Although prescription pain medication is commonly blamed for the “opioid epidemic,” such drugs play a small and shrinking role in deaths involving this category of psychoactive substances. A recent study of opioid-related deaths in Massachusetts underlines this crucial point, finding that prescription analgesics were detected without heroin or fentanyl in less than 17 percent of the cases. Furthermore, decedents had prescriptions for the opioids that showed up in toxicology tests just 1.3 percent of the time.
But it’s easier to shake down drug companies than to get at the suppliers of fentanyl. Much, much easier.
The claim is not that they cause death but they start the addiction
I never comment on blogs and I came all the way over here out of the comfort of my RSS reader to say the same thing. Seems a glaring misstep in logic here.
The trouble is, alot of use of all kinds of these chemicals is recreational, and often starts that way.
You just can’t trust people to tell accurate stories about their drug use histories, because they have motivations to fabricate tales which put them in the best possible light, with no good way to tell if they’re lying or not (cf. stated vs. revealed preferences). That’s especially true because most use is in secret, and by the time someone is telling someone else a story about it, it’s because they got caught or hit rock bottom or something, and in such circumstances the temptation to parrot what one perceives to be the socially acceptable excuse is irresistible.
We can imagine a spectrum of narratives ranging from “pure innocent victim” (PIV) to “full personal culpability” (FPC).
The PIV narrative is the one in which some upstanding middle class taxpayer has some medical issue or gets in some accident not caused by their own negligence, needs some strong painkillers, gets ‘hooked’ and ‘The System’ (criminal justice + health care + etc.) lets this PIV down by cutting them off and giving them an impossible choice between excruciating pain (either of their injury or of withdrawal symptoms) on the one hand, or consorting with the criminal element and breaking the law to acquire contraband to feed their habit.
A lot of people like to tell this story about their own path, especially when joining a class-action lawsuit. That doesn’t mean it’s true. If you have ever dealt with addicts, or perhaps were married to someone who does, you recognize the pattern of “Typical Addict Bullshit” stories. Though, to be fair, these are sometimes hard to tell apart from psedoaddiction, and there’s no substitute for good judgment and discernment.
The Full Personal Culpability narrative is that the FPC got addicted to these substances the same way lots of people always got addicted to opium, heroic, crack, etc. without any push or shove or nudge by The System. That is, they started off more-or-less normal, wanted to have some fun, knew what they were doing was illegal and risky the whole time, thought it was harmless and that they could handle it, but thought wrong.
The trouble is, people who are trying to tell stories with particular bad guys, e.g., Big Pharma or Big Government or Degenerate Culture are motivated to portray the mechanisms of the overall phenomenon as being on the place in the PIV-TPC spectrum that best fits the story and suits their broader agenda.
But the reality is that there are probably lots of people with a diverse array of stories all across the spectrum, which makes pointing to any one Bad Guy misguided or settling on any particular approach or policy futile and counterproductive.
Of course, only one set of Bad Guys has the kind of deep pockets and huge bank accounts worth shaking down. So that narrative has its own source of funding, as it were, and riding the eave of anti-corporate sentiment in general, is thus likely to win out. Magna est veritas pecunias et prevalebit
The human body was not made to deal well with these chemicals, and classically liberal human institutions were not made to deal well with social problems resulting from those chemicals being fairly cheap and easy to obtain.
Another story is one in which FPC.JoeBloe with drug coverage asks FPC.Dr.Rx for as much FPC?PIV?Purdue.Pharma OxyContin as he can get away with and sells his prescription to FPC.Corner.Dealer who resells to PIV.Addicted.Schmuck.
This story would be confirmed with a significant amount of oxycodone (crushed OxyContin) being responsible for PIV deaths and Jacob Sullum’s article/data doesn’t contradict it because FPC.Corner.Dealer cuts the prescription drugs before reselling.
Purdue Pharma could be partially culpable if it 1. mislabeled 10-hour delivery as 12-hour which significantly increases the probability of PIV addiction, 2. knowingly misreporting addiction rates, 3. knew that OxyContin was the main source of black market oxycodone yet 3a. increased sales quotas, and/or 3b. delayed introduction of crush-proof OxyNEO which would significantly reduce sales.
Mike Shupp argues that its hard to set an appropriate penalty for Purdue Pharma if this complicated story is true; transaction costs etc.
If the claim if that they start the addiction instead of they may start the addiction that may lead to overdosing, the claim is over-broad. Way more people have been prescribed opiods than have become addicted to fentanyl, let alone addicted to the point of overdosing. But I am sure that mis-prescribing opiods — in the wrong amount, to the wrong patient, at the wrong time — will be found to be for likely to be causal in a bigger number of cases.
So I would still agree with the shake the drug companies statement, and would suggest that doctors who can be shown to have mis-prescribed should be brought to justice — which is more difficult to do than just shaking.
I find the Jacob Sullum articles at Reason frustrating. Rather than clarifying the mechanisms underlying the opioid problem, the articles tend to reframe the data to support the legalization of opioid and/or to blame bad government policy. The data referenced is important but it is incorrect to infer that oral opioids do not represent a significant contribution to the overall deaths. The data itself is deficient as it can’t distinguish between oral and injected opioids.
The only inference is that the majority of deaths are due to mixed ingredient black market products. The key takeaway is that the illegal opioid market has a serious “labeling” problem in terms of ingredients and indications that directly leads to overdoses.
The short term issue is getting the correct dose for the advertised product. The long term issue is the misuse of opioids that leads to addiction.
So I see a TON of fraud pharmacies with 99.9% opioid/fraud claims.
I see a TON of doctors prescribing obviously fraudulent number of opioid RXs (podiatrists seem to be the worst).
And I see that overall prescription counts per capita are astronomically high, which means it can’t just be problem of an anecdote or a few bad apples. We all agree that there shouldn’t be more opioid prescriptions than there are people in West Virginia, right.
From all this I conclude that a lot of bad is being done in the system. Based on investigations of Purdue it seems they turned a blind eye to and/or actively funded and covered up for the above pharmacies/doctors, which was illegal. It seems they did all this to juice sales to a level anyone with common sense would see couldn’t be possible if they were only being used for legitimate medical use.
Am I missing something? Why wouldn’t we want to punish these people for blatantly breaking the law and blatantly trying to harm others for profit.
I completely agree with article is very confusing and uses studies dating back to 2007 before the epidemic happened as evidence.
Honestly, I don’t like the legal shakedowns on Purdue.
However, if libertarians are going to get anywhere politically, they have to honest about private company choices. And Purdue deserves every press it is getting right now. This is a classic example why a lot people don’t private companies.
It is completely clear Purdue knew the dangers of their prescriptions and did not care for the dangers. Purdue knows prescription drugs and they knew how dangerous it could be. They are believable as Day Pay Loans or Credit Card companies caring about too much consumer debt or Casinos caring gambling addiction. Or doctors were not as careful on prescriptions here in warning users. Or better teaching kids in High School prescription can be dangerous.
It is the degree of punishment and it’s fair/predictable application that are in question. Overzealous punishment is a slippery slope to what Acemoglu and Robinson call “extractive institutions”.
I’d agree that most people that take prescription opioids do not get addicted and that most opioid overdoses are from illicit consumption of opioids, but the claim is that prescription opioids are (were) a gateway to illicit consumption. There is something to this argument. As the authorities have clamped down on shady prescribers, pharmacies, and generally increased surveillance, addicts and thrill-seekers have been forced to switch to other forms of opioids (which may have caused its own problems).
The linked paper says as much:
Prescription opioids have also clearly been diverted for illicit consumption. When I see r=.65 between prescription opioid supply and opioid overdoses in WV (and very high supply), it’s pretty clear they’re linked somehow and that there is (was) a lot of shadiness (diversion is apt to be a big part of this!).
https://twitter.com/RCAFDM/status/957722638587133952
This, of course, does not imply that there isn’t a shakedown underway against the whole pharmaceutical industry or that the pendulum hasn’t swung too far today (overdose deaths, addictions, etc apt to substantially lag such channels). Nonetheless, it seems likely prescription opioids, both prescribed and diverted, have played a major role in getting us to this point.
But the fact that many people who overdose have used prescription opioids doesn’t necessarily show that they are a common gateway drug, only that at some point between the start of the drug addiction and the overdose, the typical overdose is likely to use prescription opioids, whether from a prescription or otherwise. An alternative theory is that prescription opioids are just another means of getting drugs for people who are already addicted. The fraction of people prescribed opioids that develop addictions is very small, and cracking down on prescriptions doesn’t seem to have had much if any effect on addiction levels.
If the main role of prescription opioids in addiction are as just another source of drugs for addicts who would be addicts regardless of the availability of legal opioids, as opposed to as initiators of addiction, then illegal opioids are probably far more likely to be substituted for legal opioids when the latter become inaccessible, and the accessibility of legal prescription opioids are less relevant to addiction and overdose levels than commonly thought.
Most people that take opioids for a short while do not get addicted, no, but when was given away like candy for routine procedures and, especially, for millions of people complaining of chronic pain, even a low probability of addiction (esp. measured in the short run) can to lead to very large increases in addiction and mortality. Wide swathes of the medical establishment were entirely too blasé about the risks, not to mention the risks associated with long-term opioid consumption. Above and beyond those actually prescribed opioids, the vast quantities of prescription opioids floating around communities (diversion from the supply chain and prescribed patients’ medicine cabinets) that wouldn’t otherwise avail themselves of much illicit drugs are apt to increase exposure risk in the broader community. Of course, fentanyl and heroin have also played a major role, especially in the later stages of addiction, but I find it entirely plausible that prescription opioids made this problem much worse than it would have otherwise been, and there is a fair amount of evidence to support this view.
IMO-The correct quantity of prescription opioids is clearly significantly greater than zero, even if it is likely to increase mortality on some margin. There is a balance to be struck between costs (risks) and benefits, but there wasn’t nearly enough consideration was given to these issues before and, clearly, it’s not entirely the fault of the pharmaceutical industry.
Consider two anecdotes: famous musicians Tom Petty and Prince. They both had some genuine medical pain, Tom Petty had a broken hip, they took black market pain medicine that was laced with fentanyl that killed them.
The policy solution is just make legal pain medicine easier to get, so people don’t have to resort to dangerous black market options. Also, I presume Prince and Tom Petty’s deaths would be categorized as “deaths of despair”, but clearly, they were rich popular happy people. They were probably too impatient to deal with the medical system to get some quick pain relief.
The big problem in general is how to separate good users from bad abusers. Otherwise you have a one-size-fits-all system that is bound to have a lot of Type I and/or Type II errors (i.e., good users not getting what they need, and bad abuse not being prevented.)
It’s not that we have Fear Of [all] Other’s Liberty, it’s that we have Fear Of [some] others [abusing] liberty.
If you are not going to go the one-size-fits-all route like prohibition, then you will need some kind of way to channel most use into a system that allows some authority to decide when to allow it. Right now we use doctors and pharmacists and regulations, but that system isn’t really working out all that well for us at the moment.
For instance, if you are in the hospital with severe pain, sometimes they will put you on a morphine drop with a button to increase the dose, but it only does so temporarily, by a little, with a low ceiling past which the button doesn’t do anything. And everything is recorded and watched in real-time by the medical staff, so there is no privacy – at least within the ‘trusted care group’ about your pain levels or use of medication. If you really need more, the doctor will have to see you first, decide whether you are lying or abusing, and the decision is his, not yours.
One legal problem is we are reluctant to (officially) treat people according to different rules with regards to general rights and privileges without some special excuse (e.g., you are in the hospital, and you gave ‘informed consent’), and we are (somewhat) squeamish about forcing people to be monitored and supervised just to do what most people consider to be normal adult activities.
But as a practical matter, there really is no alternative to something like that if we’re going to avoid one-size-fits-all.
A few years ago Medtronic was approved to market their automated diabetes device which monitors sugar levels and injects insulin as needed or on a schedule.
In principle, it should be child’s play to have such a device track, record, and communicate all that information (and much more) to health care providers and government law enforcement authorities. After all, even 50 years ago, Mission Control was able to monitor Neil Armstrong’s vital signs in real time from 250,000 miles away.
So, Tom Petty has to wear a pain-relief-box in order to get as much pain relief as he needs. That’s a minor annoyance and slight humiliation seeing as how he needs to give up some personal autonomy and privacy, but to someone who is really in a lot of chronic pain, it’s a minor annoyance – in the same way that everyone grumbled and then just adapted and acquiesced to the TSA’s procedures in order to fly.
But to someone who is trying to abuse the drugs, or to a Dr. Feelgood trying to make some cash by being knows as the guy to go to to get your pain meds, this system puts up a huge deterrent to that kind of activity, because it will be detected immediately.
In reality, the 3-day Fentanyl transdermal patch plus normal-release pills for break-through pain approximates the controlled intravenous delivery machines, which is why it has been so transformative for cancer pain and palliative care.
Knowing that fact introduces many WTF? questions whenever anyone attempts to explain the opioid crisis.
Maybe, but that is presumably the rationale of doctors who liberally prescribed opioids for chronic pain. If Prince and Tom Petty were self medicating for chronic pain alone (or even preventing withdrawal pain), they should have been using one of the “pure” slow release options, OxyContin or Fentanyl patches. I suspect that both are diverted into the black market and readily available.
Anyway you look at the crisis it seems to boil down to an information issue.
The problem with fentanyl is that it is ridiculously easy to synthesize on large scale. I could make a kilo of it out of commercially available, non-controlled chemical intermediates in far less than a week, if I chose to do so. I think what has happened is that fentanyl, though a quite old and prescribed drug, has only recently become a target of interest in the illicit drug world. As that interest has risen in recent years, the accidental deaths were sure to follow given fentanyl’s potency (and there are derivatives even more potent that are just as easy to synthesize).
I find the discussions around these matters eminently frustrating. Here are some general facts to always keep in mind in any discussion surrounding opioids:
1. The rate of increase of ALL drug-related deaths has been increasing roughly at the same rate as those for opioids; so explanations that pin blame on doctors and/or drug companies are going to have a hard time explaining the rise in overdose deaths that do no involve opioids.
2. A prescription opioid by itself is very hard to overdose on, but they are very susceptible to lethal toxicity when used in tandem with different opioids and other potentiating drugs. The vast majority of drug-related deaths involve multiple substances, and majority of opioid-related deaths involve a non-opioid substances. One wonders what affect a public health campaign to make users knowledgeable about especially unsafe usage would have.
3. From a pharmacologic standpoint, potency merely refers to the dose needed to achieve response, not necessarily the degree of response; the term for this is efficacy, and the two are distinct. A more potent drug does not at all mean it does “more” or causes “a higher high”; it is possible that a a highly potent drug is less or equally efficacious. In fact, the potent opioids like fentanyl are not any more addictive or euphoric than other prescription drugs, they just achieve the same effect at lower weight/dose (which is extremely relevant in a black market for many reasons).