The making of an opioid epidemic | Hacker News Reader

The making of an opioid epidemic

theguardian.com

99 pointsbenbreen70 comments

As someone who has chronic pain and tried everything under the sun, but only found relief in opioids, it sucks to see this attack on pain doctors by people who largely aren't affected by it.

I lost access to my medication because I moved to a new state and no doctors want to take on a new patient for fear of the DEA. Pain patients are super risky, and every script they write is scrutinized by the government. My quality of life has dropped a lot. Thank God I found Kratom (it really works for moderate pain), but rumor is that will be banned soon too in the US (where we love our drug wars). Also kratom doesn't help much during flare-ups. I'm now bed-ridden during those periods whereas before at least I could work.

Please consider the unintended consequences of a well-meaning war on opioids. They are not evil. In fact for many of us they are the only thing that allows us to live semi-normal lives.

I don't know your situation, but can empathize. In my state, you have to see a pain specialist and jump through the hoops on a regular basis. For me, opioids dulled the pain at night enough to sleep, but, they won't regularly prescribe it for my condition because, "it doesn't work."

I eventually found a doctor that prescribed low-dose naltrexone[1] (not a controlled substance) in 2mg/night doses and the pain has dropped from a nightly 8-9.9 to about a 6 or 7 except when there's a flare-up, and the next day I'm not in as much pain until later in the day. Still sucks, but I can eventually get to sleep. I have no idea how long it will work (I've found many pain meds eventually stop working for me) but for now, one day at a time...

1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962576/

It is a shame that doctors have now started leaving patients suffer out of fear of addiction. Surely there has to be a middle ground? I feel there is a risk they go too far and by not addressing pain in people they put those people at higher risk of doing desperate things like take other drugs available on the black market. I hate the feeling you get off opiods. But when I threw my back out over the counter medications did not even come close to touching the pain. It truly was crippling. Doctors would not give me anything but a family member had a handful of I forget what now but it was a prescription opiod of some type from a past surgery and it was the only thing that would even take a dent out of the pain. When my back came back I immediately stopped taking anything for it. But I truly do fear it happening again. I know I won't be able to access stronger pain medications if I have it happen again.

I'm sorry to hear this. I have a friend that works in a hospital ER and she says they rarely allow opioids even for broken bones and for post-op recovery these days, unless it's something like a back or neck surgery. Even then, many of the ER docs have started only prescribing "Extra Strength Tylenol" or NSAIDs (which are notoriously damaging to your system, as is Acetaminophen (Tylenol)). It's a sad state we find ourselves in these days.

It's possible that your pain doctor was great, but that doesn't subtract from the fact that there are doctors who act like glorified drug-dealers who prescribe oxy if you mention you've ever had a headache, and the only way that I can see to fix this is to start monitoring this more thoroughly.

I feel bad for people in your situation, but I feel like increased scrutiny is sort of a necessary evil. I got a vasectomy a couple years back, and despite me feeling nothing but a bit of soreness for two days, my doctor wrote my a prescription for 45 days of codeine. I didn't take them out of fear of it becoming a problem, but someone less informed could seriously be hurt by that.

To me this is essentially your argument: I have to suffer with excruciating pain because somebody else might make a bad decision or lack self-control, and my pain is worth it just in case it helps somebody else (evidence is lacking there anyway. Prescriptions have dropped precipitously, but opioid deaths are still rising).

Would it change your viewpoint at all to know that a lot of chronic pain patients are now committing suicide rather than face a life where they are bed-ridden and dependent on a loved one for care? And all they need is a medication and they could have some quality of life? What about the people who have been responsible with their prescriptions but are now forced to buy potentially deadly black-market opioids like heroin and fentanyl from a dealer that is surely less concerned about their health and safety than their doctor, if they want relief?

That is extremely non-compassionate. I would never wish that on you or anyone else.

I don't think that is what you are trying to say, but I struggle to see how your logic doesn't ultimately reduce to that.

Edit (after thinking more): your example of the codeine is definitely a good example of over-subscribing, but my dad had a vasectomy that ended up being a horrible recovery. Luckily he was able to sit on the couch with a bag of ice under his balls and watch football for a week, but the man was in some serious discomfort.

I tend to think education is the answer. Teach people about the risks, and then give them freedom to decide. If we boil society and our laws down to never requiring or allowing people to take responsibility for their own actions and decisions, then we end up in a bad place IMHO.

I appreciate your edit.

Please understand, and maybe I didn't make this terribly clear, but I am not saying I'm against people taking painkillers when needed. Obviously if you have crippling pain of course you should get pills. "Monitoring Doctors More" does not equate to "ban opiodes" any more than saying saying "regulating business" equates to "no business". There's a middle-ground here.

I'd also like to point out that I don't think I'm being non-compassionate in this case. Living in NY I get to see the terror of severe drug addiction every single day when I see (certain) homeless people. It seems "non-compassionate" to me to reduce all of life-crippling addiction to "making a bad decision or lacking self-control".

While some people have more addictive personalities than others, the stronger opiodes are addictive enough to ruin lives. It's easy to dismiss this as "people without self control", but I can almost guarantee that someone in your slightly-extended family has had severe problems with opiodes.

It may surprise you to learn that very few (about 2%) of people who use prescription opioids end up abusing them [1]. Also, there is also no correlation (let alone causation) between lower prescribing rates and lower overdose rates [2].

[1] https://www.politico.com/magazine/story/2018/02/21/the-myth-...

[2] https://www.painnewsnetwork.org/stories/2018/10/30/overdoses...

There were similar observations after the Vietnam war. Many soldiers were opiate addicts over there but the vast majority quit when they returned home and were no longer in the hell of combat.

Any level of scrutiny is going to leave some untreated who need it and some people getting it frivolously and perhaps getting addicted. The question is the role of individual responsibility and where the balance lies.

I totally agree with, "It seems 'non-compassionate' to me to reduce all of life-crippling addiction to 'making a bad decision or lacking self-control'." But I disagree that being prescribed opioids is a primary factor here. Many people with addiction issues, particularly homeless, are suffering from other mental health issues as well. They often abuse many substance both legal and illegal.

I think it's perfectly reasonable and appropriate for doctors to screen for these sorts of things before prescribing. However I also think making treatment for addiction more available and affordable is a better remediation strategy than having law enforcement monitor and scrutinize every act to the point where doctors are afraid to prescribe, even to patients in need.

We end up in a worse place societally if we go with line of least resistance every time. "Education and freedom to decide" results in patients asking for antibiotics for everything from a common cold upwards, and opiates for every headache and broken bone which has major consequences for everyone. Upto and including the end of the antibiotic era and stories of needless opiate epidemics.

A couple of weeks of serious discomfort, especially if a clearly temporary condition, is not something to be erased at every opportunity. It is a normal part of injury and healing and something we should not necessarily expect to automatically numb out of existence with drugs. Which is broadly what the surgeon and medical folks told me after my operation (for something else though). Along with the suggestion to try a couple of Nurofen, but to come back and talk about if it remains too much. I got ONE dose of something opiate based, the morning after. For everything else I was frankly expected to expect serious discomfort that will go away in time. It did, though my rate of swearing rose quite remarkably for a week or two. :)

For chronic conditions where nothing else has worked of course they should be available. After an appropriate level of counselling and warning of the ratcheting down of effect and addictive consequences of extended use. Which suggests a prescription regime that treads lightly down that path. Offer 2 or 3 days of opiates first and explore every avenue before they become a daily medication that you will end up addicted to.

Freedom to decide is what risks ruining it for all, including those chronic patients who have no working alternatives, as their only option becomes hidden behind a layer of freely chosen, but needless addiction. That means it's necessarily slower for those in real need to get enough coverage and dosage, but hopefully only those that truly need end up on a daily dose.

> antibiotics

There is a difference in the case of antibiotics because of the issue of drug resistance.

Most of the harm to others from opiate addiction is a secondary effect from the illegality of non-prescription drugs, leading to crime. There is no fundamental reason why someone else being an addict should be harmful to you, apart from your feelings of compassion for them.

>I feel bad for people in your situation, but I feel like increased scrutiny is sort of a necessary evil.

Or we dont torture people just because you dont like the possibility, that people could use drugs recreationally. What you describe can easily be avoided with a mandatory explanation by your doctor of the consequences of opioid consumption.

I do disagree with OP, I am hard pressed to see this as well meaning concerns. On the contrary, from my point of view thats pretty close to simply being cruel and to use the term -

Evil. Plain and simply.

It might be a more socially acceptable explanation then centuries of "pain medication is evil, because it interferes with gods will for you to suffer" but it remains the same arrogant disregard for your fellow men.

This might sound overly aggressive to you, but I think it is absolutely necessary to call it out for what it is.

You are willing to let people suffer. You are ok with your decision meaning literal torture fro them. Because you are disconnected from the horrible effect your decision would have. We life in a democracy, careless public outcry leads to real life effects.

Its pretty damn easy to voice your displeasure of being confronted with addicts if you are not the one suffering. And this careless disregard for human life has real life consequences for people whose life are already horrible.

And it is the same shit every few decades. People who are willing to accept "the necessary evil" because they are not the victims.

The world hasnt recovered from the last moral crusade against opioids and the same shit is starting again.

https://www.aljazeera.com/video/africa/2014/04/uganda-legali...

If only everyone needing pain meds had a baseball size tumor to proof that they are "legitimate patients"

There is in fact a middle ground where we help doctors find out if a patient is actually an abuse risk. Providing doctors with better insights into their patients through things like Prescription Drug Monitoring Programs (PDMPs) and easier access to information from law enforcement can allow them to better make judgement calls. Also clearer access to doctors' prescribing data and the patients it relates to can allow states to better understand who to actually investigate as over prescribing as opposed to doctors who just have a disproportionate amount of patients in need of pain management.

Under the current regime, doctors are not allowed to use judgement. Doctors face ruination of their career, even criminal prosecution, if law enforcement disagrees with them.

Doctors therefore do the obvious thing to protect themselves - they don't prescribe opiods.

Oh man, what kind of conditions causes this kind of pain?

There are surprisingly quite a few. In my case I have issues with discs in my spine and neck.

Sometimes it can be an autoimmune condition like multiple sclerosis or rheumatoid arthritis. Sometimes it can be downright mysterious such as many cases of fibromyalgia.

Mild sciatica is kind of funny but if you get a badly pinched nerve it is excruciating.

Opiates turned off the pain for 2 hours out of three, and for a third hour I suffered. I did not get a full night's sleep for 6 weeks.

Severe pain makes your life a living hell and is responsible for a lot of suicides.

I don't take pain killers now because my back got better, but I have other needs for controversial medications. It is a life of constant anxiety as the government keeps changing the rules. You never know from one appointment to the next whether the system will throw you under the bus again.

Have you tried CBD? I run a CBD company and I'd be happy to send you some products with no strings attached.

I’ve been on a Kratom regimen as well and tried CBD a few times but it didn’t seem to relieve the pain for me. What do you think of this article that came out the other day: https://www.vox.com/the-goods/2018/11/1/18024806/cbd-oil-vap...

As a consumer of CBD myself, I don't think it's a scam. I also don't believe it's a miracle drug that solves every problem. What I do think is that it has a remarkable safety profile. If you experience chronic pain, you should probably try CBD before opioids. The side-effects of CBD are pretty limited (be careful though as all interactions are unknown) compared to other pharmaceuticals used to treat the same symptoms. In other words, I don't think CBD is remarkable because of its effects. Morphine is a way better pain killer. I think CBD is special because you can take it for a long time without the same risks.

If you send me an email at evan@tryplainjane.com . I'd be happy to send you some samples as well.

That is a very kind offer, thank you!

I tried quite a few different strains of Cannabis but wasn't able to find anything that worked for me. Some high CBD strains did help a bit, but it was a mild help. It also wore off within an hour or two so I had to redose constantly, which wasn't feasible at work.

Would oil be much different than a high CBD flower?

Oral consumption generally provides longer lasting effects but have a smaller impact. Send me an email to evan@tryplainjane.com and I'll send you a couple different things. I'd love to see if any of them work for you. I can't promise they will but if they do, it's a lot safer than some of the alternatives.

Me uncle had cancer. No pain relievers worked, other than CBD.

Feel free to email at evan@tryplainjane.com if you or your uncle would want to try some of our products.

I appreciate the gesture!

My uncle passed away. The cancer kept reoccurring which was due to mutations (gene-related). My uncle's isn't related to me blood-wise, but his sons are. They have the same gene. I, AFAIK, don't have that gene. My uncle grew his own marihuana (within Dutch legal limits) because he got cancer. Before that, not.

I'm a proponent of medical marihuana however I've became an opponent of recreational marihuana usage. I am very sensitive to drugs in general and had a few psychoses in the past on marihuana (recreational usage though).

We're from The Netherlands and my father had MS and could've used medical marihuana back in the days (90's and 00's) to relax his muscles better. He declined because he was against marihuana in general. Given my uncle's positive experience, and gives I know it can work, that's saddening.

Also, I've recently started using Prozac (to make me less oversensitive; I have autism). It works, but I need to be careful with other drugs (even alcohol). I use an oxazepam when I need a needle because I have anxiety for needles.

That being said, I'm glad there's a change of breeze regarding marihuana in the world and in the USA.

second time I hear about kratom this month, do you know studies, or scientific review of it ?

When I first got my medical license about a decade and change ago, pain was the fifth vital sign and we weren't doing enough to deal with it. I (as a California requirement) even had to take CME to do a better job on treating non-malignant pain. Little did we know how the profession was being manipulated.

But what I think will happen, and some of the comments in this thread illustrate, is that the pendulum will swing in the other direction. Medicine doesn't know what to do with chronic pain. We can't define it, we have imprecise anatomic correlates, and no patient wants to be told that some fraction of it is in their head even though it's likely a combination of neurologic and psychologic factors. I remember throwing some obvious seekers out of my office but I had a lot of credible chronic pain patients when I left general practice, good people laid low in difficult ways, and I wonder what's happened to them since.

Is there a better (read: objective) measure of physical pain than asking the patient to rate it from 1-10?

The problem with asking everyone about pain, even if they're attending for something else, is that you find out a load of people live with pain.

This is a well-understood phenomenom about screening: screening people usually (not always) causes more harm than it fixes.

Back when "pain is the 5th vital sign" was being pushed people thought opioids were not addictive if used to treat pain. https://www.bbc.co.uk/news/world-us-canada-40136881

And there are drug reps telling you this medication is not addictive and that you're being negligent in leaving pain "untreated".

So, you ask everyone if they're in pain. A load of them say "yes", and you can't afford to give them physical therapy and psychological support but you can give them opioids which are dirt cheap and you've been told they're not addictive if used to treat pain. You end up flooding communities with opioid meds. You have a bunch of people still in pain, and with an opioid addiction. And then you have their friends and relatives who aren't in pain but who want to try these meds recreationally getting hooked.

It's a public health disaster.

To answer your question: ask people about pain, but set expectations first. Opioids are a poor choice for most people with long term pain.

Not much better than palcebo for neuropathic pain, but with more side effects and with risk of addiction: https://www.cochrane.org/CD006146/SYMPT_opioids-neuropathic-...

No better than paracetamol for long term back and joint pain: https://discover.dc.nihr.ac.uk/content/signal-000610/opioid-...

Not a doctor, but I would think that cortisol ("stress hormone") levels would correlate pretty well with what we think of as pain, since it does stress you out and would persist over long-term pain. And vice versa for dopamine.

People have vastly differing levels of cortisol response to pain and cortisol responds to many different stressors other than pain.

> even though it's likely a combination of neurologic and psychologic factors

That can't be emphasized enough in this debate. In short: if you arrived at some magical scan or test that indicated the presence, by degree of nerve stimulation of hand-over-a-hot-flame-type pain, and only prescribed painkillers to people over some threshold, you'd still be both excluding people who were personally suffering as much or more as those who made the cut, and including people who did not experience the same discomfort.

The human sensorium has a lot of experiences in common, but also a ton of differences.

There are lawsuits against the makers of Oxy for misrepresenting and pushing Oxy as such a miracle cure. It seems to be well understood by now that opioids are/were highly over prescribed, and there are a ton of addicts now whose lives have been ruined.

I also want to note that drugs often make life feel better, and a lot of peoples' lives for the past decade+ haven't been great. There is a social component to addiction that is inadequately talked about.

I would also suggest considering pressing your electeds regarding funding for long-lived independent drug studies for drugs such as ecstacy/MDMA, LSD, etc, as well as passing legislation inhibiting regulatory capture. I would like to see, for instance, marijuana effects thoroughly studied legally in long-lived large-cohort studies. There is potential here, but no silver herb, er, bullet.

a leading example : State of Tennessee vs Purdue Pharma; case 1-173-18; filed 15May2018 in Knox County, TN

> Dentists gave them to teenagers after pulling their wisdom teeth. Not just one or two days’ worth of pills, but a fortnight or a month’s worth, which, if they did not draw the intended recipient in, frequently sat in the medicine cabinet waiting to be discovered by someone else in the family.

This happened to me!

I got my wisdom teeth removed circa (2005-06), and they gave me a bottle of 50 generic OxyCodone pills. Fifty!

I took maybe 3 or 4 of them over the next couple days, hated the way they made me feel "robotic and distant", and just rode it out on Motrin afterwards. They sat in the cabinet until i ended up selling the rest to a "friend" a few years later.

I hate to think what could have happened if i Really liked them....

This was definitely still happening as late as 2011, I had a friend who spent two weeks basically nodding off because of the amount of opioids they were given after a routine wisdom tooth removal.

They are scarily strong.

A few years ago. I woke up vomiting and in extreme pain. Housemate drove me to 24 hour clinic. I was stuck in waiting room for hour or so. Eventually I got to see doctor. Clinic was not really confidant they knew what was wrong with me and told my housemate to take me to the hospital. I was stuck for another hour or two in waiting room at hospital all the while in extreme pain and vomiting.

I was diagnosed with a kidney stone and I was given a morphine drip. Almost immediately I was out like a light I don't even remember drifting off - scarily strong stuff I went from worst pain of my life to sleeping like a baby.

Same here (2008-2010). That shit made me sick and it only helped for like an hour anyways (0hr: took pill; 1hr: pain relief + nausea; 2-3hr: pain resurgence; 6hr: take another; rinse, repeat.). I stopped taking it after a day. I can appreciate its usefulness for chronic conditions, but damn, it's criminal how many I was prescribed in retrospect.

I generally don't get headaches, not even from drinking too much, but i remember clearly the day after i stopped taking those damn things having The Worst Headache Of My Life.

Looking back, what a blessing that was. Haven't taken another opiate since. Never will.

Remember this comment when you need serious surgery. Maybe you will come to understand how limited your understanding of pain is.

You're not entirely wrong, but you may also have a similarly limited understanding, having never been completely in thrall to an addiction. I know many recovering addicts who have white-knuckled through recovery-from-surgery (including blunt trauma from a propeller, partial hip replacement, and major oral surgery) in order to preserve their freedom from (what they described as) the intense suffering that failing to continue their recovery-from-addiction would entail.

We are all allowed to have different subjective experiences. Nobody is "wrong" here.

You would have become like the friend who bought them, I guess.

> Portenoy toured the country, describing opioids as a gift from nature and promoting access to narcotics as a moral argument. Being pain-free was a human right, he said. In 1993, he told the New York Times of a “growing literature showing that these drugs can be used for a long time, with few side-effects, and that addiction and abuse are not a problem”.

Just very similar to what is said about benzos, marijuana and are starting to be said about LSD, GHB and the likes. We need more scientific evidence to know the toll these narcotics and psychotropics can cause to us in the long term, like the same scrutiny they treated the tobacco industry.

We do. But man getting evidence in this area is hard. Human tendencies towards pleasure (from basic desire for good feelings/self-gratification to utterly destructive addiction) and towards greed (from dealers/cartels to HMOs) are both actively confounding the discovery and codification of good data regarding drug use, benefits, and abuse.

I don’t find this argument compelling. We knew for a long time that opiates were addictive, they’ve been in common use forever. We’ve come to learn that much of the information they were pushing shouldn’t have been trusted and that they seriously misrepresented these newfound non-hazardous opioids.

LSD is quite the opposite of addictive. Its showing very promising results for stopping addiction.

Persons with chronic pain should have access to treatments that work for them. For some, it may be exercise, or physical therapy, or tylenol, or a TENS unit. For a few, it may be opioids in low or high doses. Treatments need to be able to be individualized to the specific patient - one size definitely does not fit all. Your pain may respond to meditation and tylenol, but somebody with a pancreas that is autodigesting itself or chronic unrepairable partial bowel obstruction with miserable horrible daily disabling pain may actually do better with opiates. When politicians and internet experts begin dictating medical treatment regimens, individual patients will suffer and die, or commit suicide.

On the other hand, persons who enjoy abusing substances to get high or blasted or whatever the feeling may be need to have some safe way of feeding their addiction, or they will die, in large numbers. Being dependent on an illegal supply chain stretching from Kowloon to Morelia to San Diego to wherever with no quality control and no oversight is a recipe for disaster -- nobody who buys stuff on the street knows what they are getting. And to boot, actual medical treatment for addiction is not easy to obtain and limited. The much vaunted "clinics" are for rich people who don't need health insurance to pay the bills.

So we will continue to have problems in the US, and they won't be fixed.

Legalize Heroin for everyone again. If you're going to be a junkie and, let's face it, many people will prefer that over debilitating chronic pain, it'll be a safer and healthier alternative than these synthetic opiods.

Heroin used to be freely available over the counter and while it certainly did cause problems for its consumers, it wasn't even close to what these synthetic opioids are doing.

Weed.

This seems to be part of a bigger trend.

Do you feel a bit of pain? Unacceptable. We got to make it go away. Medicate it until you don't feel a thing.

Could your kid scrape a knee on the playing ground? Unacceptable, wrap it all in rubber.

Could you be offended by some text in a classic book? Unacceptable. Trigger warning, counseling on hand, feel free to skip it or read it together with a group in a safe space.

Something someone said makes you feel funny? Unacceptable. Report, protest, de-platform.

No one likes to hear "too bad, deal with it" as the response to their perceived problem, but I'm afraid we as a society are losing the essential skill of "dealing with" accidents, injustices, or just plain bad luck in favor or making someone else shoulder the blame.

Alternative explanation: the quality of care has been declining, for instance because of the ridiculously higher administrative spending in healthcare.

And the thing about painkillers is that they "fix" (to the patients' satisfaction) a hell of a lot of problems ... while bringing in extra money for the doctor and hospital. Any incompetent doctor, or just one that doesn't get the time to diagnose (administrators need to be paid, and that's justified by "productivity" of doctors. Productivity mostly means faster diagnoses. One very effective way to do that, of course, is just to make incomplete diagnoses)

Secondly giving a painkiller is almost never a stupidly wrong decision (unlike taking out a kidney that then in a biopsy turns out to be fully healthy, regardless of how many symptoms matched). So it's ALSO low risk ! And I assure you, there are no words in the universe that cause administrators to drool half as much as the words "low risk".

Didn't we want market-based medicine ? Well, this is one instance where the market based choice is blatantly obvious.

Secondly I fear like now we're seeing the opposite reaction: people are acting against patients that have chronic pain and would not be able to function without constant painkillers. These patients will go back to self-medication (ie. alcohol and/or cocaine, both "decent" painkillers) like people did 50 years ago. It is not a good evolution to replace morphine with alcohol or cocaine.

I agree, although I think it is important to keep in mind that everyone has different levels at which "deal with it" is appropriate. I've heard people say that about patients fresh out of back surgery, which I find to be ludicrous. I think this should be something between only a person and their doctor.

Eventually, the economy will crash, or at least the cheap energy will run out, and then people will be forced to get tough again.

Just "dealing with" injustices is enabling injustice through. And I am fully willing to help people in accident or bad luck assuming they will help me in bad luck.

Losing it? I personally doubt we had it in the first place. Just look at the rich and very not new history of scapegoating.

Blame the victim rather than admit a problem. Leprosy is a result of your sin. Smallpox however is blameless because it could happen to anyone. Lash out at the vulnerable rather than the source of the problem.

Survival bias is what leads to the perception of this lost golden era. Where all of the pioneer's children are healthy without doctors - nevermind the graves of the seven children and two other wives. We didn't have PTSD before WW1 just ignore all of the self medicating civil war veterans. This tendency isn't a moral component so much as a result of exposure and memory. Possibly a survival bias itself that remembering everything would be really bad for mental health.

You have never experienced real pain.

"The two doctors made no secret of who they blamed for “this preventable cause of death and disability”. “It’s about money. Money has influence, and it influenced the joint commission,” said Lucas."

And: https://www.forbes.com/sites/alexmorrell/2015/07/01/the-oxyc...

Counterpoint from Denmark that has the same movements of “wrap your kid in bubble wrap” and “it’s offensive to wear sombreros”, we don’t see an overuse of opioids or penecilum because the medical system isn’t for profit and you aren’t a customer, you are a patient. Show up saying you feel a flu coming on and would like some penicillin to curb it? The doctor will laugh at you and tell you to come back when you visibly sick, and even then she’ll tell you to just try sleeping it off. Only as a last resort do they actually prescribe harder drugs. Also, you need prescriptions even for larger packs of ibuprofen and paracetamol.

The issue in USA really seems to me to be drive in large by the fact that people are customes who want drugs and doctors are salespeople who want to sell drugs. With opioids it just so happens that the legal barrier got lowered enough that everyone who wanted it for all the wrong reasons could justify buying it anyway, and then they did.

We don’t make money by prescribing drugs. Those of us on risk sharing contracts - most of us, directly or indirectly, to a greater or lesser extent - lose money by prescribing drugs.

Your comment has little factual basis.

The patients don't, but doctors[0][1][2][3][4] and drug manufacturers[5][6][7] and distributors[8] do.

[0]: https://edition.cnn.com/2018/03/11/health/prescription-opioi...

[1]: https://www.healthleadersmedia.com/strategy/doctor-tied-insy...

[2]: http://www.waff.com/2018/08/22/doctors-indicted-overprescrib...

[3]: https://www.kansascity.com/latest-news/article214834685.html

[4]: https://www.hsph.harvard.edu/news/hsph-in-the-news/opioids-d...

[5]: https://www.vox.com/science-and-health/2018/9/7/17831710/ric...

[6]: https://www.masslive.com/news/index.ssf/2018/06/mayors_join_...

[7]: https://www.usnews.com/news/politics/articles/2018-05-16/6-m...

[8]: https://www.theatlantic.com/business/archive/2017/09/opioid-...

So much truth in this.

In Germany doctors have a "budget" per quarter allotted by the public insurers for every patient they treat.

All meds and treatments they prescribe come out of that budget, if at the end of the quarter the doctor ends up being above that budget, then he's stuck with those costs and has pay from his own profits.

In a setup like that, the doctor is held personally responsible for not overprescribing.

Just like insurers only pay a certain amount for meds for certain conditions/treatments. Creating pressure on the pharma industry to also offer smaller packages of drugs, instead of forcing wisdom teeth patients to buy a whole 50 pill bottles.

It's not perfect because it suffers from a bit of the opposite problem of underprescription and doctors being shy about prescribing expensive treatments even when they are needed.

But if that really becomes an issue then patients can just change the doctor, they are always free to do that and never forced to visit a specific doctor.

I don't think it's about money, more that the Danish government has control over healthcare and they're incentivized to not over-prescribe medication.

More people in the US also can't take time off, or are at least discouraged to do so. I have also found that many over the counter drugs for e.g. a cold that you find in Scandinavia aren't readily available in the US. Instead they suggest all kinds of fun/scary things that have been banned back home for many years.

These arent the same issue, though I agree we shouldnt take medication lightly for depression or pain but there still exists a massive industry specialized for american consumers to have these products pushed on them from all angles.

This isn't new.

The "sanatorium" concept was lost somewhere in the 20th century. The sanatorium idea was the cure by the gradual restoration of health.

Today is almost medication every time. Zero to little attention to physical and mental health restoration. It's like plastic surgery.

We have that still when called for - it is called rehab. Medicines fix things as well in many cases - at times far less gradual.

It's hypocritical that you don't just accept this as the way it is and move on.

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