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Comment by danans | Hacker News Reader

While I agree that a lot more funds for treatment are needed to fight the opioid epidemic, it is really a fundamentally different problem that road fatalities. The only thing they really have in common are the fatalities.

The opioid crisis seems like a symptom of our social problems (hopelessness in the rust belt, unscrupulous over-prescribing of pain meds) that has fatal consequences.

Short of a drug that provided a permanent cure for opioid addiction itself, I'm not sure what sort of solutions can be pursued by scientific/tech research, as opposed to addressing the root social causes.

I'm interested in what ideas others might have though.

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> I'm interested in what ideas others might have though.

I'm not from the US, but I think there is enough people already, all pointing out in the same direction:

http://www.motherjones.com/politics/2016/09/opioid-lobbying-...

Over the past decade, pharmaceutical companies have spent more than $880 million on lobbying and political contributions at the state and federal level. That’s more than eight times what the gun lobby and more than 200 times what those advocating for stricter prescribing rules spent over the same time period. The makers of prescription painkillers have adopted a 50-state strategy that includes hundreds of lobbyists and millions in campaign contributions to help kill or weaken measures aimed at stemming the tide of prescription opioids

This. Anecdotally I know a friend whose doctor offered a potentially addictive medication, when the doctor knew or at least was told the friend drank frequently. The friend did not fill prescription for fear it would become addictive.

Did the doctor just say "Here, have these drugs" or did he/she prescribe the "potentially addictive" medication for a medical issue that should have been treated with that medication? Just not taking medication that your doctor thinks is necessary is not a good choice; you rarely know more than your doctor about the risk/reward profile of the medication.

That's not true at all. Drug companies bribe prominent doctors with multi-million dollar payments to convince other doctors that drugs are safer and more widely applicable than they actually are. If you refuse to take an opioid painkiller for fear of developing addiction, you are empirically demonstrating that you know more care more than your doctor about the risk/reward profile of the medication.

http://www.nybooks.com/articles/2009/01/15/drug-companies-do...

Hydrocodone costs like $3. Drug lobbying is a problem, but not this one.

What if you are actually in pain? In that case, it might be fully rational to take the potentially addictive opioid painkiller, despite the possibility of developing an addiction.

I agree that the lobbying is a huge problem, but exposing/stopping that is a sociopolitical approach to the problem, not a scientific/technological approach. I am skeptical that the latter can do much for this problem, but I'm curious if others have ideas on that front.

That, and criminalizing drug use. When people can no longer get access to or afford pharma drugs, they shift to illegal drugs. Once they are hooked on that, they are criminals, and they hide their problem, out of shame and fear or prosecution.

The United States alone holds over 45 percent of the global pharmaceutical market [1]. And less then 5 percent of earths population. Welcome to the society of pharmaceutical addiction.

[1] https://www.statista.com/topics/1719/pharmaceutical-industry...

You're comparing a measure in dollars with a measure in people. Yes, per capita expenditure on prescription medication is high in the US. Most other countries have a national health care system which negotiates the price for the whole country. The US market is where pharmaceutical companies expect to recoup their R&D costs, which makes drugs more expensive in the US than anywhere else. This effectively means that the US subsidizes drug prices for the rest of the world in exchange for determining which drugs are safe for humans (via the FDA) and getting slightly earlier access to newly developed drugs.

> You're comparing a measure in dollars with a measure in people.

I'm not parent, but I'm sure this is intentional as the consequences of such a scenario are easy to extrapolate...

> The US market is where pharmaceutical companies expect to recoup their R&D costs.

They could do this in two ways - having high margins on their drugs, and/or selling a lot of drugs. It is no surprise to see pharma lobbying against tight laws on prescriptions, or anything that gets in the way of the 'market' getting access to their products. Not coincidentally, the opioid crises means they get to sell more drugs.

I think that they have both high margins on drugs (my gut estimate would be ten times what the rest of the world pays, but it looks like it is ordinarily only 2-5 times [0]) and they're selling a lot of drugs. It is disingenuous to claim that the US consumes 9 times more prescription drugs than the world average. The reality is probably closer to 2-5 times more drugs and that these drugs are 2-5 times more expensive by virtue of being sold in the US.

[0] https://www.vox.com/a/health-prices

Price difference may be a valid argument.

On the other hand in my home country we had some big pharmaceutical companies (compared to the size of the country) exporting drugs world wide. I thought that for example the pain killers I knew as I child would be used everywhere on the world. When I moved to Germany I realized that I was wrong. There are tons of different drugs for the same purpose with the same ingredients sold by different producers. Therefore only becasue you in the US buy some expensive - and highly addictive - pain killers you are not automatically financing the R&D of pain killers sold in Europe by Europian companies to the Europian people.

Let me be a smart ass and improve your calculation:

45% of drug revenue is generated by 5% of earth's population:

45% / 5% = 9

but you do not compare this number to 1 but to

55% of drug revenue is generated by 95% of earth's population:

55% / 95% = 0.58

So a US citizen spends 9 / 0.58 = 15.54 more on drugs as a non US citizen. Even if price difference is a valid argument, this number is still too high.

I would restate that to the "US market is where pharmaceutical companies like recoup their executive officer costs, which makes drugs more expensive in the US than anywhere else. The US subsidizes executive salaries for the rest of the world..." http://www.ibtimes.com/healthcare-pharma-ceos-paid-more-top-...

> Short of a drug that provided a permanent cure for opioid addiction itself, I'm not sure what sort of solutions can be pursued by scientific/tech research, as opposed to addressing the root social causes.

Just give them the opiates for free in supervised facilities and let them have otherwise normal, albeit constipated lives. It works and costs very little.

Every time I bring this up people look at me like I am insane for suggesting such a thing.

What people don't think about is the extra societal costs associated with drug addition: thefts/violent crimes, prison costs, unproductive time from seeking the next high, etc. Cutting out the middleman would solve a great deal of these issues, and save the taxpayer money too.

It seems the moral issue of giving "free drugs" to addicts is just too much to bear, unfortunately.

How much do you give out then? At some point you'll be giving someone a dose so high they are guaranteed to die. Obviously no one can do that because of legal justifications. However now you have to set an arbitrary limit to what someone can receive. The user may not agree with this amount and will seek to acquire more. Thereby resorting to the same tactics as before it was given away. I don't think it's as simple as you want it to be.

I honestly believe drug addiction is a symptom of a greater issue in someone's life. There is no person who wakes up and says "I think I'll get addicted to heroin today"; it becomes a means of escape and relief from something that gradually turns into its own monster and creates a terrible cycle of dependence.

By cutting out the time and money needed to "feed the beast" while providing professional help, they can break this cycle and move towards bettering themselves when they don't have the nagging of addiction voicing itself at every turn.

Of course its not simple and perhaps there will be people who refuse to better themselves. My biggest point is that it not only will save money from going underground, but allow potentially productive members of society to have a means to break the cycle.

The vast majority of heroin addicts today started with prescription painkillers. Many of them went into a doctor's office and took the pill that was prescribed to them by a trusted community member with a diploma on the wall. The problem was that these doctors were frequently either directly corrupt or under the unwitting influence of false advertising from Purdue Pharmaceuticals.

When I had my wisdom teeth pulled and was prescribed an entire bottle of Vicodin, when I didn't even need a single one, that wasn't a greater issue in my life. That was medical malfeasance and a just society would execute the principal architects of it.

A just society executing the principal architects sounds similar to Italy recently prosecuting the seismologists for incorrectly predicting earthquakes.

I agree that there is a problem with over prescription of opioids, but this problem isn't solely due to a simple conspiracy of drug makers. I think that sort of rhetoric is unhelpful.

What you fail to see in drawing your analogy is that seismologists aren't being incentivized to give specific readings. Pharmaceutical companies are loading the gun and they know it.

I see your point with the pharmaceuticals and they have a share of blame, but I would argue that the analogy has merit as the prosecution in the seismology case would not have pushed for punishment if the scientists were merely wrong.

https://www.google.com/amp/s/amp.theguardian.com/world/2013/...

From my reading (and I will admit I do not see the logical reasoning at all, which I think is why the case was later overturned) the judge thought that they were guilty not of failing to predict it, but of giving an inadequate message. Presumably, to me this implies some sort of laziness, or intent to not make more of an effort despite knowing better.

I will admit that I am biased being a doctor dealing with this daily, but I think that blaming this solely on the pharmaceutical companies is easier to do than looking at what is happening to our culture, expectations of pain, the way we deliver healthcare, how we grade healthcare (for example read about Press Ganey's Fifth Vital Sign).

Why do you think they kept taking them after they ran out?

I think this is definitely the problem in the United States. In my country they don't just willy nilly prescribe opioids. The best you get is ibuprofen. For example, after a terrible shoulder injury or tooth extraction, that's all you get. It helps with the pain, but doesn't remove it 100%, doesn't get you hooked though. Of course they give IV opioids after surgeries and such, but even then something mild and in small doses, and only for a certain period time. I remember still feeling pain after an appendectomy, but they refused to give me any more tramadol and just switched to IV ibuprofen. It's just not a thing as a prescription medicine. Except maybe for terminal cancer patients or something equally drastic.

Going off on a tangent, what my country might have a problem with, is benzos, however. They're prescribed like psychiatric vitamins.

Please check "The Rat Park drug experiment" [1][2]

[1] http://www.stuartmcmillen.com/comic/rat-park/

[2] https://en.wikipedia.org/wiki/Rat_Park

What does the manufacturer of OxyContin (Purdue) have to do with you being prescribed Vicodin? And the world generally agrees that a just society wouldn't execute anyone. And the greatest issue in your life was that you were prescribed some pills you didn't need to take, just in case you had been in pain? That's a pretty good life.

No, at least opioids don't work that way. There is no dose so high as to be guaranteed to be fatal -- it's entirely dependent upon an individual person's tolerance. There is effectively no ceiling opioid dose.

There is also, IIRC (though it's been a few years since I was last researching this) for many people a limit on the tolerance one builds up (though it certainly gets very high). I recall something about addicts in the Netherlands—which has a program like the one suggested—eventually hitting a stable dose and staying there.

> At some point you'll be giving someone a dose so high they are guaranteed to die.

This is not how opioid pharmacology works. Tolerance to the desired effects (analgesia) increases but so does tolerance to the problematic effects (respiratory depression).

Opioid use -- even chronic and long-term use -- is not a death sentence. The phenomenon of so many opioid-related deaths referred to as the "opioid epidemic" is an extremely recent one (compared to the timescale that humans have been using opiates for pain relief) and is a product of drug policy/enforcement, not of the inherent evil of opioids.

People have actually been trying vaccine approaches to opioid addiction for a while, but it's tricky since opioids are small molecules which inherently don't give you a lot to work with as far as antigen presentation.

Apparently there has been some promising evidence recently though. See Derek Lowe's blog below for details.

http://blogs.sciencemag.org/pipeline/archives/2017/06/26/a-h...

Short of a drug that provided a permanent cure for opioid addiction itself, I'm not sure what sort of solutions can be pursued by scientific/tech research

Along with its therapeutic cousins Cannabis and MDMA, look what else we have on the list of substances for which federal research funds are banned (Schedule I):

https://en.wikipedia.org/wiki/Ibogaine

> Ibogaine causes long QT syndrome at therapeutic doses, apparently by blocking hERG potassium channels in the heart.

Yea. That doesn't necessarily sound good:

> Clinical studies of ibogaine to treat drug addiction began in the early 1990s, but concerns about cardiotoxicity led to termination of those studies. There is currently insufficient data to determine whether it is useful in treating addiction.

I'm not really sure this is some sort of miracle drug that the establishment just doesn't want us to know about.

The drug is toxic in humans but I think it also means we can't do comparative trials on the mechanism in mice. There might be something to discover about the mechanism that could be brought by a different drug that doesn't have the cardiotoxicity.

I'm not really sure this is some sort of miracle drug that the establishment just doesn't want us to know about

The thing is, it doesn't matter if you're "sure" or not, because while it's on Schedule I there can be no federal funds used for research into whatever degree it may be a "miracle" (nirvana fallacy) drug. I hope we can agree that therapeutic substances have been derived from harmful ones.

Can't research be done on other countries? Has research anywhere, of any kind, determined ibogaine to be useful in the treatment of addiction?

Here's a relatively recent roundup of the state of research: http://psychedelictimes.com/iboga/the-evidence-for-ibogaine-...

I'm not inclined to trust the Psychedelic Times to be particularly neutral on the topic or scientific.

The yellow words are hyperlinks. Many of them go to outside websites.

It can be done in the US with proper licensing, "just" if you get the funds from elsewhere. Not a small hurdle by any means, but it's not like you'll be blackballed (you can see plenty of studies of schedule 1 substances on PubMed, which is run by the US government).

I don't necessarily agree with it being Schedule I, but at the same time it's not "one weird trick" that the establishment doesn't want you to know about either. It's not something that's only waiting to be packaged up and sent to drug trials to start getting used (but is held back because "the man" thinks it will upset the status quo).

Is the cardiotoxicity worse than the side effects of the drugs they would replace?

I'm not sure there is an ethical way to find out.

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