Who's at Fault for the Opioid Epidemic?

[DooDiligence]

I recently had double inguinal hernia surgery (done in 2 stages, 3 weeks apart.)

 

I was prescribed x40 Oxycodones after each procedure.

 

The 1st procedure, I took all but about 8 or 10 of the pills which I found out was unnecessary.

For the 2nd surgery, I quit taking the pills on day 3 following the procedure & started taking Motrin.

 

This was perfectly adequate to control the pain (nothing but time would take care of the discomfort.)

 

I had a follow up exam recently & asked the surgeon why they prescribe x40 pills & got what I thought was a bullshit answer.

(I totally trust this guy with regards to the procedures performed but believe that he & others are a bit aggressive with the prescription pad.)

 

I still have a full bottle from the 2nd prescription & a few pills from the 1st one.

(gotta Google how to dispose of these properly.)

 

Here's a quick article on all the finger pointing going on.

 

http://www.bradenton.com/news/local/article191485574.html

 

and another one re: the Cherokee nation filing suit.

 

http://www.tahlequahdailypress.com/news/local_news/pharm-companies-seek-to-thwart-cn-opioid-suit/article_2531e7fe-47c4-5c7c-82b2-66f4e7ebd60d.html

 

I just can't help but think that everyone is pointing in the wrong direction.

[Jurgis]

I still have a full bottle from the 2nd prescription & a few pills from the 1st one.

(gotta Google how to dispose of these properly.)

 

What kind of investor are you? Obviously, sell them to the highest bidder on a shady corner (or Craiglist).

 

You should have asked your doc for another prescription or two, you could have funded your BRK purchasing habit from the proceeds.

 

 

 

8)

[DooDiligence]

I still have a full bottle from the 2nd prescription & a few pills from the 1st one.

(gotta Google how to dispose of these properly.)

 

What kind of investor are you? Obviously, sell them to the highest bidder on a shady corner (or Craiglist).

 

You should have asked your doc for another prescription or two, you could have funded your BRK purchasing habit from the proceeds.

 

 

 

8)

 

Cheap bastard that I am, I’ll have to destroy value in this case.

 

I love your characterization of me as a “BRK addict”  ;D & I’ll continue funding this habit from legit cash.

 

I’m trying to simplify my studies since I’m devoting more time to other endeavors.

[rkbabang]

I still have a full bottle from the 2nd prescription & a few pills from the 1st one.

(gotta Google how to dispose of these properly.)

 

What kind of investor are you? Obviously, sell them to the highest bidder on a shady corner (or Craiglist).

 

You should have asked your doc for another prescription or two, you could have funded your BRK purchasing habit from the proceeds.

 

 

 

8)

 

Craigslist?  This is what bitcoin and the dark net was made for.  Download TOR and get started.

[Jurgis]

Ez way to invest into bitcoin.  8)

[Spekulatius]

Had the same surgery (Hernia) this fall and used a grand total of 2 tablets of the batch of opioids (forgot the brand) my doctor prescribed for me. I managed my pain (which was pretty strong at moments, but most of the time fairly bearable ) with Ibuprofen and went to work a week afterwards.

 

I recall to getting fairly decent batches of Vicadine (with refills) for surgeries a few years back, where I barely used more than a few. A somewhat junky acquaintance told me back then that they would go for $5/ each on the Black market (I politely declined).

 

Comparing this to Europe, it seems that the threshold for pain is much lower in the US than over there. I Even remember dentist drilling teeth without any pain treatment. He was from Russia and told me it only hurt if you think too much about what he is doing.He was right, but it is difficult to think about something else, when you are lying on a chair with a drill in your mouth going all in.

 

As to OP’s initial post, I am not quite sure what he wants to say. It’s certainly not the distributors fault, that opiate drugs make their way in circulation, maybe the doctors for prescribing too much too freely, folks for taking them too much, folks for reselling their overage.... I don’t know, the drug does no seem to do all that much other than dull your mind and removing chronic pain. They did not even work that well for the sharp pain experienced sometimes when moving around after my surgery, which was quite unpleasant but generally only lasted a for a few moments.

[Guest cherzeca]

for everyone but the aged, there should be a fulfillment process where an MD scripts a few days, then if you still have pain, you text pharmacy (using some passcode) for a few more days to be delivered.  when my daughter had her 4 wisdom teeth out 17 years ago, i stopped giving them to her after 3 days.  she cussed me out for a few days. now she is in healthcare and tells me she is grateful.

 

having said that, i know folks older than 90 who take a tramadol or three a day and if they become dependent, who is to find fault?

[tede02]

Do the world a favor get rid of them responsibly.

 

My brother died of an opioid overdose on Dec 23, 2015.  I lay the greatest blame with the pharmaceutical companies who committed fraud by first persuading health care providers that no one should ever have to endure pain in this day and age because of the “miraculous drugs we've created.”  Then (this is the fraud) the companies falsely claimed that the drugs they were manufacturing were not addictive.  Now these assholes, like Purdue Pharma, are rightfully being sued by dozens of states. I would love to see executives go to jail but I doubt it will happen.

 

I recently read that from 1999 to 2015, 183,000 Americans died from prescription opioids. That is over three times the number of people the US lost during the entire Vietnam War. 

 

The rate of opioid deaths is now over 30,000 per year. Imagine the outrage if the US were involved in a foreign conflict resulting in these kind of casualties?

 

There is plenty of blame to go around. 60 Minutes most recently profiled how the drug distributors, led by one of the biggest publicly traded companies in the US, McKesson Corp, completely neglected their responsibility to monitor and crackdown on pharmacies and other buyers who clearly were trafficking opioids. There were stories of small-town pharmacies buying enough opioids to supply every man, woman and child in the town for a year or some crazy thing.  The distributors knew the sales were illicit and not only did they do nothing about it, they fought the DEA when they (McKesson) were questioned about not reporting suspicious orders. 

 

https://www.cbsnews.com/news/whistleblowers-dea-attorneys-went-easy-on-mckesson-the-countrys-largest-drug-distributor/

 

It just pisses me off so much because this entire crisis is all about money. None of these executives or board members gives a damn about the thousands and thousands of people who have died and families that have been destroyed. The best thing that could happen to most of these executives and board members is to have a son, daughter or grandchild die from an overdose. No one deserves it more. 

 

[scorpioncapital]

There's a company PCRX whose main product is a new opiod-free post-surgery painkiller.

 

[Guest cherzeca]

Do the world a favor get rid of them responsibly.

 

My brother died of an opioid overdose on Dec 23, 2015.  I lay the greatest blame with the pharmaceutical companies who committed fraud by first persuading health care providers that no one should ever have to endure pain in this day and age because of the “miraculous drugs we've created.”  Then (this is the fraud) the companies falsely claimed that the drugs they were manufacturing were not addictive.  Now these assholes, like Purdue Pharma, are rightfully being sued by dozens of states. I would love to see executives go to jail but I doubt it will happen.

 

I recently read that from 1999 to 2015, 183,000 Americans died from prescription opioids. That is over three times the number of people the US lost during the entire Vietnam War. 

 

The rate of opioid deaths is now over 30,000 per year. Imagine the outrage if the US were involved in a foreign conflict resulting in these kind of casualties?

 

There is plenty of blame to go around. 60 Minutes most recently profiled how the drug distributors, led by one of the biggest publicly traded companies in the US, McKesson Corp, completely neglected their responsibility to monitor and crackdown on pharmacies and other buyers who clearly were trafficking opioids. There were stories of small-town pharmacies buying enough opioids to supply every man, woman and child in the town for a year or some crazy thing.  The distributors knew the sales were illicit and not only did they do nothing about it, they fought the DEA when they (McKesson) were questioned about not reporting suspicious orders. 

 

https://www.cbsnews.com/news/whistleblowers-dea-attorneys-went-easy-on-mckesson-the-countrys-largest-drug-distributor/

 

It just pisses me off so much because this entire crisis is all about money. None of these executives or board members gives a damn about the thousands and thousands of people who have died and families that have been destroyed. The best thing that could happen to most of these executives and board members is to have a son, daughter or grandchild die from an overdose. No one deserves it more.

 

sorry to read about your brother tede.

 

the sackler family (purdue pharma shareholders) gets lionized because of their charitable donations, but this is certainly blood money. 

[DooDiligence]

tede02 I am so sorry that you lost your Bro to this.

 

---

 

Personally, I believe that the prescribing physicians should be the gatekeepers here.

 

They have eyes on the patients & should be fully aware of their physical & emotional state (especially when pain management is necessary.)

 

We've become spoiled by not having to endure pain which was commonplace in the recent past.

 

---

 

After the 1st part of my hernia procedure, I was very paranoid about pain & simply didn't want to give it any chance of occurring but I learned pretty quick that it is easily manageable with OTC medications.

 

I had a failed root canal earlier this year & the endodontist told me that re-working the canal to remove an obstruction would be painless since the nerve was already gone.

 

I believed him & went without numbing & the only discomfort I experienced was from keeping my mouth wide open for 30 minutes or so & there was no need for even an aspirin afterwards.

 

He couldn't clear & re-seal the canal so I had to have the tooth extracted which DID require numbing but the pain medication was only needed for the day after the extraction & after that I was fine.

 

---

 

Maybe it's quicker/easier to go after the big guys than it is to gather up class action suits going after individual physicians?

 

How much truth is there in allegations against ABC, CAH & MCK?

 

Aren't the payers supposed to intervene here if for no other reason than cost containment?

 

If we start seeing lawyers TV ads searching for clients who want to sue prescribing physicians...?

 

Maybe we should start whacking our kids more often so they'll become a bit more tolerant to pain?

[LC]

There is an incentive mismatch.

 

Drug companies are incentivized to sell as much as possible. To do so they suggest/pay/coerce doctors to over-subscribe.

 

But this is a product where from the user's POV, you would want to use as little as possible.

 

Perhaps if there was a buyback program where you are reimbursed if you are prescribed 50 pills but only use 5.

[DooDiligence]

There is an incentive mismatch.

 

Drug companies are incentivized to sell as much as possible. To do so they suggest/pay/coerce doctors to over-subscribe.

 

But this is a product where from the user's POV, you would want to use as little as possible.

 

Perhaps if there was a buyback program where you are reimbursed if you are prescribed 50 pills but only use 5.

 

That's a fantastic idea!

[orthopa]

As a prescriber of these medications if you knew they were too strong the first time why did you pick them up in the first place? You could always ask the surgeon beforehand if you wanted some not a strong right? Why didnt you?

 

People dont show up with their "pain tolerance" ability tatooed on their forehead. People also process narcotics very differently and build a tolerance. How am I suppossed to know this beforehand if i give you pain med.

 

Secondly what the best way to figure out how much pain someone is having? Only way I know is ask them. Is everyones 5/10 pain the same? What about 10/10? People lie too.

 

People often forget that they also have a hand in their care in your example you could have very well not gotten the medication right? What if you have a high deductible insurance and the 3 days worth of pills wasnt enough and you got wacked with another cash payment? What if you ran out of pills over the weekend, could'nt control you pain, now you have an out of pocked visit to the ER?

 

You probably would rather take his bullshit answer as you put then have a $1000 plus ER bill and multiple follow up out of pocket payments for more small scripts.

 

What people who blame physicians for the opioid epidemic forget is that these people put the pills in their own mouth. I don't remember every seeing a physician jamming narcotics down someones throat.  Secondly what do you do if someone comes in your office says they have severe pain and cant live with it? Tell them they are a liar and leave? 

 

Mind suggesting to the physician community what med you would recommend if OTC meds dont work and the pt is taking an SSRI and as a result cant have ultram?

 

Medicine is difficult and there is nothing more difficult in judging someones pain. Its impossible and thus often people over prescribe at times.

 

Secondly the vast majority of narcotics that are heavily abused are generic and physicians are not incentivized at all to prescribe them. The non generic ones that they could be persuaded to prescribe almost always have anti abuse formulations which would fly in the face of a mis aligned incentive by drug companies.

[matts]

As a prescriber of these medications if you knew they were too strong the first time why did you pick them up in the first place? You could always ask the surgeon beforehand if you wanted some not a strong right? Why didnt you?

 

People dont show up with their "pain tolerance" ability tatooed on their forehead. People also process narcotics very differently and build a tolerance. How am I suppossed to know this beforehand if i give you pain med.

 

Secondly what the best way to figure out how much pain someone is having? Only way I know is ask them. Is everyones 5/10 pain the same? What about 10/10? People lie too.

 

People often forget that they also have a hand in their care in your example you could have very well not gotten the medication right? What if you have a high deductible insurance and the 3 days worth of pills wasnt enough and you got wacked with another cash payment? What if you ran out of pills over the weekend, could'nt control you pain, now you have an out of pocked visit to the ER?

 

You probably would rather take his bullshit answer as you put then have a $1000 plus ER bill and multiple follow up out of pocket payments for more small scripts.

 

What people who blame physicians for the opioid epidemic forget is that these people put the pills in their own mouth. I don't remember every seeing a physician jamming narcotics down someones throat.  Secondly what do you do if someone comes in your office says they have severe pain and cant live with it? Tell them they are a liar and leave? 

 

Mind suggesting to the physician community what med you would recommend if OTC meds dont work and the pt is taking an SSRI and as a result cant have ultram?

 

Medicine is difficult and there is nothing more difficult in judging someones pain. Its impossible and thus often people over prescribe at times.

 

Secondly the vast majority of narcotics that are heavily abused are generic and physicians are not incentivized at all to prescribe them. The non generic ones that they could be persuaded to prescribe almost always have anti abuse formulations which would fly in the face of a mis aligned incentive by drug companies.

 

thank you for your excellent rebuttal. 

[LC]

Agreed - I was not aware of the generic vs. brand name distinction!

[Cigarbutt]

I submit that many fingers are needed if looking for the "fault".

The excess opioid prescribed/consumed is based on inadequate supply/demand issues.

 

At some point, it was felt that acute and chronic pain were under-treated.

The pendulum does swing.

 

The first step is to recognize that there is a problem.

Pain is not only a symptom or a sensation, it is an experience.

Pain can be relieved but cannot be eliminated.

Simple but not easy.

But the downward spiral may start at the pharmacy.

 

 

 

[rb]

I certainly don't have the answer to the question but let me see if I can frame the issue here a bit.

 

Let's take x as some date when the opioid epidemic began. There were surgeries performed before x. There were opioids before x - some of the most popular (codeine, morfine, oxycodone, hydrocodone, fentanyl) have been around for a really, really long time. So what happened between x and now?

 

Furthermore, is this drug crisis or is it an overdose crisis. There's always been a segment of people that use/abuse drugs. Could it be that opioids are the popular drug of the day and they're just easier to overdose than the drugs of yesterday? Or maybe they don't even know what they're taking. They think they're taking something but instead they're taking lots of opioids because their illicit supplier changed the formulation to include fentanyl resulting in an opioid overdose.

 

My guess is that the second part has a lot to do with what we're seeing. The reason for this is that there has been a huge spike in ODs quite recently (2013) and quite suddenly especially related to fentanyl. This tends to point to a distinct and significant event at that specific time and I don't think it was cause by legitimate people/business behaving badly.

[Guest Cameron]

I certainly don't have the answer to the question but let me see if I can frame the issue here a bit.

 

Let's take x as some date when the opioid epidemic began. There were surgeries performed before x. There were opioids before x - some of the most popular (codeine, morfine, oxycodone, hydrocodone, fentanyl) have been around for a really, really long time. So what happened between x and now?

 

Furthermore, is this drug crisis or is it an overdose crisis. There's always been a segment of people that use/abuse drugs. Could it be that opioids are the popular drug of the day and they're just easier to overdose than the drugs of yesterday? Or maybe they don't even know what they're taking. They think they're taking something but instead they're taking lots of opioids because their illicit supplier changed the formulation to include fentanyl resulting in an opioid overdose.

 

My guess is that the second part has a lot to do with what we're seeing. The reason for this is that there has been a huge spike in ODs quite recently (2013) and quite suddenly especially related to fentanyl. This tends to point to a distinct and significant event at that specific time and I don't think it was cause by legitimate people/business behaving badly.

 

What happened between then and now is that the drugs were rediscovered, rebranded which allowed for the mass sales starting in the 1970s. In the US we had an opioid crisis in the inner cities and Vietnam vets during the 70s and no one cared (Heroin and codeine in this case). Right now codeine and morfine are really null and void. Its Oxycodone in the form of OxyContin and Percocet as well as hydrocodone in the form of Vicodin. Purdue created Oxy in 1995 and then created instructional videos claiming only 1% of people get addicted. I have a hard time believing they were clueless to what they were creating as you said opioids have been around quite a long time and its not like we didn't have a long history of opioid crisis's to look back at so not giving them any blame sort of echo's the same sentiment that Jeff Skilling had in HBS when he was asked what should a CEO do if you had a product that might be but wasn't definitively harmful to customers and he said his job as a businessman is to be a profit center, it's the governments job to step in if a product is dangerous. I'd rather not have people running drug companies thinking this way for your or my safety.

 

110 million Americans have some type of chronic pain, supply and demand and as such they were over prescribed in the 1990s. Painkiller prescriptions quadrupled from 1991 to today. Also to your inquiry about why more OD's are happening today. These pills have become more and more potent every year. In 2002 something like one and six users were taking a pill more potent than morphine, today its 1 in 3.

 

Heroin comes into play because in 2007-2009 the government sort of had enough and cracked down on the prescribers and drug companies which killed the supply so people turned to heroin. 

[Cigarbutt]

For those interested, a few more data points:

https://www.bloomberg.com/news/articles/2017-11-28/how-opioids-started-killing-americans

https://www.vox.com/science-and-health/2017/8/3/16079772/opioid-epidemic-drug-overdoses

 

Tough issue with moral overtones.

Is opioid addiction a medical condition or a case of moral failure?

Your answer may be influenced by the personal proximity to a real world example.

 

Controversies aside, the ingredients for the tide to start receding are there and the changing landscape in healthcare (data, network, AI?) may contribute.

 

For instance, in the workers compensation insurance programs, simple measures (patient and MD "education", organized follow-ups in a network and suggestions for alternatives) produce results. In these cases, there is an incentive to reduce opiates use to reduce cost. It always helps when noble incentives are encouraged by cash savings. :)

 

 

[DTEJD1997]

Hey all:

 

Like with so many things in life...there are MANY causes for the heroine/opoid problem.

 

Many different factors/people are at fault.

 

One factor is certainly depression at one's lot in life.

 

Up until the 90's...there were certainly jobs in the Midwest.  There still are, but they are harder to come by though.  Somebody may have been making $50k a year, had a good job, but they hurt their back.  The factory closes.  They lose their job.  They still have pain.  Through a series of unfortunate events/poor choices, they are broke, unemployed, can't find good work and eventually wind up on heroin.  Some things they could control/influence, some they couldn't.

 

[rkbabang]

Can you imagine having debilitating chronic pain and not being able to find a doctor willing to help you?  Because that is the other end of the spectrum.  I say that it isn’t right to put the responsibility of reading minds on doctors with possible loss of license or even jail if they get it wrong. Remove the laws, sell this stuff over the counter and put the responsibility where it belongs... on the people who decide to take them.

[UNF2007]

This is a really tough question to answer. I think part of it is there was a push in medical schools and nursing schools around the early 2000's driven by the Joint Commission, who accredits hospitals, to call pain a 5th vital sign. This was a big national push at the time. People felt pain was under treated and doctors were then somehow liable if a patient had pain and felt it wasn't being treated adequately. That opened the door in ER's with something called Press-Ganey scores, that are from patient satisfaction surveys. Part of that was a question to the patient if their pain was adequately treated. ER physicians compensation depends in part on how they score on those surveys, in many places. Also people who come in wanting narcotics and leave with nothing are probably not going to leave a good review. So in effect your incentive in the situation is to prescribe narcotics.

 

Nurses were also indoctrinated into this pain is a 5th vital sign. They drive prescribing more then people think, on the inpatient side. They are the ones that are monitoring the patient and calling the doctor for more pain meds if they think its needed. The mindset that patients should be pain free or nearly so, drove more pain meds to be given.

 

For a long time narcotic abuse of prescription was not in the lexicon for doctors. Anecdotally I did a surgical oncology rotation about 3 yrs ago at a major cancer research hospital. We were basically working with people in clinical trials, with end stage cancer. Many of them lived in other parts of the country, so we were instructed to prescribe them enough pain meds to last 3 months between visits. If someone is using 5mg of oxycodone every 4 hrs, that works out to 100's of pills. I refused to do it, and as a resident that is not something that is easy to do since your whole livelihood is dependent on graduation. But they just found someone else to write it. I even asked the person who was writing it, if they had any idea of the market value if the patient decided to sell it, I got very weird looks.

 

Also of interest is that for a period about 80% of all the oxycodone prescribed in the country was being prescribed in Florida. There were many doctors, many of them foriegn medical graduates working as family practitioners who were basically running pill mills.  The doctor would charge 200-300 for a physical exam, document back pain or some nonsense and prescribe a predetermined amount of narcotic. Which the person would fill and turn around and sell, and a portion of the narcotic would be given back to the doctor , to use or sell.

 

It's interesting to me to hear how little narcotic people can actually get by with after surgery. I have altered my own practice, and after hernia repair usually only give out 10-15 percocets or equivalent. I'll give the person my contact and they can call if they need more, almost no one does. There is a big push now for us to come up with standardized amounts of narcotic for each procedure I'm working on it now,I think it will turn out to be way less then what people are now giving out, that is locally. Nationally something similar is in the works through the ACS.

 

 

[EliG]

It's interesting to me to hear how little narcotic people can actually get by with after surgery.

 

Anecdote:

 

A close relative had Whipple surgery a few years ago. For those who don't know, Whipple is one of the biggest surgeries a person can have on their body, not counting transplants. The surgeon removes the head of pancreas, the gallbladder, the bile duct, part of the small intestine and sometimes the bottom part of the stomach. The surgeon then reconnects the remaining organs to rebuild the digestive system. The surgery takes about 6-8 hours, sometimes longer if the complications arise. Steve Jobs had this surgery for his pancreatic cancer.

 

My relative left the hospital with two pain meds: Prescription Tylenol and Tramadol (Ultram). The surgeon gave her clear instructions: stay on Tylenol as much as possible; only take Tramadol when the pain is absolutely unbearable. That's exactly what my relative did: she took only a few Tramadol pills in the first couple of days. The rest of the bottle wasn't needed.

 

Again, to put things in perspective, this is one of the biggest surgeries a person can have. Prescription Tylenol was effective enough to manage the pain.

[rukawa]

My understanding is that for heroin and all opioids its pretty difficult to have a fatality without also using alcohol or some other drug.

 

People can survive without overdosing for years. The problem is nearly always mixing drugs.