I was a drug rep and know how pharma companies pushed opioids | Hacker News Reader

I was a drug rep and know how pharma companies pushed opioids

washingtonpost.com

158 pointsvo2maxer151 comments

I find it pretty terrifying how many people there are in here jumping to defend opioids. Seems kinda off-topic for an article about how predatory practices in marketing potentially harmful substances can be problematic.

I mean, nobody is suggesting that opiods shouldn't be used to treat pain, are they? They are just saying that that misinformation campaigns run for the purpose of increasing profit at the expense of human lives isn't a great thing.

There are certainly cases where opioids should be prescribed as painkillers. But in the US, when weighing two bad things (pain, and adverse effects of a drug), pain seems to be considered more important than elsewhere, since doctors prescribe more of it.

It must be that elsewhere doctors more frequently say “yes, your condition is painful, but if normal painkillers don’t help, the next alternative is worse than the pain”.

It’s not clear to me why this discrepancy exists. Pharma can’t be the only reason. Maybe the private insurance system is a factor (“I paid a lot for this healthcare now fix my pain or I’ll take my business elsewhere”)?

Anecdotally, I have heard grumblings from nurse friends that a big annoyance is that "patient satisfaction" is now a big portion of performance reviews, since patients' satisfaction can go down for things that make them better.

Keep in mind that not only insurance is a factor, but also the fact that many hospital systems themselves are private and have lots of cost pressures. A fair amount of advertising I've seen is for hospital systems.

Or patient satisfaction can go down because they are the face of a system that has many operational 'opportunities' to improve efficacy of care in the inpatient setting. They are grumbling because they have almost zero control over any of it.

Patient satisfaction is part of performance reviews because CMS decided to use it as an input for their hospital ratings that are posted online. They also adjust payments to hospitals based on the results.

Also, most hospitals in the US are nonprofits, though that doesn't free them from cost pressures or the need to advertise.

This is pure speculation, but I could see several scenarios that might produce the discrepancy:

America's fear of regulation results in more workers being injured and developing chronic pain.

America's broken healthcare system means that people are less likely to have access to alternatives such as physical therapy, meditation, counseling, etc.

America's weak social safety net means that people have to relieve their pain so that they can continue working.

Cultural factors result in people being less accepting of pain as part of their lives.

It really is about companies like Purdue that pushed these drugs and worked to change the protocols around pain management. Even generic manufacturers of cheap generics were making a fortune due to volume.

My mom ran different units in busy NYC hospitals in the 80s. At that time, the protocols for most pain events were Tylenol and/or Motrin. Getting more than 600mg of Motrin was unusual.

When I had back problems in the early 2000s, the protocols were totally different. If you had back pain, once the newer NSAIDS like Vioxx and Celebrex were mostly removed from the market, the substitute was an opioid. In my case, physical therapy, motrin/aleve, etc helped until surgery was required. I know a few people who went to opioid route, and a couple of them have struggled with dependency.

"nobody is suggesting that opiods shouldn't be used to treat pain, are they?"

Many doctors and pharmacies in the US have swung the pendulum to that end. Probably for liability reasons.

Or because they realize that if they prescribe opioids they are possibly dooming a patient.

Are you arguing that opioids shouldn't (ever) be used to treat pain?

Probably just vanishingly. Anyways rare enough that a market for illicit prescription opioids would be difficult to sustain.

I had a bone marrow biopsy, where they can’t anesthetize you and sure burrowing into my bone with a scalpel hurt. But whatever. Life is pain.

For a great many years, they were almost solely for people with serious, chronic pain. Cancer sufferers or people with severe diseases. It wasn't until Oxycontin and the marketing push associated with it that it became so widely prescribed as a regular use pain-killer.

That's of course when the addiction rate for opioids went through the roof. Entirely disconnected I'm sure.

I don't know if they should be used for pain. I'm not educated enough on it to make a statement like that, for or against. What I can say with absolute certainty is Purdue Pharama created a disaster on the scale of natural events by selling legal medication. Every facet of that should be analyzed so we can make sure it never happens again.

Hydrocodone is an opiate, and was used pretty regularly for pain from wisdom extraction, lacerations, etc. Was used for years with little fanfare before oxycontin and friends. It is now lumped in with them.

This is also partly because more recent studies have determined that for important types of post-surgical pain of this sort, combination ibuprofen+acetaminophen is actually more effective than hydrocodone.

https://www.aafp.org/afp/2018/0301/p348.html

is one example, for patients presenting in the ER with extremity pain, and one that's specific to impacted wisdom tooth extraction is:

https://www.ncbi.nlm.nih.gov/pubmed/28586638

("CONCLUSION: Codeine 60 mg added to a regimen of paracetamol 1,000 mg and ibuprofen 400 mg does not improve analgesia after third molar surgery.")

There's a study I'm very curious to see the results of for this question for post-caesarian patients: https://clinicaltrials.gov/ct2/show/NCT03372382 (study is still underway).

And there's been really promising results for other forms of post-surgical pain management. One great example is the use of a QL nerve block administered during surgery to manage post-caesarian pain:

https://sci-hub.tw/https://rapm.bmj.com/content/early/2019/1...

"QL block has been associated with reduced postoperative opioid consumption and pain scores in patients undergoing cesarean delivery, [... but more study is needed because the studies weren't big/comprehensive enough ...]"

There are lots of caveats here (in other words, don't believe some random schmuck on the Internet over your doctor) -- different types of pain may respond differently, different people may respond differently, etc., etc. Ibuprofen impairs clotting and is inappropriate for use with some patients and some types of injury. Acetaminophen has to be dosed carefully to avoid liver toxicity. No free lunch. But it's certainly promising from the perspective of non-narcotic pain treatment _in some circumstances_.

(Please don't misconstrue what I'm saying, of course, as suggesting we can or should eliminate opiates. There's a place for everything in our arsenal. But there's been a lot of progress in the last decade that open up alternatives in some cases.)

Glossary, in case it's helpful: acetaminophen (US) = paracetamol (UK) = tylenol (brand name). ibuprofen = motrin = advil. oxycodone/acetaminophen = percoset (brand name; ratios may vary).

Having been on both, I can say personally hydrocodone seemed more effective.

My anecdotal data says the opposite. I've been prescribed opioid pain killers (Codeine/acetaminophen and Tramadol) a few different times (post regular and oral surgery, after a particularly nasty wrist and ankle sprain, and most recently after getting some second degree burns from a cooking accident). The first couple of times I was prescribed them I remember thinking how bad the pain must have been to have still felt so intense after taking opioids- but eventually I realized that the prescribed opioid pain killers were just not doing much to help at all, and Ibuprofen was far more effective for me. These days I don't even bother filling the prescription and just go straight to advil to manage pain.

I'm certainly not well educated in medicine, so it's hard to say whether my experiences can be generalized to the broader population, but if my experiences are at all common it does make me wonder why the are so broadly prescribed, and why I was never advised to even try NSAIDs before escalating to opioids with their associated side effects and addiction risk.

Right. The core problem with Oxycontin wasn't that it was an opiate: it was that Purdue sold it as an opiate that resisted addiction. This meant doctors prescribed it more readily and were less concerned about monitoring patients afterwards.

This wasn't the first opiate which was touted to be less addictive than morphine.

That would be heroin. Our institutional memory is woefully short.

“Resisted addiction”? Do you have a source for that? My understanding is the FDA would never let the say that.

My understanding is that they said opioid addiction (in general) was a relatively minor problem and it shouldn’t stop doctors from prescribing them.

I said they sold it as that, not that it was that and that was the source of the issue.

“Delayed absorption as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.”

That's what the FDA allowed them to publish. Possibly the most dangerous single sentence in the history of medicines.

Ahhh, that makes sense.

It is actually true though. Delayed release would be expected to reduce abuse liability.

That doesn’t mean OxyContin is not addictive, it just means it’s expected to be less addictive than immediate release oxycodone.

People figured out pretty quickly that if you crush the pills, you absorb the oxycodone quickly. It was the coating that delayed absorption.

Are there any slow release drugs that you can't do this with? Shouldn't this be obvious to the doctors?

As a general rule Doctors trust the documentation given to them by the pharmaceutical companies, which in turn is approved after several rounds with the FDA, so one would think that the documentation would be pretty reliable.

The source of the issue really is just how hard Purdue was fudging their data. And I mean, you can say that a drug company shouldn't be the sole tester of it's own drugs and I'd agree with you, but good luck getting average people to want to pay for it by funding the FDA.

I wonder if it is normal for slow release drugs to come with warnings telling you that you can crush them up and abuse them?

This is true, so users were pretty quickly able to get around it.

Although manufacturers have created a tamper proof version, but that just led users to move to heroin.

Yes and no.

The first fault is that even the studies done by Purdue prior to release did not indicate anything close to the 1% addiction rate they advertised, it was more like 8-12%.

The second, most Oxycontin users who aren't well off eventually move to heroin, because the effects are very similar, and the street price for Oxycontin is much higher. Ironically, where Marijuana was demonized for a nonexistent gateway property in the original war on drugs, Oxycontin was actually demonstrably a gateway drug for heroin.

There's a very well researched episode of the podcast "Behind the Bastards" hosted by Robert Evans that drills down exactly into all of Purdue's dirty little secrets surrounding Oxycontin. Once you realized just how many numbers were fudged, how many studies fiddled with, it becomes clear just how much had to be made to go wrong in order for this epidemic to really kick off. It's quite damning.

the article submitted specifically address this and cites figures that Purdue marketed from one incredibly flimsy sentence to claim 1% addiction rates, when reality according to the article is 8-12%

Right. Purdue claimed opioids in general were less addictive, not that oxycodone itself was less addictive.

No no, Purdue claimed that Oxycontin's time-release formula was believed to reduce it's addictiveness.

Which yes, is a pretty logical follow through, but also you'd expect more rigorous proof than "we think it'll do that" for medicines.

Codeine+Paracetomol was available OTC here in Australia until addicts ruined the fun. It was great to have for non-everyday pain like that once a year killer headache.

A doctor should consider the possibility that they are dooming their patient to something far worse than pain. I'm not saying that we should never use opioids ever, but we definitely need to either change how they're used (only administered by professionals in a clinical setting) or change how society deals with users (we decriminalize opioids and work towards better quality control and legal availability.)

> I mean, nobody is suggesting that opiods shouldn't be used to treat pain, are they?

Well...yes. Some are quite explicit about it, but even the ones who aren't are advocating for a policy where that is an inevitable result at the margins, yes. It's not like there's a box with a switch that says "dispense opioids responsibly for real issues" on one side and "just hand them out like candy" on the other, and we're debating toggling it.

If you make opioids harder to get, then some people who should get them will now not (which is bad), and some people who should not get them now won't (which is good), but the correct balance is deeply unclear, and unlikely to be determined in the middle of a moral panic.

Note in the linked article, especially, the offhand discussion of "pseudo-addiction".

> If patients reported withdrawal symptoms like nausea or the shakes, the reps were trained to call this “pseudo-addiction.” A doctor who was skeptical of this concept could find studies to back it up — many of them conducted by J. David Haddox, Purdue’s scientific adviser. His research claimed that these symptoms resembled drug-seeking behavior but were actually caused by unrelieved pain. This pain, of course, could be treated by increasing the opioid dosage; these patients should not be diagnosed with addiction. Though “pseudo-addiction” became a popular term in medical literature, there has been no empirical evidence backing up the concept.

This is, frankly, absurd. Are we really questioning whether under-treated pain can sometimes exist, or can cause nausea or shaking? Are we really going to go down the "let's see empirical evidence" road when discussing, effectively, the concept of pain? Here's some empirical evidence; go kick a wall, now your foot hurts. That isn't the feeling of painkiller withdrawal.

For a lengthy discussion of this, I recommend the inimitable Scott Alexander: https://slatestarcodex.com/2019/09/16/against-against-pseudo...

In particular check out his "case 1". Yes, the push against over-prescribing opioids mean real people in real pain will not get the treatment that our current understanding of medical science says they should receive. The costs may be worthwhile, but they exist.

> and some people who should not get them now won't (which is good)

It checks a box. Whether or not the long term result is actually positive or "good" for that individual seems far less clear, particularly if your plans only extend as far as cutting off their supply.

> but the correct balance is deeply unclear, and unlikely to be determined in the middle of a moral panic.

I feel like drug abuse is indicative of other more serious underlying problems, and unless you address those, you're just shifting problems from one domain to another.

Both valid points. I'm pretty keen on the concept of harm reduction, but how much overlap there is between harm reduction and blindly trying to reduce the consumption of opioids remains to be seen.

> how much overlap there is between harm reduction and blindly trying to reduce the consumption of opioids remains to be seen.

The answer is "none".

"Harm reduction" has a specific meaning im the context of addiction (such as needle exchange programs, etc). Cutting people off from their access to legal opiods does not qualify as "harm reduction", but the opposite as it pushes people to unsafe street drugs.

Both my mom and my wife found that opiods cause more trouble than good for them in terms of pain relief, while Tylenol and Ibuprofen work just fine.

My mom had surgery recently and the oxycodone had her nauseous and vomiting through the night the first night after her surgery. After which she decided to just not take them.

Not to mention that opioids put your digestive tract basically to sleep, leading to severe constipation.

hydrocodone is not equivalent to Tylenol.

So your offering an anecdote of two people who tried a strong painkiller, and discovered they only needed a weaker one, as evidence of...what? That nobody every needs strong painkillers?

Paracetamol and ibuprofen are the right choice in a lot of cases, but I don't think any medical professional would dream of suggesting they're the only painkillers that you'll ever need!

I think the point is they were offered opioids in a pain management setting that didn't require them.

My point was that in my personal experience, both my wife, recovering from a C-section, and my mom, recovering from reconstructive surgery on her arm where they broke and plated her forearm back together, found that pain was perfectly manageable and had fewer side effects with standard pain medications.

This suggests to me that opioids are not needed nearly so often as they are prescribed, even if they are warranted in certain situations.

As a counter-anecdote, NSAIDs like Ibuprofen cause GI tract bleeding in me (a haemophilia patient) and have put me in hospital twice, once in the ICCU with my family called to say their goodbyes etc.

If I have a severely painful joint bleed (common in my condition) or surgery, I'm taking the opioids.

I’m guessing you have hemophilia?

Correct.

My wife is on an antiangiogenic and NSAIDs cause her nose to bleed pretty profusely for more or less the same reason. I always wonder why it's 'ok' for nosebleeds when there is likely to be similar vasculature all through the body, but the docs don't really get too wound up about it.

> nobody is suggesting that opiods shouldn't be used to treat pain, are they?

Literally everyone is suggesting this. Not sure if you had any surgeries/medical producers these days. You will now get prescription strength ibuprofin or something like that instead of opioids.

My father in law spent one month straight of sleeping < 1 hr /night due to post op pain but the doc refused to prescribe opioids.

So yes, lots of people are suggesting not using opioids for pain. Perhaps you are using a different/extreme definition of pain in your sentence.

> You will now get prescription strength ibuprofin or something like that instead of opioids.

That is incorrect. "You will" is not the same as "You are more likely to". They still give intraveneous delotin when your appendix bursts or your gall bladder duct is blocked in the short term. It should come as no surprise, that major medical surgery (eg some pain from open heart surgery), is not mitigated by ibuprofin and the like.

> That is incorrect. "You will" is not the same as "You are more likely to".

Yes you are right. That's what i meant. thank you.

> They are just saying that that misinformation campaigns run for the purpose of increasing profit at the expense of human lives isn't a great thing.

Sure, no one can reasonably disagree with that. I don't think folks defending opioids are staking that claim. To your earlier question,

> I mean, nobody is suggesting that opiods shouldn't be used to treat pain, are they?

Kinda, yes, actually. Or rather, since regulators and doctors cannot actually tell the difference between someone in pain and someone not in pain, the response to a perceived overprescription crisis has been to swing towards underprescribing — restricting access to and increasing the difficulty of obtaining opioids for everyone.

I find it kinda terrifying how willing people are to blame pharma cos when the largest increase in deaths has to do with non-pharma opiods.

Availability of illicitly manufactured synthetic opioids (e.g., fentanyl) that traditionally were prescription medications has increased. This has blurred the lines between prescription and illicit opioid-involved deaths. In one study in 27 states, Gladden et al. examined data on drug products obtained by law enforcement that tested positive for fentanyl (fentanyl submissions) and deaths involving synthetic opioids other than methadone (referred to as synthetic opioids). From 2013 to 2014, fentanyl submissions increased by 426%. The increases were strongly correlated with increases in synthetic opioid deaths but not with pharmaceutical fentanyl prescribing rates, suggesting that the increases were largely due to IMF. In a recent report, fentanyl was detected in at least half of the opioid overdose deaths from July to December 2016 in 7 of the 10 states examined. [0]

0. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844400/

The CDC describes overdose deaths as occurring in three waves [1]. Normal pharmaceuticals are involved in wave one, starting in the 1990s. Clearly pharma co.s aren’t involved in wave two, heroin. What’s their culpability for wave three, the synthetic opiods starting in 2013? NIH above says not majorly. If pharma cos aren’t the source of fentanyl and wave two’s heroin, why are they the media focus point?

1. https://www.cdc.gov/drugoverdose/epidemic/index.html

As I understand it, the argument is that the prescription opioids got people addicted and when they could no longer get prescription opioids they turned to illicit opioids.

Can anyone comment on the validity or invalidity of that argument?

~75% of opioid misuse starts with people using them without a prescription. [0]

~90% of people who are prescribed opioids never develop addiction problems. [1]

Despite being in the midst of an opioid crisis with skyrocketing mortality rates, the mortality rate from prescription opiates has been ~stable for the last ~15 years. [2]

[0] https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTab...

[1] https://www.ncbi.nlm.nih.gov/pubmed/25785523

[2] http://www.ncsl.org/portals/1/documents/health/APeeples0118_...

Opioid use without a prescription includes the massive amount of oxycodone sold as a street drug, which helped to seed this crisis.

I knew of people buying oxycodone on the street a decade ago, and it was clear their dealers had a supply of name brand pills beyond "pills stolen from the medicine cabinet".

Wow, one in 10 people prescribed opioids become addicted? I wouldn't like those odds.

I don't know if that statistic is per course of prescription or per person, It's probably even lower if you know your family to have no history of addiction. If it is per person I'm frankly surprised it's that low given how prevalent genetic predisposition to addictive behaviors is.

Sounds great, until you realize that there are >200M opioid prescriptions filled every year. The numbers are large in absolute terms.

Something like 6% of american adults abuse alcohol -- and alcohol is less "addictive" than an opioid for most of the population.

One illustration of this is that when they changed the formula to prevent injection and insufflation, heroin use rose. [0]

I seem to recall earlier stories linking the rise of prescription opiates in general to a resurgence in what had been declining heroin abuse, but I'm not finding anything.

[0] https://www.latimes.com/local/lanow/la-me-oxycontin-20170109...

>I mean, nobody is suggesting that opiods shouldn't be used to treat pain, are they?

SSC had a good piece on that: https://slatestarcodex.com/2019/09/16/against-against-pseudo...

And then, pot is legalized, and the marketing machine will be pushing that.

As I grow older, I've become way more conservative about legalizing drugs.

You should become more conservative about drug marketing and profits, less about legalization.

> nobody is suggesting that opiods shouldn't be used to treat pain, are they?

If there's enough overreaction to opioid dependency, it does impede the use of opioids to treat pain. Making it harder to get opioids also, typically, makes it harder to get opioids to treat pain. Bureaucratic systems, put simply, suck.

Whenever you talk about the "opioid epidemic", a large part of what you're talking about is people buying heroin and fentanyl from drug dealers. Making it harder to get oxycodone does zero to stop people from buying heroin and fentanyl on the street. It does a hell of a lot to stop the use of oxycodone to treat pain.

That’s the tail end of the problem. Drug companies claimed that newer versions of opioids weren’t addictive, and produced bogus research that backed those claims.

So the protocols changed, and doctors in many areas of practice started treating opioids like ibuprofen. Hydrocodone or oxy isn’t the best choice for chronic pain, and as chronic users take it, their tolerance increases and their ability to get an effective, legal prescription slowly goes away.

The black market offered cheaper, but more dangerous alternatives.

I feel like this also suggests that doctors suck. If engineers couldn't interpret the information coming from the security community and due to their inability to deal with their own industry inputs they got thousands of people killed per year, it would be a far more serious deal. As far as I know, Google isn't getting thousands of people killed, but nobody is talking about reigning in the medical community.

Somehow there's no egg on the medical community's face. Is medically checking the doctor now the responsibility of patients?

> As far as I know, Google isn't getting thousands of people killed per year,

At google's scale it doesn't take much bureaucratic indifference to have an outsized effect.

I would be surprised if google wasn't-- but it's spread out over thousands of distinct causes. Like maps effectively directing people to turn onto railroad tracks and google being unwilling to do anything about it (https://www.theverge.com/2019/8/12/20802036/google-apple-mic...), or maps and especially waze directing highway level flows of traffic through residential neighborhoods.

I feel that even a bad luck spike in death by the thousands would be noticed, but you are suggesting that thousands might be dying for years and nobody notices.

People are dying. People did notice-- though not of quite as many as thousands. Action is not being taken to do anything about it, various states are considering passing laws to force google to take action as a result.

I know people that moved from prescription opioids to street opioids. The jump from treating pain to addiction/simply enjoying the high is surprisingly small.

PS: That’s not to say it’s purely the drug companies issue. While recovering from surgery in the hospital and on an clicker IV drip I had a doctor suggest I try ‘upping my dose’ for the fun of it.

This is exactly what's happened in Australia. Over-the-counter opioids (codeine, primarily) were banned last year. People were destroying their livers and stomachs due to overdosing on the adulterants (paracetomol/acetaminophen and ibuprofen) that were specifically put in to stop people taking them in bulk.

Now ordinary people with ordinary aches and pains can't get effective painkillers without visiting a doctor (or a quick trip to NZ where they're still available).

If your "ordinary" aches and pains require medication with adverse effects as significant as addiction, maybe they're not that ordinary ?

Is the threshold for visiting a doctor that high in Australia ? From my European perspective, seeing your GP is a routine and cheap thing to do, and definitely warranted before starting an addictive drug.

Ibuprofen always worked for my ordinary aches. I find it justified to require a visit to a doctor if the pain doesn't react to Ibuprofen.

Ibuprofen fucks my stomach. Paracetamol does nothing for me for pain (as predicted by the literature). Mild opiates like codeine kill it dead. And taking it once isn't an addiction problem.

It seems making it harder to get oxycodone actually increase the amount of people buying opiates on the street. There is a strong correlation between increase use of street opiates and the creation of opiate tracking DBs and crack down on pill mills.

The point is that people have the right to choose what to do with their bodies. Laws against drug use are morally equivalent to laws against abortion, homosexuality, etc.

This may be completely unpopular opinion, but as a temporary user of pain killers I am thankful I was prescribed them. I was experiencing chronic and hard to diagnose pain. I was in a very dark and scary place and was constantly wondering how people without access to these medicines continue their will to live. I was having difficulty making it through a work day and as a desk worker I was able to tolerate them during the day.

I am thankful my doctor was so willing to prescribe them for me. Looking back on the experience in hindsight I would have preferred to stay on them longer instead of transitioning to other medicines during physical therapy. There was a lot of suffering during that time.

If you’re all right with my asking, where was the pain located, and from what cause?

In my own case it was in the throat, literally unable to swallow anything for days due to severe pain, cause was mono.

Fun fact I discovered through the ordeal is that the very act of thinking about saliva causes saliva to secrete, so it's practically impossible once you realize you have a saliva problem to stop it, since with a problem on hand you cannot but think about it and the very act of thinking about the problem causes the very problem to worsen

The problem isn't that they work to relieve pain, it's that they're addictive.

Anecdotally, I once knew a fellow who "accidentally" broke his own finger to get a prescription.

They aren't addictive to the vast majority of people.

In this respect it's similar to alcohol: only harmful to a small group of people, but for them very harmful.

I think the key is looking for commonalities of the people at risk of addiction and finding alternative therapies for them.

Can you please show a single credible source that claims that things like heroin or opium "aren't addictive to vast majority of the people"?

From everything I ever read or heard on that topic this is simply not true, I wonder what makes you say those things...

And that statement about alcohol is an outright lie in the way you state it.

Alcohol, Heroin and Nicotine. All are super addictive and after some time the body becomes chemically dependant. It's why you get "dope-sick" when you kick.

People can drink alcohol every day without being addicted to it.

Maybe some very few, or 'a glass a day' type consumption, sure.

I've seen alcoholic withdrawal and it's not pretty. Drying out from a real addiction can need medical attention.

Some people smoke cigarettes every day without being addicted to them, and I'm sure some people can smoke opium every day without being addicted to it (probably can't say the same for injecting heroin).

Doesn't mean it's good for you (neither is drinking every day).

You don't have to inject heroin to consume it, FWIW. You're right that intravenous use is probably more addiction prone (not to mention, dangerous for all kinds of reasons).

People can consume nicotine and heroin every day without being addicted to it, in whatever sense you are imagining that means for alcohol users.

"Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them. Between 8 and 12 percent develop an opioid use disorder." [0]

"According to the 2017 NSDUH, 14.1 million adults ages 18 and older (5.7 percent of this age group) had AUD (Alcohol Use Disorder)." [1]

depending on your definition of "vast", these seem to support GP's claims (certainly not an "outright lie"). the rates compared here aren't quite apples-to-apples, but they do suggest the rate of addiction to alcohol is pretty similar to that of opioids.

[0] https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdos...

[1] https://www.niaaa.nih.gov/publications/brochures-and-fact-sh...

The percentage is twice higher, and opioids are regulated and hard to get to boot.

It's plausible that we would be looking at 20%+ if you could get them at the store like you can a beer.

It's also plausible that the 8% figure is representative of unfettered access. Conceivably everyone who wants opioids has access to opioids in some form or another now, and those who want it especially badly will put in special effort to get it. Heroin and kratom are easier to obtain than prescription opioids (if you don't have a visually obvious physical trauma and health insurance).

We know the number of patients prescribed opioids each year; it peaked in 2012 (it has been declining since then)[1]. We could look at abuse / addiction data over some period where prescriptions rose, and see if the disease rate rose significantly. It would be suggestive, if not conclusive, because we prescribe opioids to something like 20% of the population each year. (For comparison, about 66% of persons >12, or 55% of the total population, drinks any alcohol in a given year; figures from 2014.[2])

> After a steady increase in the overall national opioid prescribing rate starting in 2006, the total number of prescriptions dispensed peaked in 2012 at more than 255 million and a prescribing rate of 81.3 prescriptions per 100 persons.

I don't have good figures for historical rates of opioid addiction at hand, but we can look at 2016 (roughly).[3]

> In 2016, an estimated 1,753,000, or 0.7% of persons aged 12 and older, reported a substance use disorder in the past year involving misuse of prescription pain relievers

Going back to [1], the prescribing rate was 66.5 per 100 in 2016 and (in 2017, but taking for representative) "an average of 3.4 opioid prescriptions dispensed per patient." So we get 66.5/3.4 => ~19.6 per 100 people prescribed opiates, or 19.6% of people. 0.7% / 19.6% is an addiction rate of about 3.5%. There are definitely holes in this, but it's definitely plausible that the real rate for unfettered acecss is single digit.

We could also look at Portugal as an example. Decriminalization isn't the same thing as full legalization and unfettered access, but[4]:

> It is estimated that there were 33 290 high-risk opioid users in Portugal in 2015, which is about 5.2 per 1 000 of the adult population. In the same year, the number of people who inject drugs was estimated at 13 160 (2 per 1 000 people aged 15-64).

("High risk" in EMCDDA terms is injecting drug use or any long-term or regular use; it's a reasonable proxy for addiction, although might overestimate.[5])

[1]: https://www.cdc.gov/drugoverdose/data/prescribing/prescribin...

[2]: https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTab...

[3]: https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surv...

[4]: http://www.emcdda.europa.eu/publications/country-drug-report...

[5]: http://www.emcdda.europa.eu/data/2014/methods-hrdu

I have met people who claim to have tried various hard drugs without addiction, but they usually don't talk about it because of the taboo. As a non-using bystander I would find it interesting if both prescription and banned substances had something like LD50 but for addiction. A measure of what dosage pattern will lead to 50% of the population being addicted. An AD50.

For better or worse I know a lot of people who smoke methamphetamine. Never smoked it myself and never would.

Most of them smoke it recreationally without it causing any problems in their life or addiction. They have no issues when they're not smoking it, they can stop when they want, and they don't let it negatively affect the rest of their life (work, relationships, etc.). Some of them are weekly smokers, some of them are only once or twice a year. But around 10-20% of the people I know who smoke it have issues with dependence and addiction, and it's caused massive problems for them (and those around them) and for some of them it's destroyed their life.

I don't know anyone who uses heroin, but I'd imagine that it's the same.

"Hard drugs" are surprisingly non-addictive, less addictive than nicotine and probably even less addictive than caffeine. The reason why these drugs are "hard" though is that if people do develop an addiction, it's so incredibly destructive. It becomes their life, everything they do becomes drug-seeking behaviour. They don't even like the drug any more, but they need to keep doing it just to feel normal.

> The reason why these drugs are "hard" though is that if people do develop an addiction, it's so incredibly destructive.

Eh. Do you know many alcoholics? The "hard" qualifier is mostly just arbitrary societal taboos reinforced by the federal government.

https://www.latimes.com/projects/oxycontin-part1/

"Purdue tells doctors to prescribe stronger doses, not more frequent ones, when patients complain that OxyContin doesn’t last 12 hours."

The key is better education and destigmatisation around addiction and its causes, and encouraging open dialogue. Otherwise we'd end up in a weird, accidentally classist society where poor (and other "at-risk") people aren't allowed opioids but wealthy people are.

People don't want to, or choose to become addicted, and it's not like people take a drug once and they're instantly hooked. People being prescribed potentially addictive medication (and those around them, friends and family) need to be educated on the warning signs of dependence, and encouraged to talk about it. There shouldn't be a stigma in admitting addiction, it's not a moral or personal failing, but it's treated as such by so many people.

First of all, I am not an expert on opioids nor am I a trained doctor. For what it's worth, I have lived with chronic pain, so I do know what it is like to suffer.

I do not think the problem is that opioids are evil, but that they were clearly (to the point of obvious fraud) being sold in great quantities to people to abuse for recreational purposes. Obviously it can be frustrating because now people with legitimate medical pain have one less option for dealing with their suffering (although based on studies I have read, opioids are actually not the first choice for most users), and they are the victims of the flagrant corruption of the pharmaceutical companies in question.

I am not saying doctors need to be perfect in diagnosing problems and always knowing what to prescribe, and magically predicting when a patient will become addicted (even if it is to treat a legitimate medical condition). I am saying the corruption of overprescribing drugs for the obvious profiteering should be stopped, and those found responsible should face legal consequences (I assume something like 20 years jailtime, plus forfeiture of all assets gained illicitly after thorough audits - when going after billions of dollars it is easy to come up with the money for audits).

I am glad that opioids were able to help you and I am glad you were able to get them when you needed! I understand there is a lot of villification of opioids and in the outrage some people want them banned entirely and that would likely be a loss (similar to what happened with marijuana, ketamine, and other drugs that were always suspected to have real medical benefits and we are now getting real clinical studies to support these hypotheses). But the corruption is real, and the criminals need to be punished, and the overselling needs to be stopped.

You make some excellent and sympathetic points, I assume in large part because of your own experience with chronic pain. Good doctors, who care emotionally for their patients, are more than willing to alleviate the discomfort. One of the main problems now is that States are implementing even more restrictions for opioid prescription. Many doctors feel as if they are being closely watched, and those that register as prescribing opioids, are somehow under even more scrutiny. I know many who don’t go near these substances any more, not even renewing their DEA registration.

I think "recreational" is not the correct term to use for most of the people taking opioids without a prescription.

So many addicts start out using for some pain, and become addicted. They then buy from shady doctors or people who get drugs from shady doctors. Or they might use them to feel numb because they are depressed.

I am just not sure that a majority of illegal opioid users are people who started their habit by thinking "I am looking to have a good time to night, let me take some opioids"

Wasn't it the case that oxycodone was marketed as working for 12 hours (per its patent) when it only worked for 8? And that doctors were told by the pharmaceutical company to increase the dose rather than make it more frequent?

Recreational users wouldn't be the problem since addiction is the intended result.

Do you know at the top of your head statistically how likely are the people taking the drugs you are taking to overdose and die?

In raw numbers (so this is not a probability), half as many as alcohol.

https://www.caron.org/blog/2019/05/alcohol-is-killing-more-p...

Any serious research to back that up? But even then I have to ask so what? What does that have to do with anything? I never claimed that alcohol isn't killing people or that this is a problem that must reduce attention to other problems

My source cites numbers for opioid and and alcohol deaths according to the Center for Disease Control. Anchoring opioid deaths against alcohol provides a frame of reference for many people, since alcohol is so ubiquitous in human culture.

I tried googling for the odds of becoming addicted to those substances and couldn't readily find anything for either. Hopefully someone else sees this and can shed some light, because it would be interesting to me as well.

Calculating long-term effects is a lot harder and ambiguous than thing easy to measure like ODs, for example that post includes cardiovascular diseases and cancer but did they compare how many drink alcohol and exercise vs those who don't? And afterwards compare people that don't exercise vs people that drink alcohol and exercise, and people that exercise that never drink alcohol vs people who exercise that drink it each weekend? Are there differences between people that drink pure alcohols (Vodka, Whisky) vs non-pure ones (beer), and also how much is enough drinking to notice those negative symptoms, once a year? once a month?

> But recent studies estimate that 21 to 29 percent of patients prescribed opioids end up misusing them, and the rate of addiction actually ranges between 8 and 12 percent.

Apart from the problems about how opioids are prescribed that were touched on in the article, one of the big problems with how opioids and other potentially addictive drugs are prescribed is that there's incredibly poor eduction around addiction, and a deep societal stigma against addiction.

Drug dependance and addiction isn't a moral or mental failing. It can (and does) happen to the most virtuous and intelligent people. Patients aren't educated to recognise the symptoms of beginning dependence and addiction, and if they do recognise it, they're reluctant to communicate this with their doctor for fear of being cut off entirely. Instead of being open and up front when they start to develop a problem, because of stigma and fear of being labelled a junkie, people will hide their behaviour, causing further problems. Also, because of the attached stigma, friends and family will often be reluctant to raise any concerns they have.

Your kind of response is exactly the kind of attitude and stigma that furthers the problem.

> constantly wondering how people without access to these medicines continue their will to live

They often don't.

People who have never needed particular drugs often struggle to understand how important they are to those who actually need them. It's incredibly hard to empathise with someone's plight if you've never experienced it yourself.

I have far too many people who aren't doctors telling me that I don't really need stimulant medication to manage my ADHD and I'd be fine without it. Often they'll go on to describe how, as someone without ADHD, Ritalin or dextroamphetamine gets them all wired up.

Ritalin literally just straightens me out and makes me feel normal (unless I eat a handful). I can certainly manage without it, I did for over 20 years, but life is a lot easier when I have the option to use it. It's a tool in a toolbox of management strategies. I'm an adult and am capable of giving informed consent, I had a discussion with my doctor about potential side-effects and long term use, including dependance and what would happen if I stopped taking medication. I have a fairly comprehensive understanding of ADHD and stimulant medication, more than your average moon worshiping hippie, that's for sure.

I've gotten the same in regards to using benzos (Xanax, Valium) for anxiety. If you need them, you need them. Breathing exercises or trying to distract yourself won't work. If you've never experienced a panic attack or had serious anxiety, you can't understand how bad it is. If you take an appropriate dose, you don't become a sleepy zombie, you become a functioning human.

I have friends who are on anti-depressants and I've seen exactly the same thing happen to them. Positive thinking and yoga won't cure clinical depression.

It's demeaning and condescending to assume that someone hasn't considered actually trying to solve their mental health issues without medication or drugs. It's actually incredibly insulting to have someone with no qualifications or subject knowledge tell me how I should manage my mental health and that I shouldn't be taking medication. It's like telling someone who needs glasses, which I also do, that they should try opening their eyes and looking harder (I've actually had people tell me I should try exercising my eyes), or telling someone with asthma that they should just breathe deeper. You wouldn't tell someone in a wheelchair that if they simply think about walking hard enough they'll be be able to stand.

Very few in this discussion are asking to ban opioids. However corruption of the Doctor-patient relationship is a big problem.

There’s a word for this on the street - a “pusher”. I for one don’t want to wonder if my doctor is getting kickbacks for prescribing specific meds.

No one's calling for a ban on opioids because they're already banned — they're DEA schedule II. There is an extremely limited exception where they can be prescribed, by a professional cartel (AMA), to extremely limited numbers of patients in limited quantities. And people have clamored for that exception to be further limited over the past decade or so.

I think the general sense of people's objections aren't to the medications themselves, it's to the repeated revelations of just how determinedly companies lied and bribed and incentivized the use of opioids.

I for one would love to see pharma marketing info limited to nothing more than summaries of prescribing quidelines, and anything resembling sales pitches or opinion of any sort heavily penalized until the current pusher system ends.

I see the oncologist every three weeks. And the radiologist every few months. They always ask if I need any pills. I haven't taken a opioid in six months. And I have a ton of oxy and hydromorphone sitting in my bathroom from when I was deep into chemo. Hundreds of pills sitting there that I have no desire to take.

I found that lorazepam and a Advil helped more.

And from my experience the most egregious prescribers of opioids aren't doctors, but dentists. I got 30 hydrocodone for having a tooth pulled. That is absurd.

"I have a ton of oxy and hydromorphone sitting in my bathroom"

Not a good idea to keep them, IMO.

I have absolutely no desire to do them. The constipation is unbearable for me when I take them. I do enjoy a hydrocodone.

But it has been a year and they treat the cancer, and then another scan and there is a new spot, rinse and repeat.

Another round of radiation starts next week. So not a terrible idea to keep some pills around. But this batch of radiation should be easy. 5 treatments over two weeks. Probably won't even get a sunburn from it!. And it might seem odd to be really happy about radiation. But I was thinking it would be another few months of chemo. So radiation is fantastic.

I tend to agree, maybe because I have had a similar experience.

Went to the ER with severe abdominal pain, but took more than 24 hours to diagnose and therefore admitted and get on morphine. Even though it was only a little more than 24 hours, it was possibly one of the most miserable 24 hours of my life.

Then magically morphine goes in and things were tolerable. Over the next 10 days I was on low dose IV morphine (couldn't take anything in pill form because GI tract wasn't really working), but they wear out pretty quickly. The hour or so between the time the previous dose wears off and the next dose the morphine was definitely on my mind a lot. Although in my case it wasn't wanting to get high but rather remove the pain.

Previous to this episode I held that opinion that opioids were rarely needed and people should just tough it out. e.g. when I had my wisdom teeth pulled I was prescribed opioids but didn't take any. But this episode definitely changed my mind. Not sure what I would've done in that 10 days if I wasn't on morphine.

Do you think your doctor wouldn't have prescribed them if not for aggressive pharma marketing? Was it difficult to obtain a prescription?

Hmmm... this article seems like a real world demonstration of the principles outlined in "Influence:The Psychology of Persuasion" by Robert Cialdini [0]

1. Reciprocity - check 2. Social Proof - check 3. Authority induced bias - check 4. Scarcity - check 5. Commitment and consistency - check

Damn scary how even highly qualified professionals fall prey to the same old tactics.

[0] https://en.wikipedia.org/wiki/Influence:_Science_and_Practic...

The fact that so much effort and so many dollars are expended to "sell" drugs to patients via the trust that doctors engender, illustrates just how broken medicine is in the U.S.

Isn't there a professional and ethical obligation to prescribe painkillers to people who are in significant pain?

I would argue that the obligation should rather lie in finding the cause of the pain, and working on fixing that, rather than fixing the symptoms

Suppose it takes time to figure out and fix the cause of the pain, or is impossible to find the cause and/or fix it.

My neighbor got addicted to opioids after he got in a motorcycle accident and broke many bones.

He eventually broke the addiction but said he was super grateful for opioids.

So, yeah... sometimes the source of the cause of pain is "multiple broken bones"

Terminal cancer sucks.

Have you ever been on call?

Imagine that you are on call, and you get paged for something, and there is no way to stop the page from going off even though you're aware of the issue and trying to resolve it.

You could also, if you'd like, imagine that your alarms were misconfigured and they were going off for literally no good reason, but there was no way to silence the mechanism that's paging you.

It's kind of like that.

There is. However, opioids also treat psychological pain and inhibit anger and rage - these are some of the unspoken reasons people from abusive backgrounds become so easily dependent on opioids.

Note that dependence here is distinct from addiction.

I guess it depends. In other countries, like Germany, doctors have a very different stance on people in pain.

“Pain is a part of life. We cannot eliminate it nor do we want to. The pain will guide you. You will know when to rest more; you will know when you are healing. If I give you Vicodin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you. You might overexert yourself because you are no longer feeling the pain signals. All you need is rest. And please be careful with ibuprofen. It’s not good for your kidneys. Only take it if you must. Your body will heal itself with rest.”

From: https://www.nytimes.com/2018/01/27/opinion/sunday/surgery-ge...

Yes. When stubbing a toe I've historically employed two strategies for dealing with it. In my youth I would shout and hop around the room, i.e. distract myself. Nowadays I pay as much attention to the pain as is possible and practical. Remarkably this approach does seem to alleviate the pain.

So my guess is that the function of pain is to direct attention to injury. Not just for thinking about ways to avoid repeat injuries but purely and simply to promote the healing response. Which is not to say that I wouldn't welcome a painkiller if the pain was great enough. It's just that the suffering caused does seems to increase with the efforts one makes to distract oneself from it.

There is a level of pain where it becomes totally debilitating and all consuming. I can meditate over light headaches or other pain but from time to time I get migraines where I either want to die or take anything that will make it go away.

With very severe pain I don't see why one couldn't adopt a dual strategy of alleviating it both with drugs and by focussing on it during its most intense moments.

> Your body will heal itself with rest.

Love too keep my arm permenantly lowered because ibuprofen is evil and rest is good

Ibuprofen is an OTC medicine in Germany.

I'm German and that is highly exaggerated.

While doctors here are in fact very careful and conversative with opiates, if you need them, you get them. Almost all of the people with chronic pain I know get opiates, or cannabis.

While that is exaggerated, it's close to what many people here think

> Isn't there a professional and ethical obligation to prescribe painkillers to people who are in significant pain?

No. There is a professional and ethical obligation to inform patients of the options available, and the costs and benefits of each option, so that the patient can make an informed choice about what is best for them in their particular case. That includes informing the patient about how best to use painkillers: for example, that you should take them only if taking them benefits you more than not taking them (for example, only take them right before bed so the pain doesn't prevent you from sleeping, and the healing you get from sleep outweighs the risks involved with the painkiller).

There have been a number of updates and revisions of the medical code of ethics dating back to the Hippocratic Oath. Below is the American Medical Association Principles of Medical Ethics from 1957 [1], and for a longer look [2].

Section 1. The principle objective of the medical profession is to render service to humanity with full respect for the dignity of man. Physicians should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion.

Section 2. Physicians should strive continually to improve medical knowledge and skill, and should make available to their patients and colleagues the benefits of their professional attainments.

Section 3. A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily associate professionally with anyone who violates this principle.

Section 4.The medical professional should safeguard the public and itself against physicians deficient in moral character or professional competence. Physicians should observe all laws, uphold the dignity and honor of the profession and accept its self-imposed disciplines. They should expose, without hesitation, illegal or unethical conduct of fellow members of the profession.

Section 5. A physician may choose whom he will serve. In an emergency, however, he should render service to the best of his ability. Having undertaken the care of a patient, he may not neglect him; and unless he has been discharged he may discontinue his services only after giving adequate notice. He should not solicit patients.

Section 6. A physician should not dispose of his services under terms of conditions which tend to interfere with or impair the free and complete exercise of his medical judgment and skill or tend to cause deterioration of the quality of medical care.

Section 7. In the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him, or under his supervision, to his patients. His fee should be commensurate with services rendered and the patient's ability to pay. He should neither pay nor receive a commission for referral of patients. Drugs, remedies or appliances may be dispensed or supplied by the physician provided it is in the best interests of the patients.

Section 8. A physician should seek consultation upon request; in doubtful or difficult cases; or whenever it appears that the quality of medical service may be enhanced thereby.

Section 9. A physician may not reveal the confidences entrusted to him in the course of medical attendance, or the deficiencies he may observe in the character of patients, unless he is required to do so by law or unless it becomes necessary in order to protect the welfare of the individual or of the community.

Section 10. The honored ideals of the medical profession imply that the responsibilities of the physician extend not only to the individual, but also to society where these responsibilities deserve his interest and participation in activities which have the purpose of improving both the health and the well-being of the individual and the community.

[1] American Medical Association. Principles of medical ethics. Appendix F. 1957:355–257. In: Baker RB. The American Medical Ethics Revolution. Baltimore, MD: Johns Hopkins University Press.

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399321/

Maybe, but only if is attached to an ethical obligation of declaring how likely you are to become addicted, and how likely you are to die from overdose, and how likely is to create other permanent damages.

> Since I left the industry in 2000...

That's a significant time to be out of the industry and still speak with credibility about today's methods and practices. Not impossible to be entirely on point, but it would be more credible from someone closer to practices in at least the last decade.

I suppose if it were "since I left Google/Microsoft .." you'd be more right, but industry-wide practice is usually something that's relatively out in the open especially for former insiders

The author left the pharmaceutical marketing industry in 2000; now, the author works as a doctor. From the bottom of the essay:

> When I was a drug rep, I really believed my pitch for our products — and I believed that by exerting influence over doctors, I helped patients access medicine they needed. As a doctor, I now have colleagues — colleagues with sharp, clinically trained minds and only the best of intentions — who think they write prescriptions on a wholly rational basis.

In 2000, the author would have been witness and/or a party to the industry most excessive and unmonitored marketing practices, i.e. well before the federal push for transparency and disclosure [0]. Now, as a doctor – albeit an ER doctor, who may not be the biggest target for pharma reps – he likely has decent awareness of how both pharma marketing and doctor attitudes have changed.

[0] https://www.propublica.org/article/we-found-over-700-doctors...

Back in the early 2000s I built a web app for a big pharma that was used to compile doctor's responses to questions on survey cards that were mailed out.

These could be anything from multi-choice questions about awareness of drug products, whether they prescribed particular drugs for specific treatments and I think from memory there may have been incentives like prize draws like trips to conferences for filling in the survey (return postage paid as well).

I can't imagine this having changing so much (maybe more online or in partnership with clinic software) as it served as both promoting a drug for a specific treatment and identifying individual doctors responsiveness to future marketing.

Things have tightened up a bit since then, though not completely. My dad ran hospitals for a living when I was a kid and we got tons of free tickets to sporting events from various vendors trying to sell him stuff. He would have to listen to a 10 minute pitch from some salesman (that he always made fun of later) and in return he got a free night out with the family. I remember being mad when that dried up in the mid-2000s. I later learned that CMS had implemented some regulations cracking down on the practice.

These days, thanks to the ACA, you can look up exactly how much money your doctor has received from medical device manufacturers or pharmaceutical companies (https://www.cms.gov/openpayments/)

My 5 year old had to have surgery to repair a small abdominal hernea. Not a big deal, most kids recover incredibly fast and are back to running around within 2 or 4 days. We were given a prescription for enough opioids for 3 months at the maximum daily dosage. She needed one day, half the daily max.

After some dental surgery, I was given a prescription for some powerful painkillers, and the pharmacist told me they could only fill all of it or none of it. I literally couldn't obtain a lesser amount. (And thankfully, ultimately didn't need any of it.)

I think that's just a property of the prescription system. Even if you were prescribed something harmless like anti-histamines it's still all-or-nothing, otherwise it would count as the pharmacy not honoring the specifics of the prescription.

There's a lot of anecdotes in this thread about people being prescribed "too much".

What would your anecdote be if your child was in severe pain after the surgery, occurring in the middle of the night, and you needed to get the meds after hours?

What if you had to drive back in to get a paper script?

What if you had to wait 2 days?

I rarely (almost never as a radiologist now) write outpatient narcotic prescriptions anymore, but when I did, I often prescribed in a pattern so I could avoid people becoming uncomfortably symptomatic in an inconvenient time for them (and us). I'm not sure what the best situation here is, other than giving you the RX and telling you to not fill it?

There is a big difference between a reasonable margin of safety, say double what was expected, and the 3 months which was 30x the expected need. Three months is not an emergency contingency.

"When my patient’s loved ones ask how this could have happened, or start to blame themselves, I think with anger about how, for years, drug companies promoted the idea that addiction was not a common effect of the medication but rather a personal failing of the addict."

Shouldn't that be, "...I promoted the idea..."

The author says they didn't sell the opioids. Your point is valid though.

It would be nice if actual statistics were floating around that identified causes of drug addiction. I grew up surrounded by crack and heroin addicts, anecdotally not a single one I met was pushed opiods by a doctor, they instead had a lifetime of drug seeking behavior and pooled money with other drug addicts, and whatever was cheap and available on the streets they took which often was heroin (now synthetics like fentanyl). In that same country pushing drugs by doctors was not common like it seems it is common in the US, yet we still had an enormous out of control street addict problem with no end in sight.

It would also be interesting to see Portugal research as they decriminalized all drugs, if they still have an out of control street addict problem and culture of drug taking, or Japan research why they don't have a drug taking culture.

That people can become addicted to crack and heroin without being prescribed opioids does not necessarily preclude people getting addicted to opioids after being prescribed opioids.

One the best sources is the National Institute on Drug Abuse:

https://www.drugabuse.gov/

In 2005, the large majority of heroin addicts in the US were concurrent or former pill opioid addicts, but as of 2015 or so, it's about 50%.[1]

[1]: https://www.ncbi.nlm.nih.gov/pubmed/28582659

Title should be "I was a drug rep. I know how pharma companies pushed opioids.", as per the original article.

Here's a tl;dr of the article (quoted from the article itself) to save you a click:

> Medical students and doctors didn’t just learn how to assess and pay attention to patients’ pain — they also internalized the idea that prescribing opioids was a professional, even an ethical, obligation. Exaggerating the clinical significance of pain drastically expanded the market for opioids, bringing them to populations with a high risk for addiction, like adolescents.

The code of conduct changed around 2009 as the author points out. Prior to that time it was a torrent of all kinds of expensive gifts, which were not restricted to opioid prescriptions. The higher the number of “scripts” a physician had, the more extravagant the giveaways.

Interestingly, prior to the opioid frenzy, the culture was one of great restraint often leading to under medication of pain and unnecessary suffering for patients. This was superseded by the conviction that pain had to be eliminated if at all possible, it was a physician’s moral imperative to do so. Now in hindsight, it’s clear that Pharma was driving a lot of this ethos.

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