Opioid crisis: Johnson and Johnson hit by landmark ruling
bbc.com
bbc.com
Incentivizing restraint and honest advertising is only possible by punishing executives, personally [1]. Especially those in sales.
And fair compensation is many, many times this number. So I fail to see how this is anything other than an injustice, and fear that it will take the pressure off of other court cases against opioid sellers.
Reading the book "Dreamland" [2] on the opioid crisis changed my life. Even as someone from a part of Ohio hurt by opioids, it's hard to imagine the venality of these people, the callousness of the Mexican drug dealers who swoop in behind them, and the magnitude of suffering their perfect storm concocts.
[1] https://news.ycombinator.com/item?id=19669453 [2] https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidem...
So far it’s been a few high profile cases, but obviously the problem runs deeper than that.
And J&J is by no means a major opioid manufacturer. As the article states, their drugs were less than 1% of all prescription opioids.
I think J&J got hit because they have deep pockets.
Finally - the reasoning here should he similar to gun and a murderer. If guns don’t pull triggers but people do, then similarily here only responsible people should be these that abused said drug, especially when it was manufactured and sold accordingly with laws and doctor’s prescription.
Lawn darts killed one kid and got banned. Cars got forced to be safer with seat belts and airbags, with the industry kicking and screaming throughout.
But would banning opioids have more positive than negative - who knows. Hence your gun analogy fits this situation perfectly. Though some would say banning guns would be easier than banning opioids.
Equally most things banned, end up shifting them into criminal distribution and quality. Though I've yet to find a lawn dart dealer, I dare say that somebody somewhere sells them illegally - nature of banning something alas. Hmm, just had a quick look and Amazon has many lawn darts for sale :(.
That depends. We had a case locally where a shop was repeatedly robbed, made little effort to improve security, and wound up shut down for it.
https://www.democratandchronicle.com/story/news/2018/08/16/d...
> As a result, MCSO investigators obtained a court order to close down the business and take control of its inventory, which Baxter described as "hundreds of guns and pallets of ammunition."
> "For more than a decade, the Monroe County Sheriff’s Office has attempted to work with the owner to improve security for his facility, Baxter said.
For clarity: Metal-tipped lawn darts were banned. You can get a foam Nerf one now, sure.
Thought they were banned in the UK as well, seems not so...yet.
[edit add] https://www.crowndarts.com/ sells them (metal tips) and will ship to the USA and Canada! that was just a quick look, so guarantee more avenues to procure them.
Where can I read more about this?
Car companies want to sell cars and therefore they want to minimize the overhead spent on regulatory compliance. It's really easy to sit here in 2019 and clutch your pearls about the evil car companies not wanting air bags in everything but the reality is that those car companies were catering to consumers (or at least a fairly accurate approximation of consumers). Consumers regarded airbags and seat-belts as minor incremental safety improvements in their day (the way we would think about something like blind spot detection today) and generally cared more about price than they did about the presence of those specific features and would gladly forgo airbags in exchange for several hundred dollars of the purchase price.
1st gen airbags also have a well deserved reputation for turning accidents you could have walked away from with bruises into a trip to the hospital so many people actively didn't want them.
Edit: Yes, I'm totally wrong and everybody in 1965 was tripping over themselves to buy a new car specifically for the seat-belts and everyone in 1985 could not get enough airbags and the car companies totally misread what consumers wanted. <eyeroll/>
> Automakers objected, contending that manufacturing costs would rise, seat belts would imply increased accident rates and safety wasn’t a selling point with customers.
Decades later, they did the same with airbags, ironically trying to get out of it by pushing mandatory buckle-up laws to shift responsibility from the industry to consumers.
https://www.latimes.com/archives/la-xpm-1985-02-19-mn-546-st...
Since USA is big distances, 1 has strong opposition, and 2 even stronger.
They could also make the drivers license short time, like 2 years requiring a refresh exam, but that'd be a real pain in the rear.
You could mandate built in breathalyzers, but they would routinly be failing or bypassed... Though it's a good attempt.
Ultimately getting rid of reducing number of unsafe human drivers would be good.
Nothing? Much has been done and continues to be done to make roads and cars safer. US road deaths, per population, have fallen by almost 2/3 since their peak in 1969. By miles travelled, deaths have fallen almost 80% since the 1960s.
This has largely been a result of regulation, including:
- Standardized crash testing
- Compulsory seatbelts
- Compulsory electronic traction/stability control
- Compulsory airbags
etc
Automatic Emergency Braking (AEB) is currently in the process of being adopted, and will be fitted in all new US passenger vehicles by 2022. Further significant improvements from things like lane keeping and self driving technologies can be expected in the coming years/decades.
The had the non-hospital fentanyl market cornered for a while. Their patches were only for chronic use by patients already tolerant to opioids.
Even if they had less than 1% of the market, they would have had a much larger proportion of the high-dose market, where mortality risk ramps up.
They've had a Opoid conference in Boston the past few years.
This seems to be an attempt by the states to reign in egregiously bad behavior by these businesses/ doctors that are supposed to be federally regulated (which frankly seemed to be lacking). Opioids things seem addictive enough to warrant some review on if there aren't other pain-killers that can replace them completely perhaps excepting in a few exceptional circumstances.
Considering the A) relative minor role that J&J played compared to the other original defendants, B) the relatively small size of the aggrieved population compared to the potential population with a cause of action, and C) the particular law they brought suit under... this is in fact a pretty spectacular result overall for the State.
Really the bigger question is why the State settled with the other defendants for so little. That tells you all you need to know about whether the State thought this verdict was likely, and what they thought the scale of damages might be for the major players, let alone the side-show that was J&J.
In other words, if a company gets hit with an $X fine for Foo, the options are:
1. The company determined the profit from Foo was greater than $X multiplied by the probability of getting caught.
2. The company's governance meant decision-makers on Foo received bonuses for its profits, but were insulated from the costs/fines, and acted in their personal interests but against the company's interests.
3. The company underestimated $X or the probability of getting caught.
4. The company or its employees were irrational.
And if you're the efficient-market-Homo-economicus type that believes 3 and 4 are impossible, that only leaves 1 and 2 - requiring fines larger than $X irrespective of what $X is or personal executive liability respectively.
Of course, the downside to this argument is the results if you transfer it elsewhere in the justice system; by this logic, every crime should have infinite punishment - but an automatic death penalty for speeding is an absurd result.
But, the penalty for a crime isn't set by logic, it's set by legislative process, which prevents the absurd result.
Ex, Enron execs went to prison for years, yet no one died due to their actions. Big Pharma knowingly oversells a highly addictive substance that results in people's death....and yet the corporate veil is not pierced (where's the 10+ year prison sentences).
And even more so, you can attempt to make a rational decision, and still be wrong.
It’s also often said about the market, that it can remain irrational longer than you can remain solvent.
The saying that the market can remain irrational longer than you can remain solvent directly contradicts the efficient market hypothesis.
Your argument ignores the fact that when this "unbounded liability" hits the company, it might bankrupt the company, but that is completely irrelevant to the responsible people, who usually get to keep the fat bonuses they earned and go on to work in another company, doing the same things. A company has, in principle, a strong incentive to prevent this, which is why there are CCOs and compliance departments. But in practice, this too often loses out to the stronger incentive to maximise profits.
2. One thing I took away from Dreamland was that there wasn't one factor to blame. Instead it was 4-6 separate factors that came together in a nightmarish perfect storm vortex to create this crisis.
Which means the pharmaceutical companies have plenty of blame here, but still only 20-30% of the total.
But companies are not allowed to advertise them. Same rules as we have for cigarettes and politicians, and it completely bypasses the question of whether a given advert is biased / truthful.
None of the aforementioned side-effects exist for opioids. The only major concern is constipation (especially in the elderly), nausea, aaaaand euphoria. Yes. That is it. Respiratory depression and other severe adverse effects are not really an issue if you are taking therapeutic doses, especially if taken orally. If you are taking it intravenously, then you are properly under medical supervision anyway. There is a reason for why the elderly usually receive opioids instead of NSAIDs. It is more effective, and it has a better safety profile. The issue is with questionable products with adulterants and unknown purity. Harm reduction policies, and the end on the War on Drugs can improve the situation tremendously. Portugal is a great example of this.
https://en.wikipedia.org/wiki/Nonsteroidal_anti-inflammatory...
https://en.wikipedia.org/wiki/Opioid#Adverse_effects
As for addiction: https://global.oup.com/academic/product/addiction-and-choice...
An excellent book, it is worth reading. According to my experiences many people have lots of misconceptions regarding addiction.
There is nothing wrong with opioids, we do not need a replacement. The issue stems from questionable products from the black market. Plus, why should we ban X or look for a replacement of Y just because there are people who consume it recklessly? This hurts everyone, and is a terrible "solution". If anything, we need harm reduction policies. I would rather not deprive people from the legal access of effective painkillers because some reckless people overdosed on them. There will always be reckless people. Always. This is not a reason to hurt innocent and non-reckless people.
since it has become so much more difficult to divert prescriptions those seeking them have resorted to fentanyl and heroin which is not the fault of J&J or any other company.
The real cause it the drug war that too many nations practice. this has led the over dose issues we have seen. it is not legal sellers of drugs or their advertising. quit buying into this sham sold by politicians and the media, the reason it exist is to simply redirect blame and shake down the companies by relying on ignorance
Catch it early, give warnings and fines before you have a national health crisis in your hands.
Instead we should be spending more money at the FDA level. The surgeon general should have the resources that say that condition X, the approved drugs are A, B, C, D and E. You can also do in a phased fashion. You always prescribe A. Only if that fails do you prescribe B, etc. There are lots of treatment plans like this already (usually driven by insurance costs) but these could be built by leading physicians in each specialty. There are providers that have the knowledge of what works and doesn't but we do an awful job of capturing it. Most doctors just know what they learned in school 30 years ago or what they can google. We need better codification of successful treatment options for each condition X.
Having experienced a vaguely diagnosed condition that the doctor treated with intuition, I hope you don't get put in charge.
Is the idea that a user sees a drug advertised then goes to their doctor to ask for that specific one? Wouldn't the doctor give you a yay or nay for needing it then perscribing it?
Do doctors in the US let the patient decide whether they should be perscribed the drug despite not agreeing with it?
Am I just supposed to go to my GP and ask for a drug I saw on TV? Are there really that many drugs so that any decent GP doesn't know most of them?
1. If an individual sees drug advertisements with particular symptoms they might think that they have them, which would make their concerns sound more probable to doctors when they complain about it.
2. In the US medical malpractice suits are a big issue, so that fear often causes things that might be considered on the edges of unnecessary in most countries to be converted to "maybe, I don't want to get sued if something does happen". This is magnified by point 1.
Take more people thinking they are sick, multiplied by multiple conditions, multiplied by doctors effectively excessively afraid of false negatives in diagnosing, and you have one big public health concern and some big marketing bonuses.
I'm not sure about this statement. Pharma is literally paying doctors to push their drugs. Obvious conflict of interest no?
E.g. https://www.abcactionnews.com/news/full-circle/pharmaceutica...
There is another problem, and I don't know how it is resolved elsewhere. Pharma companies have paid sales rep that travel to medical offices, and push their product directly to doctors. This is ostensibly in the name of educating the MDs, but they hand out free samples. The hope is to convince the MDs that this drug is better than its predecessor.
Additionally, some commercials are targeted at people who have undiagnosed problems, who may not even realize that what they have is unusual. Those commercials start with a list of symptoms, a recommendation to talk with a doctor, and a note that if you do have a particular condition a new drug could potentially help.
And, of course, there are ads for things that people can readily self-diagnose, like erectile dysfunction.
In practice, the ads leave a lot to be desired. Probably the worst marketing campaign I remember was Nexium, which ran ads for several years encouraging people to talk with their doctors about “the purple pill,” without ever mentioning what it could treat. The tag line — “little, purple, different” — didn’t help.
IIRC, this trick lets them avoid the big list of disclaimers and side-effects, as they're not making any medical claims in the ad. Nasty, IMO.
What I do not feel is completely justified in this story is that the blame is put solely on the pharmaceutical.
Yes they played their part. They most likely knew how addicting their drug is from day 1 during their clinical trials.
Why is direct marketing to consumers in the USA even allowed?
Why are pharmaceutical companies still allowed to wine and dine doctors to persuade them to prescribe their drugs?
What about the other players?
Why do doctors even prescribe these heavy drugs, despite knowing that there are serious addictions risks? I doubt doctors would prescribe heroin if someone has pain.
Why do patients insist on getting the heavy drugs to numb pain instead of taking or accepting doctors advice and take a less strong pain killer and accept some pain.
I think we should have a good look at how the healthcare system is organized and scrutinize all players.
No sarcasm and not in agreement personally, yet if I had nine 0’s before the decimal in my bank account I would play the hand the deals me the best, despite what the system needs, as long as it’s within legal means.
If we change the legal means it changes everything you listed as a problem.
US corporate morality is utterly broken. It's essentially sociopathy with dividends.
In America it's practically taboo to tell someone they don't need a thing and the tolerance for any discomfort is extremely low.
If you washed someone's wounds in salt water when there were alternatives it would be rightfully regarded as sadism - why the tolerance for unnecessary pain and suffering otherwise?
> Yeah, pain has a purpose. It stops you from doing stuff your body isn't ready yet. So making it bearable, but still tangibly is making you able to do stuff (like this video), but stops you from running down the road and injuring yourself again / lengthening the time to recovery. (Yeah, I'm a fan of that approach)
Also, this isn't just how it works in Germany - this applies to most non-US countries I'd say.
I don't know if that counts as a "landmark ruling", but maybe it will. We'll have to wait and see if anyone else crashes up on the rocks.
It does give a good roadmap for how to sue and win against J&J though.
EDIT: There might be a way to use this case as a basis for collateral estoppel, meaning that J&J would have a harder time disputing the liability (since they were decided to be liable in this case) but I'm not sure if that applies across state lines.
I've never heard of someone making this argument successfully.
No, because:
(1) trial (as opposed to appellate) court rulings have almost no weight as precedent, and
(2) state court rulings on state law issues have almost no weight as precedent for courts in other states applying different state laws, and
(3) precedent doesn't allow or bar states or other litigants from pursuing cases, it just impacts the expected results.
The real indicator is share-price being up 2% after the ruling. The investors think J&J got off easy.
The market has already priced in what it anticipates the future judgements will be (but that expectation may be wrong; for instance it could be $0—in which case GPs only if there are no future judgements is literally correct—but there may turn out to be substantial future judgements.)
If the market had already priced in all future events, the price would never move.
I don't think that holds. Let's say we all knew everything about the future, and we all use it to instantaneously and perfectly compute The Right Price for every security. We all know that this stock will pay out a total of $X in dividends over the next Y years before the company goes out of business, and what all the future prices will be. Time moves forward, we pass a dividend payment. I think the price of the stock has to fall?
What % of profits made by J&J in Oklahoma? Presumably the risk is that other states could decide that this could be a good way to get income too?
If you extrapolate and assume similar settlements in 49 other states, that would come out to 250% of their annual profits. Which may not happen, but the point is that 3% should be viewed in some kind of perspective.
Easy relative to the (amount weighted?) balance of probability. The stock price doesn't speak to whether they got off easy or hard relative to what's just.
IMO, the fine is appropriate because J&J was an inappropriate scapegoat in the first place — the damage they did is nothing compared to Purdue, for example.
J&J isn't being scapegoated, they just decided to roll the dice and take it to trial.
Otherwise I think we’ll just keep being surprised by corporate amorality, over and over again.
Jobs, capital assets, and technology are preserved. I fail to see how this is a disadvantage. Volkswagon should have been hit with a $1 trillion dollar fine, and for every shareholder and executive to be completely wiped out.
the IP part may have some value though. it would be interesting to see what would happen if every successful judgment resulted in all relevant patents going to the public domain. play funny business with a certain pharmaceutical and it becomes a generic ahead of schedule.
I suspect "make an example out of 'em" style punishments are just not very effective. if every few years a big company gets a back-breaking fine, it would make for some good news stories, but it would also be pretty easy to design a portfolio resilient against these outcomes.
if I could wave a magic wand and set up the system exactly how I wanted, I would implement pretty much the opposite. moderate fines (maybe 1.5-2x the illicit gains) with a very high rate of conviction. raise the salary of prosecutors and investigators until you get people who can make it happen. I believe this would not only be more effective, but much more fair.
Fines aren’t going to work, I think that is pretty clear, as many others have said. They are very much an instrument of ‘make an example of ‘em’ aren’t they?
I bet that when a large bank thinks about their ‘worst case scenario’, they are thinking about Lehman Brothers, not a mega fine. Being a senior executive in a company that got corp-deathed is surely career ending.
So it'd be very much like an ordinary death penalty, then, with dependents left behind in a worse position. Well, fortunately it would also mean you shouldn't work for a bad company the same way you shouldn't assist criminals generally, in that you can share in the blame.
Think of the poor workers is such a poor argument as any worker can be laid off or fired at a moment's notice.
They know that at worst they’ll have a small hit on quarterly profits, but stocks won’t change and nothing serious will happen because nobody wants to hurt those poor job creators.
think about speeding. a speeding ticket is a meaningful amount of money to most people (usually well over $100 in the us); in some states (eg Virginia) speeding turns into a criminal offense if you are going 20+ over. and yet, most people still speed sometimes and a sizeable chunk of drivers speed almost all the time. on the other hand, speed camera tickets give a $40-50 fine but they get you every time you go 12+ over the limit as you pass the camera. almost no one exceeds the limit by more than 10mph in photo enforced zones. the fine is much lower, but the consistent enforcement makes it much more effective.
Still collateral damage in the form of private savings being wiped out, but you can bet this won't happen more than once before the rest of the capitalist class wises up.
Jail time for board members and executives is probably also effective.
If a corporate "death penalty" becomes a thing in the USA, large, profitable companies will shift their main business overseas to other, less risky countries. They may still sell their products to US consumers, but it becomes very difficult for the US courts to shut down a company that isn't officially in the US. The best they can do is forbid that company from doing business in the US.
Civil forfeiture seems like no big deal, I dunno what the issue would be here.
J&J was only 1% of the market for these types of drugs, and also this;
> Oklahoma wanted J&J to help it address the epidemic for the next 30 years by funding addiction treatment and prevention programs.
> Balkman said in his written ruling that the award covered only one year of addressing the crisis because Oklahoma did not demonstrate the time and costs needed beyond that.
So it’s worth considering the amount that J&J was fined in that context.
Another friend had a persistent cough getting over a cold and was given oxycodone in liquid form "to help sleep." She never took it.
Both of these were at major facilities in the Bay Area. Thinking at least some of the blame falls on the docs.
When the doctor is misinformed, or their incentive is to please pharmaceutical companies, your trust is betrayed without any warning.
My friend is a psychiatrist and says that any night of any week, she can go out and get a $100+ meal free from pharma reps. Organized meals have speakers that are marketing drugs to them. Informal meals just have the sales rep saying the same talking points.
If anyone thinks she or her coworkers can make unbiased decisions about what the describe, they're very naive.
Countries where antibiotics can be had over the counter for people with viral colds should be shut out of international trade.
Countries where giving antibiotics to healthy livestock is allowed should be shut out of international trade.
These aren't even controversial measures.
In the past I had a persistent cough bad enough that it keep me up several nights. Mucinex would do nothing. Vix did nothing. Eventually each coughing spell was causing head splitting pain. Codeine was a crucial treatment option.
I have a feeling getting hooked on codeine cough syrup would be extremely difficult given a single bottle with perhaps 10 doses.
It should not be inappropriate to prescribe codeine cough syrup to an adult who actually has a serious persistent cough.
Recent studies are pointing to this being a better pain solution than opioids.
I'm not saying opioids should go away, but they are not always the best option.
This attitude toward this stuff makes me think that most just don't realize how bad it is. Most people mean well but don't know any better.
Disposing medicines like this is irresponsible. You should always use a drug disposal service. Local sheriffs can take narcotics off your hands.
https://www.fda.gov/drugs/disposal-unused-medicines-what-you...
In particular don't advertise as 2x a day with the advice to increase the prescription if there are withdrawal effects, when the correct prescription is to go to 3x a day and do not increase the dosage. The false advertising is a recipe to increase sales but create a serious drug addiction that will need to be supplemented somehow.
https://beta.washingtonpost.com/investigations/76-billion-op...
I suffer from chronic pain and am prescribed (weak) opioids to help manage that pain. I've tried numerous other medications, but the ones I'm on are the only ones I can tolerate and that actually help at all.
I am responsible, only ever taking them as prescribed. Even with some pain management, life is not easy; with none, it is unbearable - I honestly don't know if I'd still be here without any pain management.
Opioids are plainly being over-prescribed in the US, but we have to be really careful not to withdraw them from those that actually need them.
I wonder how it compares when some truly needs pain treatment.
But, I recently got a prescription for Sativex, which is essentially a very expensive cannabis tincture.
My biggest issue with it is that you end up swallowing most of it - and eating cannabis is very different to smoking, as THC is metabolised to 11-OH-THC, which is much more psychoactive. I found it made me really anxious, which is not nice at all!
I've been experimenting with it, trying to ensure I don't swallow any of it. It does help with the pain, but only a little... and it impairs me in the process - it's really important to me that I can still function cognitively.
I also find the way it helps is different than opioids - it's kind of similar to alcohol, in that it's more like a distraction from the pain, whereas opioids actually negate some of the pain.
There is a lot of good evidence for cannabis helping with neuropathic pain, so I'd encourage others to try it if they legally and financially can.
Morphine makes life bearable and allows me to work and contribute to society.
I would otherwise be in bed all day from the chronic pain.
Having chronic pain is like being under water. And pain relief is like coming up for air.
These laws have made it so I can literally only get a maximum of 90mg of morphine daily when I really need 200mg, what I used to be on.
It's terrible that those of us who actually use these drugs responsible are being screwed over, and average joes like yourself demonize opioids when they have medicinal value.
I will agree that synthetics are bad and I specifically ask for morphine versus Oxycodone or Hydrocodone. The synthetics are pretty much just a way to make more money and they are way more addictive.
Also Oxycontin was marketed as having a 12 hour dosing schedule. But the half life is about 2/3rds if that. That sets up a yoyo dosing schedule that's known to be highly addictive.
https://www.latimes.com/projects/oxycontin-part1/
> Purdue’s researchers, meanwhile, were conducting at least a half dozen clinical trials, according to the company’s FDA application. In study after study, many patients given OxyContin every 12 hours would ask for more medication before their next scheduled dose.
> For example, in one study of 164 cancer patients, one third of those given OxyContin dropped out because they found the treatment “ineffective,” according to an FDA analysis of the study. Researchers then changed the rules of the study to allow patients to take supplemental painkillers, known as “rescue medication,” in between 12-hour doses of OxyContin.
The every 12 hour dosing was approved by the FDA which looked at the clinical trial data and approved 12 hour dosing.
After it was launched, the company kept promoting 12 hours because if they didn't, the FDA would sanction them. As a drug manufacture you can't just change the FDA approved dosing wily nilly.
And if you're Purdue, you have every incentive to lower the dosing interval because you can charge more. You make more money with every 8 hour dosing (which is still better than most drugs) than every 12 hours.
If they lowered the dosing schedule they'd be competing directly with generic opiates.
The article addresses this.
> Company officials worried that if OxyContin wasn’t seen as a 12-hour drug, insurance companies and hospitals would balk at paying hundreds of dollars a bottle. Some already were.
> If a doctor complained that OxyContin didn’t last, Purdue reps were to recommend increasing the strength of the dose rather than the frequency. There is no ceiling on the amount of OxyContin a patient can be prescribed, sales reps were to remind doctors, according to the presentation and other training materials.
In terms of price, they were quite expensive, but I've never met an insurer who is happy with the price of a drug.
They didn't do that because they decided money was more important than hundreds of thousands of peoples lives.
The FDA approves their dosing schedule after a careful examination of the clinical trial data. They are required to stick to 12 hour dosing. Based on anecdotal reports, you're suggesting they withdrawal the drug from the market?
Secondly, the bond strength is what makes them much more addictive. It's why Heroin is more addictive than Morphine. Why Fentanyl is more addictive than Heroin. And so on. Weaker drugs, one may need to take higher mg doses but tend to be less addictive.
76B doses being a six month supply would mean 416M doses a day for America's 50M people with chronic pain (not all of which have pain conditions suited to opiate treatment, incidentally). Almost ten doses a day for each and every one one of them?
And it's by dosage units, so if your doctor says "take two every four hours", you'll be consuming 12 each day.
The number isn't that shocking.
> if your doctor says "take two every four hours"
That'd be weird for an Q12H drug, wouldn't it?
19.6 million people * 4 pills/person/day * 6 years ~= 172bn pills
Given that figure is significantly _more_ than the actual number prescribed, it doesn't strike me as overprescripton. Yes, there are issues with diversion, and the number of pain sufferers may be inflated by people faking pain (to get opioids or malingering for other reasons), but the volume of pills prescribed alone don't suggest there is a major issue.
Furthermore, 11.6 million 'true' high-impact chronic pain sufferers would still get you to the shipped figure[4], and I find it hard to believe that 8 million people are faking pain, especially as the data is gathered from a survey, rather than a situation that may result in opioids or any other non-clinical benefit.
[1] https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm
[2] https://www.washingtonpost.com/graphics/2019/investigations/...
[3] I (non-US) am on (up to) 8 opioid-containing pills per day, so taking 4 as a rough average doesn't seem unreasonable
[4] 11.6 million people * 4 pills/person/day * 6 years ~= 101bn pills
For inflammation-type pain, paracetamol or NSAIDs (Nonsteroidal anti-inflammatory drugs) can be remarkably effective.
For neuropathic pain, gabapentoids are likely a better first-line treatment, with SNRIs (Serotonin–norepinephrine reuptake inhibitors) or TCAs (tricyclics) as second-line.
There are of course many people for whom opioids are appropriate, but they should only be used where less potentially harmful medications have been tried first. My understanding of the situation in the US is that they are often prescribed as 1st-line treatments, or inappropriately after surgeries where NSAIDs would be more appropriate.
I also wasn't attempting to do a rigorous accounting of all prescribed pills, but show that the 76bn figure _alone_ doesn't immediately point to overprescribing. It's a big number, but in context it doesn't seem out of the question. Furthermore, it doesn't rule out overprescribing, but that would require a more in-depth analysis than just looking that at the headline figure.
[1] "the dose is usually not more than 12 tablets per day" - https://www.mayoclinic.org/drugs-supplements/hydrocodone-and...
[2] "Roxicodone: Adults—10 to 30 milligrams (mg) every 4 hours as needed." https://www.mayoclinic.org/drugs-supplements/oxycodone-oral-...
[3] "At first, 15 to 60 milligrams (mg) every 4 hours as needed[...] the dose is usually not more than 360 mg per day." At the maximum daily dose, that puts you at 6 60mg pils/day, and in my non-US experience, the lower strength pills are often used to increase the dose of the combining drug (acetaminophen/paracetamol) - I am on 90mg/day, but it is still 8 pills https://www.mayoclinic.org/drugs-supplements/codeine-oral-ro...
https://marginalrevolution.com/marginalrevolution/2019/05/ho...
>In August of 2010, Purdue Pharma replaced old OxyContin with a new, anti-abuse version of OxyContin. The new version was just as good at reducing pain as the old but it was more difficult to turn it into an injectable to produce a high. If physicians are altruists who balance treating their patient’s pain against their fear of patient addiction and downstream abuse then they should increase their prescriptions of new Oxy. From the point of view of health, the new Oxy is simply a better drug and with less abuse to worry about altruistic physicians should be more willing on the margin to prescribe Oxy to reduce pain. So what happened? Prescriptions for Oxy fell immediately and dramatically when the better version was released.
In my non-US jurisdiction, the big insurers used it as an opportunity to say: "Switch to something that seems less addictive than oxycodone entirely instead of switching them to some other oxycodone"
I've had severe chronic pain for over a decade from an auto accident. It's well documented as are the injuries. I've never been offered opioids and have been told by multiple doctors that surgery would be pointless and counterproductive. If I was offered opioids I'd turn them down since I understand the potential for abuse.
However it would have been nice to be asked. Fact is no doctor I've seen will prescribe them to any other than people with stage 4 cancer, people actually in the hospital following surgery, or the like.
Yet every two bit junkie creep and criminal in the area has an unending forever supply that originated in legal sources made by reputable pharma corps and sold by honest pharmacists having received a legit script.
How is this? Pain clinics. Pain clinics are prescribing these things. Not regular doctors who for over a decade have been scared to hell of prescribing them no matter how bad off a legit patient is.
So will it "get a lot more difficult for people who suffer from pain that needs opioids to actually get them"? I say no, because those people aren't getting them right now anyone. Excepting cancer, people in the hospital, and some other specific cases.
But it's OK. Because those of us with severe incurable chronic pain need to just learn to live with it. Opioids provide short term cures, rapidly develop tolerance and addiction. They are not good choices for chronic pain. Nor is anything else apparently. The field of medicine is in the medieval period, as far as how most people experience it. Propaganda about genetic cures and Star Trek like technology is fiction, mostly pushed by lying companies and speculators.
Most cancers your choice is to die without treatment since your insurance if you have it isn't going to pay for much and you'll go bankrupt on the copays. Then you die same date as you would have otherwise, probably earlier because the therapy weakens you and makes you sick and miserable. You'll also experience utter misery and horror during your last few months. Choosing to reject modern medical miracles is the best choice for most people with serious problems. Or go after stuff that at least does no physical harm, like alternative treatments, faith healing, or other quakery that's at least cheaper and less miserable. Yet the medical field peddles false hope to the overwhelming majority of people with this problem. Same goes for chronic pain. Surgery will make you worse and pills will ruin your health and may turn you into a criminal addict. Mountebanks selling such false hope really are dealers in misery and horror.
Truth be told, poppies are easy to grow. If I really wanted opioids I'd just grow them again. Yeah, it's not Oxy, but it does the job.
Did you use your poppies to make laudanum? That seems the most straightforward. If you did, was it addictive at all? Side effects, problems? Did you develop tolerance?
I believe I was lucky because after the first surgery I had, the doctor gave me the prescription, but off the record told me that he's doing that only because of hospital protocol and I should not take the pills. He told me to my face to not fill the prescription. Because of that (which was my first run-in with pain management) I never touched opioids. In my experience, the worst offenders have been the dentists. Now I do believe there are legitimate uses for this type of medication but honestly prescribing me 20-30 vicodins for a tooth extraction is a bit overkill.
If you're caucasian, you might be in the 5-10% of people that lack the genes (CYP 2D6 liver enzyme) to metabolize it into something that works well.
There's lots of safer alternatives. There could be some niche cases for it but as a general pain killer it should never be used.
US is rather unusual in allowing direct drug marketing to consumers, and "marketing" to physicians.
This is despite the dose being static for well over a year (20mg/day), and they are still effective. Going three or more days without sleep was at least a monthly incident before taking tamazepam, and missing a night was weekly - three days has only occurred once since, and missing a night's sleep is rare. This has resulted in an improvement to my other symptoms.
[1] basically anytime I see a doctor other than my regular doctors, who understand the situation
[2] I do not believe thinking you have only blinked, then looking at the clock and realising over four hours have passed is a safe situation. I suspect I just fell asleep, but I don't remember that, or even waking up -- I thought I was just checking the time, and then four hours disappeared. This happened on multiple occasions, and I'm fairly sure I didn't just misremember the time (though even that would be disconcerting), as it was also brighter outside.
Conservatively is how most strong opioids should be presrcribed. The general rule is that they should not be prescribed for chronic non-cancer pain.
The Arthur Anderson firm got deep-sixed for felony obstruction of justice. Enron's Ken Lay was convicted of 10 counts of wire and bank fraud. (Skilling just got out of jail.)
Tens of thousands of dead Americans: 'nuisance'? I can think of only a couple of 'justifications' for the disparity.
Corporate pusher's victims were just Regular Joes. Who the law protects and who the law binds aren't always in sync.
Not true. Probably the biggest losers for Enron were the rank-and-file employees of the company. Not only did they lose their jobs, but more than half of the Enron employees' 401k was invested in Enron stock.
And Enron happened to freeze the 401k plan at the time where the stock started to drop and people could have sold.
https://www.nytimes.com/2001/11/22/business/employees-retire...
Opiates are also a fun and addictive drug. As long as they exist and are generally available, some percent of the sub-population will abuse them. We can try our best to keep them only for medical use, but once the prescription leaves the pharmacy there's not much you can do. You can't blame the legal manufacturer when that happens, if they took all required steps to keep their drugs in the legal channels. Maybe you think that's true, but that the opiate manufacturers have used their power and influence to over-prescribe their products. That assumes that opiates are over-utilized in American healthcare. And that's a narrative that simply isn't borne out by the data.
Only 0.19% of opiate-treated chronic pain patients without a prior history develop any form of abuse or addiction[1]. And remember these are chronic-pain patients who take tolerance-escalating doses over years or even decades. Virtually no one develops an opiate addiction from following their medically prescribed treatment regiment.
The death rate from prescription opiates has not budged since 2006[2]. The vast majority of opiate overdoses in America are not prescription opiates, but illicit fentanyl, and to a lesser extent heroin and methadone. Nor do chronic pain patients face any major risk of overdose. The fatal overdose mortality rate for long-term opiate-prescribed patients is 17 per 100,000[3]. And that number doesn't exclude the subset of the population engaged in abusive behavior like mixing with alcohol, snorting pills, or hoarding medication.
Finally the sizable majority of prescription drug abusers in this country do not source from a doctor or the healthcare system at all. The vast majority get their drugs either from the black market or a friend or relative. On the National Drug Use Survey only 18% of prescription drug abusers report doctors as their primary source. And among street prostitutes (a high at-risk group) only 5%[4].
All of this goes to show that there is very little evidence of any sort of over-prescription of opiates in America. To begin with the vast majority of the opiate crisis has to do with fentanyl, not prescription drugs. But even when it comes to prescription drug abuse, the intersection with medical users is vanishingly small.
However what there is a major problem in America is untreated chronic pain. 50 million American suffer chronic pain[5]. And 20 million suffer high-impact chronic pain which severely impairs normal life function. More than 10% of suicides are linked to chronic pain[6]. High-dosage opiates are absolutely essential for this group to live any sort of normal life. As long as there are such massive numbers of legitimate pain patients, the law of large numbers guarantees a large supply of diverted opiates. Even under the tightest controls. There's simply no way around that except by denying most of the legitimate patients treatment for their debilitating conditions.
[1] https://www.ncbi.nlm.nih.gov/pubmed/18489635 [2] http://www.ncsl.org/portals/1/documents/health/APeeples0118_... [3] https://annals.org/aim/article-abstract/745518/opioid-prescr... [4] http://sci-hub.tw/https://www.tandfonline.com/doi/abs/10.108... [5] https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm [6] https://www.ehidc.org/sites/default/files/resources/files/Ch...
The criminal behaviour was aggressively selling something that already sells itself.
> Only 0.19% of opiate-treated chronic pain patients without a prior history develop any form of abuse or addiction.
Your cited meta-analysis looked at nonmalignant chronic pain patients receiving chronic opiate therapy: There is not a strong indication for this therapy in that group.
When they looked at all recipients, the abuse/addiction rate was 3.27%.
" In the urine toxicology grouping, there were five studies (15,442 CPPs exposed). Here, 20.4% of the CPPs had no prescribed opioid in urine and/or a nonprescribed opioid in urine." In other words, 20% were clearly diverting to non-prescribed users, and/or already supplementing their opioids.
How could the authors suggest that there was only 3% demonstrated abuse/addiction or aberrant behaviour when 20% were diverting their entire RX or supplementing????
The 3% figure includes includes those patients with a pre-existing history of addiction/abuse. Now it's debatable whether previous addicts should get opiates for chronic pain conditions, it's irrelevant to the specific question of opiate prescriptions create new addictions. Because by definitions those with a history already had a pre-existing addiction.
Regardless 3% is still an extraordinarily low percent for chronic pain patients treated for years at a time. For reference 3% is less than or on par with the abuse/addiction rate of long-term prescribed ADHD medication[1].
> In other words, 20% were clearly diverting to non-prescribed users, and/or already supplementing their opioids.
Your characterization of the findings are mis-leading. Opiates frequently metabolize to another active opioid inside the body. Morphine commonly metabolizes to hydromorphone[2]. Codeine metabolizes to morphine[3]. Oxycodone metabolizes to oxymorphone[4]. Hydrocodone metabolizes to hydromorphone[4].
Furthermore many of these metabolic pathways are only just recently discovered (like morphine to hydromorphone). The reality is that our current understanding and technology is not advanced enough to tell from urine toxicology which specific opiates were consumed and which are the byproducts of metabolism.
[1]https://slatestarcodex.com/2017/12/28/adderall-risks-much-mo... [2] https://www.ncbi.nlm.nih.gov/pubmed/16620524 [3] https://www.ncbi.nlm.nih.gov/books/NBK100662/ [4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704133/
I’m pretty sure the authors were accounting for that. Otherwise they’re not investigating anything of value. Especially if they’re lumping them in with a group that didn’t have any opiates in their screen.
People misusing pain medication is a small price to pay to have pain medication available for people who need it. There wont be an optimal solution by pushing down on pharma companies and doctors, it will be quite a lot worse then today.
To put it simply, if you are lobbying to combat the so called "opioid crisis" you should think damn hard about the consequences of your actions. Because if or better when there is another backlash peoples suffering caused by a lack of pain medication will be on your hands.
You don't think that's a bit disingenuous?
I don't think it is fair to criticize medical practices across cultures. Every culture has a different view on these and optimizes for different things.
This is finally being questioned by studies. Multiple studies have recently come out that show non-opioid pain killers are as effective and sometimes more effective than opioids in both chronic and acute pain. Now, I don't think opioids need to be made illegal because they do have their uses, but they are clearly over-prescribed when more conservative options may work.
https://www.theepochtimes.com/opioids-no-better-than-ibuprof...
https://medicalxpress.com/news/2018-04-ibuprofen-acetaminoph...
Of course the punishment isn't the same.
You could actually argue that someone selling heroin to an addict is doing something consensual, where both parties know what they're getting into. You can't say the same of opioid manufacturers, who intentionally buried vital info and muddied the waters of public perception.
The intention was to make money, knowing that millions of people would be harmed. Who cares if the method was "just marketing"?
Yes, ineffective and dangerous.
> "Opioids are ineffective in the treatment of chronic pain, and the dangerous risks associated with using and abusing opioids have led to America's most deadly drug epidemic."
-- National Safety Council[1]
> "Ibuprofen Plus Acetaminophen Equals Opioid Plus Acetaminophen for Acute Severe Extremity Pain"
-- Govt-funded trial at UVA[2]
> "Ibuprofen, acetaminophen more effective than opioids in treating dental pain"
-- Case Western Reserve University[3]
> "In summary, reliable conclusions about the effectiveness of long-term opioid therapy for chronic pain are not possible due to the paucity of research to date. Accumulating evidence supports the increased risk for serious harms associated with long-term opioid therapy, including overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction; for some harms, the risk seems to be dose-dependent."
-- NIH[4]
And after that, you're welcome to look at examples where pharma execs admitted to misleading doctors about both safety and efficacy[5].
1. https://www.nsc.org/home-safety/safety-topics/opioids/treati...
2. https://www.aafp.org/afp/2018/0301/p348.html
3. https://annals.org/aim/fullarticle/2089370/effectiveness-ris...
4. https://www.sciencedaily.com/releases/2018/04/180417181101.h...
5. https://www.wbur.org/npr/690556552/lawsuit-details-how-the-s...
Your other two sources are just subsets of pain and ignores many other uses of opioids.
If there's no evidence something is effective, it should be considered ineffective. I've found sources that say there's incomplete evidence and sources that say opioids aren't significantly better than placebo, but no unbiased reviewer says that they're more effective than OTC and generic painkillers.
One of the worst cases is probably https://www.cnn.com/2014/04/02/justice/delaware-du-pont-rape...
> Though Robert H. Richards IV was convicted of rape, the wealthy heir to the du Pont family fortune was spared prison by a Delaware court in 2009 because he would "not fare well" behind bars,
The term is https://en.wikipedia.org/wiki/Affluenza. It is surprising how blatant and obvious it is.
Yeah $500M out of $80B in revenue is pocket change, about 0.6%.
The pharma CEOs are gonna use this landmark to help them navigate to a bigger private yacht and faster private jet.
Fine for causing a substantial amount of those "400,000 overdose deaths": 0.5bn
Yeah, I'm totally convinced that they'll behave from now on.
JJ makes pain killers, markets them, doctors prescribe them (?), patients get addicted.
I have trouble understanding why this is primarily JJs fault. Either Drs should be looking after their patients, or these drugs need to be prescription only, if not already.
There seems to be a big elephant that's getting ignored here...
People seem to think there can only be one point of failure, one organisation or person to blame. The opioid crisis is complex and many things failed. You're right that doctors should not have prescribed as many opioids, but that doesn't absolve the makers or the insurance companies.
I'm not saying there's one point of failure, note in my prior reply I wrote "primarily" their fault. But Drs are the professionals here, they have a duty towards their patients. If a Dr prescribes something for me, I expect them to have weighed up the pros and cons. If Amazon recommends something I have no such expectation.
in the UK you can buy cocodomol, which is an opioid painkiller over the counter. but it has huge text reading "no more than 3 days usage" becaues of addiction risk. it's like JJ said to docs, we got cocodomol, but you can prescribe them for months because we made them non-addictive, and that's the lie.
But I doubt that most addicts overdosed with opioids obtained under prescription. Most likely overdosed on illegal opioids that they resorted to, after their prescriptions got cut off.
Such judgements are factored into large corporations' plans from the start. The politicians get to look good for "doing something", the company gets to be absolved of blame, and they're only out a small percentage of their profits.
What became the popular but essentially dubious interpretation of the trends was that the typical opioid victim was a patient who received Oxycontin, Percocet, or Vicodin from her doctor for a tooth extraction or sprained ankle and then stumbled into addiction.
In fact, only 22 to 35 percent of “misusers” of pain medication report receiving drugs from their doctor
[1]https://www.theatlantic.com/ideas/archive/2019/08/what-ameri...
Or are you just trying to dismiss the entire article because of her political views?
The author acknowledges it's a crisis, but simply asks questions about the true cause.
I mean, that's been the conservative playbook for decades. Deny entirely first. Once it becomes undeniable, deny attribution. Once that becomes undeniable, claim nothing can be done anyways.
Climate change, air pollution, fossil fuels...
This data suggests that for the vast majority of patients, addiction was not an issue and the cause of the opioid epidemic was in fact people that used illegal opioids to begin with.
But not treating pain and also causing addiction in 30% of your patients isn't just "not very good", it's catastrophic.
> In fact, only 22 to 35 percent of “misusers” of pain medication report receiving drugs from their doctor
Because of the floods of prescription meds available many people get meds from their family and friends. The ultimate source was a doctor prescribing them, but the meds have been passed on.
2. "Why Was Johnson & Johnson the Only Opioid Maker on Trial in Oklahoma?"
Other states are suing a range of drug makers, distributors and retailers. Here are three reasons Johnson & Johnson was the only company on trial in Oklahoma.
https://www.nytimes.com/2019/08/26/health/opioids-johnson-an...