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It's been widely understood since the 1970s, if not longer, that opioids have a high potential for addiction and that long term use tends to be harmful. Sure, he seems to have been quite a junior employee, but I knew opioids were a high risk category of drugs when I was in high school. I don't think he's the worst guy in the world, but I do think McKinsey style consulting and this experience in particular is a net negative.

Potential for addiction yes but we are looking at it from the lens of a post Purdue media bias. People abuse plenty of drugs that aren't opioids and we aren't say seeing a big push against Xanax for example because that wasn't in any crosshairs of media spectacle. People die on Xanax but it doesn't seem to matter because people write them off as combining with alcohol or that they were addicts. And indeed most drugs of this sort are not particularly harmful if they are used within recommendations. At a certain point a doctor can't control what you chose to do at home with your prescription and that doesn't mean you shouldn't have people who would use it responsibly not receive it even if it means some will abuse it.

> At a certain point a doctor can't control what you chose to do at home with your prescription and that doesn't mean you shouldn't have people who would use it responsibly not receive it even if it means some will abuse it

I'd like to think that most of those decisions are coming from datasets that suggest, on average, certain medications tend to lead to abuse, including from people with no prior history of abuse.

I'm quite libertarian in a lot of my views, but this particular one on lax drug controls I've never really been able to buy into.

I can't remember the exact stats but something like 5% of doctors were writing 75% of the sales for these products.

It isn't that they lead to abuse, it is that people who are using heroin will abuse them, and will go to doctors who facilitate that.

Dentists were handing opioid prescriptions out like candy to teenagers getting their wisdom teeth out. How many of those kids were previously on heroin and were picking dentists who would hook them up?

It's a massively common procedure and defaulting to "here's some addictive painkillers just in case you want them" was an insane thing to do, even if only 1% of cases turn out badly.

I got my wisdom teeth out at 16 or 17 and was given a prescription for oxycodone. I was really excited because I had read about oxy online and wanted to try it. But also I knew it was referred to as hillbilly heroin because of how addictive it was, so I had to be careful. I didn't take any of the oxy after the surgery and just took ibuprofen, so I could save the oxy for later on. I got high off it a few times and loved it. Later on I got a chance to try some hydrocodone and I thought that was even better, because the oxycodone was a little too much for me. I didn't nod off on the hydros. Anyway, opiates are great, that's why I haven't used them since high school.

Exact same thing happened to me. I got my wisdom teeth pulled and the guy prescribed me Percocet.

Interesting experience was signing a form in triplicate (white copy me, yellow copy walgreens, pink copy DEA) to pick it up.

Never took any.

Same thing happened to me in 2007. In retrospect it seems crazy.

Same thing, same year. Got an entire bottle of strong painkillers and didn't need/take any of them.

You have it exactly backwards. People got hooked by the doctors, and pivoted to heroin when they were tagged as pill seekers.

I had a spinal fusion in my early 20s. I was discharged from the hospital with a script for 90 days of opioid painkillers, 3x a day. $10 copay… I took like 4-5 and was done. I had a extensive support network between my lovely wife and family… people who do not develop a opioid problem like 60% of the time.

The standard of care changed because of Perdue. Dentists were handing out 30 day scripts, people were getting opioids for minor ortho issues, etc.

As abuse became more prevalent, sourcing prescription pills got expensive. Heroin was more available and cheaper - the use of this stuff became way broader than the stereotype of hypes selling plasma, etc.

> I'm quite libertarian in a lot of my views, but this particular one on lax drug controls I've never really been able to buy into.

Ok, I'll bite ;)

Let's agree that the "liberal" approach is harm-reduction -- safe injection sites, needle exchanges, free filters, test sites, community disease screening, etc.

In places where this has been tried (see: SF), it seems to provide some relief to people on the ground, but it's done nothing to address in the inflow of addicts against ever more dangerous supply.

What if the correct liberal position was actually "free pain pills for anyone that needs them, with compassion for all users", and what we think of as "liberal" policies even in SF are actually appeasement of a puritanical system?

That would make the libertarian position "you can't be giving out free pills with government money, make them buy them when they need them like the rest of us" and the world would return to order.

The right-wing position would remain "the government should use force to prevent people from doing immoral things".

As for the addicts, they will now be using a safer route of administration with controlled dosing and not be economically hindered.

As for the cartels, they will no longer find money in the drug trade.

For a while I thought I understood the dynamics of how things got the way they are, but it seems like everyone else has forgotten, so maybe we could try a new approach soon.

I spend a good portion of my time in community service, mostly in areas where drug abuse is rampant. During this time, I've talked with a fair number of addicts, and I'd say over 90% of them stem from either being introduced to drugs by a friend (peer pressure) or following after the drug addiction of an existing family member. Generally, within a year or two, they were on the streets resorting to crime to fuel their addiction.

Now, my experience is not representative as a whole, but it's generally what fuels my thoughts on this subject. If this is the story I hear quite frequently, why would I want these drugs to be introduced legally into people's lives? That's why I've always had issues understanding people pushing for legalization.

I understand how it can come across as puritanical ("I know what's best for you"). However, when all data suggests that engaging in drug use almost universally results in poverty, why would we as a society want to unleash such a thing upon people? It's for the betterment of humanity that life-ruining drugs are illegal.

At least those are my thoughts.

I have never heard of someone on the streets directly for marijuana usage. Opioids are actually cheap to produce, expensive to buy.

The poverty is quite related to the costs, and I think that's where I challenge your take.

That said, the most compelling take i have heard in the first half of 'In the realm of hungry ghosts' by Gabor Mate`. He points out that we need to consider the fact that some people may be much more predisposed to opioid addiction, by either default wiring or by life experiences. In this case, is the freedom of the majority of folks to take what they want worth the risk to those who would suffer from it? I don't believe he supports the criminalization of the drug use, but he makes a good point that we need to think about this reality of different-risks.

The reason why I come back to legalization is that I cannot tolerate the fact we have such massive funding sources for the cartels (and police) in the illegal trade. It is deeply compelling to me that we would be better off without funding that society destroying business.

> I have never heard of someone on the streets directly for marijuana usage

Yeah, I'm certainly not talking about this class of drugs. The context of the discussion is opioids, and I'm mainly referring to the more destructive ones. I had no issue when marijuana was legalized in my state.

> The poverty is quite related to the costs, and I think that's where I challenge your take.

I'm not sure that represents the whole picture. Beyond relationships, the main thing most people I've met in this situation lost was their job. Followed by whatever housing situation they had. Sure, cost doesn't make it any easier on them, but from my perspective, it was the drug abuse and the resulting cycles of high/low that led to their financial demise.

> The reason why I come back to legalization is that I cannot tolerate the fact we have such massive funding sources for the cartels (and police) in the illegal trade

Yeah, I agree, and I have the same feelings. I just can't, in good faith, support legalization with all I've seen. It's a complicated problem.

Benzos are hard to overdose and die off of. You're more likely to die from withdrawals, or yeah, mixing with alcohol. That's user error.

I have first hand experience of being addicted to benzos and drinking at the same time. I could have died. This was the Heath Ledger era, so I knew what could happen, but benzo addiction is so horrible that I didn’t care. I would go to bed some nights not knowing if I’d wake up. Fuck it. At least I could sleep.

Would that be user error, or would it be the doctor’s fault for not telling me how addictive the benzos were? I was mentally ill. He told me to take them every day. I didn’t take them excessively. I took them as prescribed. It was only after the addiction got out of control that I started drinking again. Mentally ill people make bad decisions. The doctor made no effort to ensure I was safe. He kept upping my dose.

It’s worth watching the documentary “As Prescribed”[0], which is about benzo addiction. A lot of people go through what I went through. Some don’t survive. We blame drug dealers for ODs but not psychiatrists. Why?

[0] https://youtu.be/bDPPdWsN0mk?si=ckAiPvawFVAB4xEE

I'm surprised your doctor didn't warn you about that. Growing up, I knew about benzos not from anyone taking it as prescribed, but as a recreational drug

Also the opioid epidemic actually did make benzos much harder to get. Atleast where I live, your primary doctor is very unlikely to prescribe them and instead will refer you to a psychiatrist. The people I know who were on Ambien or Atvian have been cut off.

I think the ADHD drugs are probably next. My conspiracy theory is too much of the professional class (including doctors) is using them regularly, so it's much hard to crack down on.

we are looking at it from the lens of a post Purdue media bias

include me out of your of your assumptions, please. I knew the Purdue pharma stuff was bad from the get-go, and it's not because I'm prudish about drugs or a huge believer in regulating everything to the point of paralysis. It was because the combination of high physical potential for abuse + strong economic incentives to monetize that leads to bad results. Wars have literally been fought over this in the past.

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

You might be familiar with Adam Smith's famous economic example of the pin factory. Here's Rudyard Kipling's description of an opium factory operated by the British colonial power in 19th century India, an equally brilliant illustration of commercial logic but applied in service of perverse incentives.

https://ota.bodleian.ox.ac.uk/repository/xmlui/handle/20.500...

When I was in my mid to late 20s I was at a consulting firm and later in government directly. I wasn’t assigned to anything particularly objectionable or anything, but I’ve looked back on it a lot and it’s heavily influenced how I operate in the tech industry now, 20 years later. In government and in consulting I saw a lot of misaligned incentives that led to empire building, duplicative efforts, and treatment of individuals that I didn’t really find to be effective. And today, I’m really good at spotting that and stopping it quickly, because I think much of that was not the best way to operate. But I didn’t immediately get into it and realize it wasn’t how I would run things - and experiencing being part of the machine for a bit first taught me lessons that I would not have learned as an outside observer.

If you made the same assumptions about me based on what I did in my 20s, you’d actually be assuming the direct opposite of what I believe in and how I work today. We’re all shaped by our experiences, but that shaping doesn’t always mean we grow into the behaviors that we experienced during our formative early career. Maybe this guy looks on that experience and knows exactly what he doesn’t want to see happen.

I’d say it goes back considerably further than the 1970s.

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

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

I’m still struck by how deeply immoral it is to start a war and say “You WILL allow us to sell you opium!”

I hate regulatory capture as much as anyone, but...

Others have talked about the question of innocence but I think your comment illustrates not getting the dynamic of regulatory capture. The situation of regulatory capture is about there being "revolving door" between industry and regulators, so that the regulators use same criteria as companies for regulatory decisions. This dynamic results in broad regulatory capture regardless of the individual bad deeds.

Only a complete moron wouldn't know about the addictive potential of opiates in 2007-2015

Seeing that comment at -1 makes me chuckle. Imagine not knowing opiates are addictive anytime past the 1800s

> scientific literature he would've had access to at the time would not have suggested they were especially harmful.

Only if you pretend to be blind. McKinsey knew exactly the effects of opioids which is why they were condemned as well

The banality of evil. He was just doing his job.

Opioids are not a particularly harmful to most people. The harm is in the addiction not the chemical. Opioids are useful for treating acute pain, such as after surgery. They are less useful for chronic pain but if the doctor and patient are able to responsibly manage dose escalation as tolerance develops they are also useful for chronic pain.

Yeah he was just an innocent marketing consultant:

“ In a March 2008 PowerPoint presentation, Tsai outlined a marketing strategy for the drug that included guidance on targeting “specific physician segments to grow high-prescriber group (i.e., physicians more sensitive to patient needs)” and an idea to introduce “coupons” for the drug as part of a pilot program.”

Are you trying to say this quote is painting him as not innocent? That really doesn't seem so sinister. Sinister would be buying billboard space in west virginia like something out of newport cigarettes playbook.

Yes, it is fairly obvious that he wasn't innocent based on that quote.

The high-prescribers were people operating out of strip malls, often with unclear credentials, and whose main clientele were opioid addicts. Many of these people (I am choosing not to use the word doctors) ended up in prison...consultants who were advising them, not so much.

There are a large number of people who could do this job, it is reasonable to ask whether the person you want doing this job is someone who, at best, was unaware that these people were breaking the law. And, to be clear, he was Partner of their Healthcare practice whilst this was going on...he wasn't just making Powerpoints.

The revolving door between consultancies and government must continue. No-one is more skilled than running government than lawyers and consultants who have lots of experience in...advising other people how to run things.

> The high-prescribers were people operating out of strip malls, often with unclear credentials, and whose main clientele were opioid addicts.

I think this is an assumption. May be right but for all doctors who “listen to patients needs” to be pill pushers deserving prison time seems a little too inconvenient. At the end of the day he is asked to optimize a business in a consultancy not to play to his moral principles and get replaced on the project for someone who will optimize it for business needs. At least he is potentially seeing all the inputs with these relationships and a side of the healthcare industry a lot of people wouldn’t have any experience with without holding these positions themselves to be able to be in these rooms where these conversations are held.

"Are you trying to say this quote is painting him as not innocent?"

Correct. Instead of targeting just people that medically need it, this quote paints him as specifically advertising to and targeting the addicted patients of less-than-reputable doctors who would over-proscribe this, get the patient addicted, and thus have them in the loop of buying more painkillers.

If you buy the assumption that “listens to patiens needs” = pill pusher maybe. I don’t think that is so black and white. The coupons also make sense to get ahead of competitors in a world of copays for most prescriptions.

I don't live there, so I wouldn't know, but did they run out of other candidates that haven't shilled tramadol?

To be frank, the issue is that our society is not more damning of people involved in the low-level actioning of great injustices.

A far bigger issue with our society is our willingness to brand someone forever based on what they did decades prior—we (as a society) pay lip service to the idea that people change, but we don't truly believe it.

It's the same punitive impulse that causes the permanent second-class citizenship bestowed upon anyone who finishes a prison term.

Generally, that problem is separate. The impact of little Eichmanns everywhere is greater than the loss of productivity from people convicted of crimes who can’t get a job later imo.

Our society is very forgiving if you propagate “faceless” evil. It’s unforgiving if there’s a human face to it. Part of this ties into the power of monetary capital over social capital.

> Our society is very forgiving if you propagate “faceless” evil. It’s unforgiving if there’s a human face to it.

How does this track with your assertion that "the issue is that our society is not more damning of people involved in the low-level actioning of great injustices"?

Isn't your impulse to damn now that there's a low-level face to the faceless evil the exact same impulse as the one people have to condemn a low-level drug runner for the rest of their life?

> Isn't your impulse to damn now that there's a low-level face to the faceless evil the exact same impulse as the one people have to condemn a low-level drug runner for the rest of their life?

First, there’s a disconnect here in my opinion: the low level drug offender deals with headwinds entering professional society writ large, not specific industry. This is much more consequential and, in my opinion, unfair. Being a drug runner doesn’t imply you would be a bad sales rep, but that’s how our society operates. If we were considering that low-level drug dealers face a specific impediment to becoming public health officials, I would argue that’s at least more sensible.

Both the drug dealer and this guy have probably caused outsized social health impacts (and, don’t forget, deaths) through their actions. That invites scrutiny.

Second, I have no delusions. Yes, I think this guy should be heavily scrutinized. Perhaps it’s not exactly fair that your actions follow you for your life, but if you have a hand in one of the worst public health crises of recent years, that’s damning if you want to run a public health office. Civil servants necessarily should be held to a higher standard. All that said, I doubt he will be disqualified from the office.

There’s a wider question: what are we prioritizing? Individual fairness or public health (more generally, public good)? I think from that frame (and a similar framing in many industries) more people should be made an example of if they have worked against the interests of an office they seek. Airline lobbyists should not be heads of transportation (and heads should be legally disallowed from entering lobbying for a period after office), food magnates who seek to dilute and adulterate their products as much as legally allowable should not run the USDA, the parallels are numerous. These people hold the wrong incentive (making money) highest. By making examples of these people and disqualifying them, you right the scale to some degree and influence the actions of others.

I don’t have the time at the moment to make a wider argument of systems, but if you look at China vs. the US…

I feel the gap to be crossed here is whether the low-level employee demonstrably took pro-active steps in their subsequent career to either

  1. steer far clear of, 
  (incl. steering clear of *the fruits of*), or

  2. mitigate/neutralize/counter the effects of...

...the gestalt whose function they were supporting prior.

But I do feel we as society participants should not be bkinkered from recognizing social-scale pathologies in the atomic units that form our society. Those atomic units are individuals - their decisions, actions, and yes their career-paths.

No it's not. The issue with our society is allowing the people who built the system and created the incentives that caused it to get off without jail time.

That’s worked really well in other areas of criminal justice. /s

Yes, that's why I wish for nurses to get murdered too, not just health care CEOs

"I was just doing my job."