The more opioids doctors prescribe, the more money they make | Hacker News Reader

The more opioids doctors prescribe, the more money they make

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177 pointsfahd77739 comments

I've done study of these exact datasets with Splunk and applied machine learning to detect anomalies in prescribed drugs comparing each doctor/provider behavior to his peer group.

Doing this on a past HHS/CMS datasets - i was able to discover anomalies that was proven to be actual fraud/crime:

Was interesting to discover anomaly in 2015 provider behavior data and then read about that same provider just being raided by DEA in 2018.

Interesting data!

https://imgur.com/a/eIySC

https://imgur.com/a/5BTo6

Do you have any papers or writeups on your methodology and dataset? Would be very interesting to see whether this could direct law enforcement (or, barring that, making it public knowledge so consumers can choose to avoid doctors where there is evidence of questionable behavior).

Yes. Here was initial write up:

https://www.splunk.com/blog/2017/09/28/building-a-60-billion...

https://www.splunk.com/blog/2017/10/03/building-a-60-billion...

Also I combined prescription dataset with provider payment dataset and it allows to discover potential conflict of interest where provider got compensated by drug manufacturer (speaking fees, stock, conferences).

Good idea to make this data publicly searchable.

It’s not that difficult.

So anyone could search for his favorite doctor name and find how much and for which drugs the doctor billed Medicare for. And how often, how much and when he was compensated by drug manufacturers.

Did you publish your findings? How do I get my hands on the data?

Data is available on data.cms.gov

I published initial research (with 2014 datasets) on splunkbase.com Search “Splunk security essentials for fraud detection” app.

(Free app with anonymized data embedded into it. You need to download/install free Splunk to use it).

Latest discovery for 2015 datasets (for which I attached snapshots) are not published yet - I plan to do it.

Also - I’ll be speaking about it next week (Splunk for fraud detection seminar)

why cant this be used by the law enforcement as probable cause for shutting down dodgy providers?

Because some statistical analysis showing a particular entity is an outlier isn't sufficient evidence to prove they are drug dealers. It is enough to start an investigation, of course.

They do!

Similar approaches are used to identify Medicare and Medicaid fraud.

It occurred to me, reading a few days ago that Trump had suggested that some drug dealers should face the death penalty, that maybe that should apply to some of these pharma executives.

I don't actually support the use of the death penalty, at least not in cases like this, but it is astonishing that we allow thinly-disguised kickbacks to doctors for prescribing addictive drugs. That's as much pushing as what the neighborhood drug dealer does — and more effective. This scam needs to be shut down yesterday.

Apparently we can only have one conflict-of-interest story on the front page at once per mods, but some readers might be interested in further reading on the topic from last year: http://journals.plos.org/plosone/article?id=10.1371/journal.... (Methods may also be useful to folks wondering how/where to get the data, and what a pain it is to link it...!)

We were interested in how physician payments drive prescribing costs across specialties, rather than for specific meds.

I can’t help but wonder about the overlap between US regions with high opioid use rates and US regions with high suicide rates.

I don’t doubt the incentives in the article contribute to the issue, but I wonder how we can account for the regional discrepancies.

I would assume there's a high correlation between experiencing long term pain and opioid use.

It also seems there would be a large degree of overlap between people experiencing difficult to treat long-term pain and people who commit suicide.

therefore, while it's certainly not an advertisement for the effectiveness of opioids for the treatment of long term pain, it seems unsurprising that there would be a great deal of correlation between opioid use and suicide, even if opioid use didn't cause suicide.

I mean, there are several mechanisms wherein opioid use could be the causative factor, sure; I'm just saying that even if opioids mostly worked as designed and never made anything worse, I would expect there to be a lot of overlap between the people who are prescribed opioids over long periods of time and people who commit suicide.

Reducing access to methods is a key part of suicide prevention work.

In the US the main methods are guns and opioid medication. Reducing access is politicially difficult, but would save tens of thousands of lives each year.

If you have a stockpile of medication please either keep it locked away, or give it back to the pharmacist. A disturbing number of children die after taking their grandparent's medication that's been left out because "we don't have children around".

You can look up your doctor here to see if they've "Received Drug or Device Company Money"

https://projects.propublica.org/docdollars/

>As tens of thousands of Americans die from prescription opioid overdoses each year

The number of people apparently come from the CDC https://www.cdc.gov/nchs/data/databriefs/db294.pdf

Is there some data about the circumstances? I was formerly under the impression, that overdoses can generally be categorized into two. Cut drugs and this no information about the dosage and intentional overdoses.

How are tens of thousands of people overdosing with a product with a known content? Are all of those first time users?

Sometimes, people addicted to prescribed opiates get cut off by programs to fight opiate addiction. And some of them eventually turn to illegal drugs, and have no clue how to use them safely.

Yes sure, but those arent listed under "die from prescription opioid overdose".

Maybe, maybe not. I mean, Teva oxycodone HCl is arguably still a prescription opioid, even if it's been obtained without a prescription.

I have to blame the language barrier, thanks for pointing this out. I assumed prescription drugs as being prescribed.

It is an ambiguous construction. And abuse can include doctor shopping to get multiple concurrent prescriptions.

People mix and match drugs, they lose track of dosing (easy to do when you’re wrecked on opioids), and as their tolerance increases they up their dose. They also frequently take a prescribed drug in unsafe ways, such as insufflation or injection.

The part of mixed consume patterns is something I missed. With the high number I disregarded poly drug use. I expected them to be negligibly in the number of death. But apparently with availability comes the category of occasional consumers.

Up until now my picture of opioid addicts was people with daily consumption patterns. Even with an increasing tolerance I didnt think accidental overdose deaths were a common phenomenon for an addict.

I thought the matter of unsafe consumption in form of injection and co is a matter for first time users of a specific product. Otherwise an addict know the dosage quite well.

That said, it will be a problem of hard to dose substances. Changing the ingestion method of for example transdermal fentanyl gets you killed quickly if you cant measure the dosage for the extremely small margin of error with improper measurement tools. I assume it will be similar with the other products on the list.

Thanks a lot for the input and the different perspective.

I didn't see the specific number the article quoted in the link you mentioned, but it looks like the tracking is based on what drugs were involved not context so I'm not sure how many of those deaths are in the context you are describing.

One thing that surprised me when I looked into it a little bit a while ago is that benzos + opioids were the most common combination involved in fatality (in New York city IIRC, not specific to type of opioid), followed by alcohol + opoids. But it made sense when I learned that the thing that tends to kill people with opoid overdose is not breathing. Pain can make it really hard to sleep and stuff that helps you sleep can also bring you closer to not breathing.

I'm not sure how many people on long term opioid prescriptions regularly use a recording pulse oximeter overnight, but I'd guess very few. There seems to be some connection between long term opioid use and central sleep apnea [0]. It sounds like apnea is considered a known complication at this point [1] but I don't know how well doctors are monitoring for it. I don't know if there is any evidence to support or refute this, but it at least seems possible that some number of the deaths could be from people who have breathing trouble at night for a long time without realizing it and something relatively minor might be enough to kill them.

I couldn't find anything if prior obstructive apnea is linked to opioid deaths, but I did find an interesting letter to the editor [2] that references an interesting retrospective study on opioid deaths in Canada using prescription information [3]. A quote from that study:

"In the primary analysis, 593 deaths met the inclusion criteria for this study ( Figure 2 ), including eligibility for public drug coverage, receipt of an opioid prescription overlapping the index date, and no evidence of cancer or palliative care. Of these, 498 (84.0%) were matched to at least 1 control. The coroner’s toxicologic screening detected more than 1 opioid type in 193 (38.8%), benzodiazepines in 301 (60.4%), and ethanol in 92 (18.5%) of these cases."

That seems like an amazingly high number of people with benzos in their system at the time of death. If I understand the study correctly the data table is showing that in 84.5% of deaths and 64.4% of controls there was a benzo prescription within 180 days (for controls index date was the same as the day of the matched death). I could imagine that often benzos might often be tried before starting opioids, so I'm not sure how often people have prescriptions for both at the same time but even if not that often many patients seem likely to have them available. I can easily imagine for someone in pain that a small (even if not that small) chance of death can be easy to overlook when trying to sleep. I am amazed that there aren't more people who die due to this. [2] mentions some alternative sleep aids that might be less likely to cause respiratory issues.

[0] Filiatrault et al. 2016. Medium Increased Risk for Central Sleep Apnea but Not Obstructive Sleep Apnea in Long-Term Opioid Users: A Systematic Review and Meta-Analysis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795290/

[1] Kahan et al. 2011. Canadian guideline for safe and effective use of opioids for chronic noncancer pain. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215602/

[2] Geller. 2017. Opioid therapy and sleep apnea. https://www.mdedge.com/ccjm/article/129989/pain/opioid-thera...

[3][PDF] Gomes et al. 2011. Opioid Dose and Drug-Related Mortality in Patients With Nonmalignant Pain. https://www.researchgate.net/profile/Michael_Paterson/public...

My pleasure, and I’d just add two more things; sometimes Rx users will venture into the world of the black market, and get more than they bargained for. More commonly though, a disproportionate number of overdoses are found among people who had been in recovery. Their tolerance is reduced, they chase their dragon at old doses, and it levels them.

Outside of the top few, the amounts those doctors are receiving from drug companies is barely consequential (<25k) compared to the stable, huge incomes they can pull from their “patients” in a pain clinic.

https://www.theguardian.com/commentisfree/2017/nov/07/truth-...

"Do no harm! unless of course you can sedate your clients forever... then it's a gray enough area that we'll just all get rich!" My heart curls into strange shapes when I think of all the friends I've lost to opiates.

The more wet streets that doctors walk through, the more it rains.

Really curious how previous societies dealt with opioid misuse when opium and related products (e.g. laudanum) were far less regulated. I’m just confused why a substance that’s been a cornerstone of medicine for centuries (millennia?) is causing so many problems now. Is it less about the drug itself and more about the state of society? The cultural or legal context?

How many opiate addicts does the average person know today (sans internet access)? I know for me it's 0, and I don't exactly run in the most wholesome friend groups.

My guess is it's always been a problem to the same extent, but the extent is exaggerated today, due to increased visibility (internet and media), and fairly recent (since the start of the war on drugs in the U.S.) incentives for bad news to spread.

I knew quite a few pretty well, called them friends: they're all dead but one.

Some of them kept it well hidden, till the HIV struck (far less an issue now), or they O.D.ed. I guess you might know one or two but maybe not as friends, but as familiar faces or friends of friends.

As to the size of the problem, I can not tell if it's the same or larger or less, since my observations are based on my age group (old) and survivor bias. I have seen two towns suffer under the epedemic it was in Europe in the 80's and 90's. These same towns now do not display the same issues with the 13 to 30 year old zombies.

The issues I read about in the US seem rather distant to me here in Europe.

Opiate addiction isn't related to how wholesome your friends are.

I also don't run in the most wholesome group of friends (at least by traditional standards) and also don't know any opoid users.

However, every time I walk to the supermarket I walk past a park where there's about half a dozen heroin addicts shooting up. They just do it in plain sight. There's also needle deposit boxes in all the public toilets and alleyways. Just the other day I saw a dead addict being wheeled into an ambulance.

Opiate abuse isn't related to how wholesome you are. There are plenty of god-fearing addicts.

Overdose death rates have increased massively over the past 20 years (https://www.drugabuse.gov/related-topics/trends-statistics/o...)

It's definitely a growing problem. Fentanyl and other synthetic opioids are making it even worse.

In a Massachusetts suburb it's pretty rare to find some who doesn't know an opiate addict. Some of my neighbors, family, co-workers, classmates and friends have been addicted. Most towns have a Suboxone/Methadone clinic.

A close friend has used oxycodone for back pain, for many years. But this is under a doctor's care. So are they an addict? I don't know. It has been years since they went without it, however.

Growing up in pretty typical Suburbia, USA, probably more than I can fit on my hands.

interesting anecdote

From what I'm aware, there are variety of reasons. In China opium use was common for a long time. However, smoked opium is less potent then consuming it in other fashions and generally speaking it was less available and more expensive.

Sure, but eating the ash, which contains much of the opium, is pretty common.

https://news.brown.edu/articles/2017/08/opioids-influence

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