing new market entrants or patents? Or something else artificially preventing new market entry like legal risk?

Not sure why you differentiate, patents are regulations too.

Patents are intellectual property rights established by law. Congress passes laws giving the executive branch the right and responsibility to create regulations but much of the content of those regulations are not dictated by law.

The patents didn't exist until the federal patent office approved them, in the same mechanical structure a regulatory agency approves a regulation. It is still on the authority of the executive to approve a patent or not.

I think we could add this to Jeff Bezos' ideas for philanthropic endeavors. Hell, it doesn't even need to be philanthropic. Amazon seems to have no problem with razor-thin profit margins: Why not create a company which has no problem making and selling generic-only drugs at razor-thin margins? There would seem to be a lot of room to undercut a business who sells for $4500 what might be produced for $20.

I think our capitalism may actually suffer from too much profit taking and not enough competition. I want the market to serve me (the consumer) not the other way around. I'm sure the producer see things differently... There doesn't seem to be a lot of appetite for companies to go after profitable businesses that don't have big margins.

There would be a Jeff Bezos if the drug market was as unregulated as the book market. Because of the regulations, instead there will be a Martin Shkreli.

Generally curious what the efficacy rates of opioid rehabilitation are. How many times does it take for someone to kick heroin? For how long? What's the cost breakdown for a turn in rehab?

"In recent weeks, Butler County Sheriff Richard K. Jones has drawn national attention for vowing that his deputies will never carry Narcan because he doesn’t want them playing the role of paramedic."

This is one of the sickest, most disgusting, most disturbing, most inhumane things I have ever heard. I guess police are not satisfied with just shooting unarmed people, now they have to let sick addicts die. So they can save $50, an amount that would be even less if it could be negotiated by a program like Medicaid or Medicare. At least it finally confirms the fact that a lot of police, like Jones, would rather stand around, do nothing, and let the people they are supposed to serve and protect die while they watch. What a sick, disgusting mother fucker. No, there's isn't a word in the English language that even begins to describe this lowlife. And the give this piece of shit a fucking gun? I wonder how many he's murdered so far without impunity?

I think it is time to (re)read The Final Circle of Paradise by A and B Strugatskie.

[1] https://en.wikipedia.org/wiki/The_Final_Circle_of_Paradise

Situation in US is quite close to one described there.

Why are the opoid manufacturers who are creating this addiction in the first place not being billed for it?

How did they create it?

Consumers can't buy direct, can they? There's always a middleman. Why not blame pharmacies or better yet, doctors?

> How did they create it?

They mislead doctors about safe usage of their product.

I'm not sure I buy that, at least not over the long term. People on the front line are going to see the effects of drug abuse more sharply than anybody. There's no way drug companies would be able to mislead a good doctor. Maybe once or twice, but eventually any doctor will start to see problems that they are creating.

I think I would put most of the blame on doctors. IIRC, doctors themselves have a pretty bad record with respect to drug abuse and addiction.

You mean like poppy plants? This addiction wasn't created by drugs - drugs are merely a coping mechanism for a world that people can't fucking deal with.

The root causes aren't opioid manufacturing it's whole slew of things from poor physical and mental health care in this country, worsening job prospects for people, a culture that ties worth and value to working hard and monetary prosperity, etc...

While people's life situation is always a factor, the drug makers ought to take some responsibility for lying about their drugs to make them seem safer. Purdue Pharma in particular: http://theweek.com/articles/541564/how-american-opiate-epide...

The US prescribes far more opioid medication than any other country.

This and @panic's response, both.

Quantity and dosing of opioids.

Or their executives sent to jail for life or executed in the streets like other drug kingpins?

Regardless of whether or not you regard opioid addiction as a disease, please please consider the slippery slope you're sledding down if you buy into this. Who's going to deny insulin to people whose credit card statements show more than 3 Dairy Queen visits this month? Who's going to deny chemo to people who smoked too many Pall Malls, in your opinion? This reeks from top to bottom, and yes, narcan isn't nearly as expensive as chemo, so yes, the slippery slope is pretty much guaranteed to go there. Proceed with caution.

That's why I think Kratom could be of huge benefit to a lot of people struggling with opioid addiction. It's cheap, otc, and a ton of people have had success with it.

How bout requiring opioid makers to pay for needed Narcan doses?

Why hasn't the price come down. Can we expect the cartels to start to manufacture opioids and anti-opioids?

Are these overdoses accidental or deliberate? The article does not seem to address this question.

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