Not that pharma is angelic here, but don't the doctors have the largest measure of blame for writing unnecessary scripts, failing to monitor for abuse, and failing to encourage alternate options?
I'm in favor of maximum MD power. I think they should be allowed to prescribe everything from cocaine to bleach, or any other chemical compound, as suits the patient care, if they know what they're doing.
But they should also bear maximum accountability for what they prescribe, including abuse potential.
A more helpful line of inquiry to me is the culture of Rx usage. As a society, our patients expect drugs when they go to a doctor and a doctor's average time per patient is around 10-15 minutes. Does not seem like enough time to understand the patient's needs and create an individualized solution. Further, RX medicine is highly profitable and encouraged from the pharma.
In this case it looks like they are incentives for pain pills to be issued on both sides -- money maker for pharma and time saver for doctors (a third side -- convenience and feel good for the patient).
It is not as useful to find so-called bad actors but instead we should evaluate the medical system as a whole and put in safeguards to do less harm. Patients have generally too much influence on doctors for their treatment (otherwise why would direct to consumer marketing exist?), that doctors are not educating patients enough on the risks of narcotics and that pharma has $$ incentive to push medicine. That things like physical therapy and lifestyle changes will better deal with root causes than drugs that only address the symptom (but feel better and are easier to swallow). It's a recipe for a disaster.
I was in a motorcycle accident a few years ago and broke over 10 bones. The worst part of my recovery was kicking my addiction to narcotics. I did not understand what I was getting into and I was never given a path to get off them (not in a coherent way, not until I called to say I was going through withdrawals). This should not be.
Patients tend to give doctors higher customer satisfaction scores when the doctor writes a prescription, regardless of whether the patient really needs it. Patients like to feel that the doctor is taking their problems seriously and doing something. This is one of the negative aspects of moving to a more consumer-driven healthcare model. Providers try to optimize their customer satisfaction scores to bring in more business, and large provider organizations sometimes use those scores as one factor in paying doctors.
I feel your pain, it's scary when you're blind-sided by how deep of a pit you're in. When you realize you're probably in worse shape than the guy on the corner hustling to buy a rock, and you got it from the lady you trust your child's healthcare to. I don't know if it's a willful ignorance, or if many doctors live healthy lives and have no concept of how scarily painful withdrawal is. I can't tell you how many times I've heard it's like having the flu. If people are having flu like that, then it's amazing more people don't die every winter.
Well, there is also information asymmetry at play here. Patients could have legit pain, and then go to multiple doctors, without the others finding out. Then they could sell those to other people, or use them all themselves.
On the other hand, the pharmacies might know, but that could be worked around by a motivated pill-obtainer.
The pharma companies, however, definitely know that they sent 780 million painkillers to a state with only 1.8 million men, women, and children.
I am not saying it is their duty to do something about this, but maybe they have some high-level information that others do not.
I really don't see a way this could be fixed without giving every doctor in the US access to some huge database of every prescription of every person in the country -- which I would not be cool with, nor would anyone else, other than maybe law enforcement agencies.
Between Surescripts providing centralized medication history, and statewide controlled substance prescription registries, doctors can no longer claim ignorance when dealing with drug-seeking patients. But those sources of information were spotty and incomplete up to a few years ago.
This is exactly right. My wife is a pharmacist and our state only recently implemented the database of medication history. In the past a seeker could go to any doctor, or any pharmacist and they would have no idea of this patients medical / prescription history. So even if they denied the patient their prescription, they would just go somewhere else. When WV tightened the restrictions and limits on suboxone seekers would just leave the state to get ahold of it.
> Patients could have legit pain, and then go to multiple doctors, without the others finding out. Then they could sell those to other people, or use them all themselves
I can't imagine many people that have real pain bad enough to need opioids are going to be selling them to other people.
For people that really need them to manage pain, they can literally be a live saver.
Opioids are worth lots on the street. Even people with "real pain" still need money right? Especially in a state like WV.
So if you can get enough pills to cover your own pain management (meaning you likely can't work anyway), and you know you can get and sell more pills by going to other doctors, why not?
I had a friend who was a pharmacist and worked at several places like CVS. He said they routinely refused to fulfill prescriptions to people they felt were either gaming the system or were using outright fraud to get their meds.
He said after a while it became a game. User would get a script and come in totally strung out. My buddy would refuse to refill their meds. User would call doctor and yell and them. Doctor would call Pharmacy and yell at my friend, who would then have to tell the Doctor what was going on. Most of the time, he said the Doctors had no idea this person had 15 different scripts for pain killers.
For me, there's still too many loopholes to exploit in the process.
I think the drug dealers could learn a thing or two from our pharma industry.
When I had back pain, the doctor handed me a prescription for 100 hydrocodone tablets. I took none; just some physical therapy and stretching gave me immense relief. Later, I was shocked to find out from a friend that the street value of these tablets was $5/each.
Probably more a fault of your doctor or the laws. There should be limits on that kind of painkillers, especially if you use it first time. If the doctor restricts the amount to a few days' usage, potential misuse is much easier to detect.
They could start with mandated patient education on the effects and addiction potential of these drugs, as well as a treatment plan to taper off. I had a severe injury in late 2013 and received neither of these things. We should work on the basics before pushing for more restrictions.
To expand: I had maybe 4 different doctors writing me RX for pain meds at the time and none of them were coordinating. I remember having far more drugs than I needed for the first few months -- I had prescriptions to spare. This is because I had several doctors treating me but again, none were coordinating.
I've never been quite able to grasp the logic of those people who think that, while the War on Drugs is a bad idea, the FDA being able to ban whatever drugs it likes is a good idea. Either the government should have the power to ban drugs or it shouldn't, but too many people seem to want it both ways: prohibition without enforcement.
Okay, but what I'm saying is that once the tools are in place to ban various substances for personal consumption, and make those bans stick through enforcement, then that's all the tools you need for a War on Drugs. I mean, at that point, it's just "ban this thing, and not that thing, because it's what I want."
What takes doublethink is imagining that, once these powers are in place, they won't be used against one's preferred substances.
In practice the War on Drugs has involved arresting and imprisoning a lot of people and the militarization of police.
How many people are in prison for violating FDA rulings? I'm sure there are a few, but policing egregious behavior is probably a step that a reasonable society takes out onto that slippery slope of having rules about a thing.
Let me try to clarify: if you have rules prohibiting the creation and sale of substances solely for personal consumption by competent, consenting adults, then you have the primary tool needed to conduct a War on Drugs. I think that it is a mistaken notion to imagine creating this power, and saying "don't worry, we'll only ban dangerous things, and not harmless things, because we'll know better." I think that is definitely not the case. Yes, many people want a different mix of things banned and permitted. But people should not fool themselves into thinking that is what they will get, because a power like that is pretty much always used for more things than its creators intend. We cannot simultaneously prohibit things, and not enforce that prohibition through, ultimately, threats of imprisonment. If the maximum penalty for a drug charge is a ticket, then the prohibition on drugs will simply not be effective.
The War on Drugs has involved arresting and imprisoning a lot of people, because a lot of people really want drugs. Once the soft enforcement mechanisms (reprimands, misdemeanors, fines of legitimate businesses) fail, then if you really want to suppress the act, you have to ramp up the level of force. The reason that fewer people are imprisoned under FDA rulings is, I would say, because the FDA is more lenient, and because the things it bans are far more niche and less desired. You can have effective, or you can have gentle, but you cannot have both.
I recognized that you think it's a slippery slope, I'm not sure what you think I'm not getting.
I do believe that you can tell store fronts not to market literal gasoline as a restorative tonic without automatically escalating to violent raids. As far as I can tell, a rule against marketing gasoline as a restorative falls afoul of the standard you declare in your first sentence. People aren't very comfortable shrugging and not doing anything about perceived problems (illicit distribution of the restorative gasoline), but we'd be better off if we did that more often.
(I do understand that the example is ridiculous because there is no demand for a restorative gasoline tonic amongst competent adults, it's just that there is ample evidence that people want some assurances about safety. A less ridiculous example would be requiring people buying cocaine to go through some sort of educational material that made the risk of forming a habit clear, and regulating the manufacture of the cocaine that is eventually sold so that it is not adulterated)
Yes, of course, rules against incorrectly marked or marketed or adulterated products are different from the war on drugs. What I'm saying is that drug-war-type activities are based on rules prohibiting the sale of particular goods even with zero promises as to their safety or efficacy. (And the FDA does enforce a number of such rules, though certainly not that many compared to other bodies.)
If someone was convinced that gasoline would cure their hair loss, they couldn't get it through a pharmacy, but they could still get it from someone making no such promises. If someone was convinced that cocaine would cure their hair loss, they can't get it any way, any how - even just as something labelled "dangerous goods, do not consume". That's the prohibitive authority that leads to raids and cartel warfare. And that's the power that many people still support the FDA/DEA/government having, and which I am pointing out is the root of the problems with the drug war.
racism and guns are the tools you need for the War on Drugs, laws prohibiting some drugs are just there to make it easier to claim a veneer of legitimacy.
What makes a War on Drugs doable is the laws prohibiting drugs. It's literally what makes it legally possible. You'll note that very few adults are arrested for "possession of alcohol".
> Either the government should have the power to ban drugs or it shouldn't
Surely there is middle ground. A drug can be regulated but not banned. The way a drug is prescribed could be regulated. This needs to happen with opiates. That doesn't mean they should be banned but the addiction potential is very serious for these drugs (and vastly underestimated when they first entered the market).
"Regulated but not banned" is not a middle ground between "banned or not". It is "not banned". I am not saying that you can't have regulations on a drug, I am saying that if you make a drug entirely illegal, and it is in sufficiently high demand, then you will have drug-war-type effects.
The FDA bans drugs from making unverified medical claims. That's the raison d'etre for its existence. Given the circumstances, they do a pretty damn good job of this.
You can put whatever the hell you want in your non-FDA-approved snake oil supplement - but then you won't have the legitimacy of the medical establishment behind you. This legitimacy depends on your drug having verifiable, understood effects. You can't have it both ways.
Well, they still destroy unapproved drugs at the border and raid places like whole milk producers and nutritional supplement makers. It's not exactly "caveat emptor" over at the FDA.
My point is really that, if somebody's solution to the problem of people overdosing on drugs is to ban them or prohibit access, then they're defacto acquiescing to the tools that make the War on Drugs possible. People seem to expect drugs they don't like to just "go away", without any of the nasty raiding and shooting.
There are plenty of snake oil manufacturers who manage to operate within the boundaries of the law. Those don't get raided.
The milk salesman wasn't raided for selling whole milk. He was raided for selling unpasteurized milk... Across state lines.
Generally speaking, clearing the bar for FDA tolerance of nutritional supplements is quite easy. They don't care that your product works, only that you don't put actively dangerous things in it. It's caveat emptor for efficiency, but not for safety - which is a pretty reasonable place to draw the line.
I understand that, yes. But what I am saying is that, even with a "safety" criterion, the War on Drugs is completely prosecutable. Heck, alcohol is dangerous as hell, as evidenced by the number of deaths it precipitates. There is nearly always a safety criterion that can be thought up for "products for personal consumption" (as opposed to, say, environmental pollutants) You can have prohibition of "unsafe substances", or you can have an end to the War on Drugs. I don't think you can have both.
If personal possession and consumption stopped being a crime, that would effectively end the War on Drugs overnight. That kind of drug policy would make the current state of affairs unrecognizable. (Yes, I am well aware of how in the current legal framework, anyone can be accused of being a dealer.)
The FDA approach to regulation goes after dealers and manufacturers - not their customers. So yes, we absolutely can end the War on Drugs, and keep the FDA's enforcement mechanisms.
I honestly have a lot more sympathy for an addict, or a bystander, whose life was destroyed by the state, then I do for his heroin dealer. I think most people opposing the War on Drugs on grounds other then ideological anarcho-capitalism share this assessment.
> If personal possession and consumption stopped being a crime, that would effectively end the War on Drugs overnight.
Well, sure, the current way it's being done. But you'd still have cartel warfare for selling territory, adulterated goods, and to effectively shut down distributors, you'd have to define smaller and smaller amounts of substance as qualifying for "dealing", as dealers learned what they could and couldn't get away with. Perhaps I should not have used the capital-letter "War on Drugs" to refer to this. But you would still have much of what you have now.
Now, would it be net improvement if enforcement of drug laws moved towards a dealers-and-manufacturers model? Sure, I think so. But my point is that there would still be no principle in place preventing that model from expanding again into a broader prohibition, involving new substances, posessions, uses, or what have you. It would be like saying "we'll have free speech, except if it's bad, or we don't like the person saying it, or some other reason that we might think up later." There's no sufficiently strong principle preventing prohibitions from continually increasing.
> I honestly have a lot more sympathy for an addict, or a bystander, whose life was destroyed by the state, then I do for his heroin dealer. I think most people opposing the War on Drugs on grounds other then ideological anarcho-capitalism share this assessment.
That's probably true. However, I don't think sympathy is an effective basis for judging whether things should be legal. And if observing that a government with an expansive power to ban things will probably use and aggrandize that power makes me an anarcho-capitalist (rather than, say, just a boring classical liberal) then so be it.
Sometimes I think there will be movies like 'Blow' in 20 years that will be about the wild west times of prescription drugs, and the kingpins who had houses filled with money from the proceeds.
I mean, I don't know what those numbers are. But when people give a per capita value for something that occurs over time, nearly always, that value is per annum. But here it wasn't, it was over several years.
It'd be like saying "the per capita income of New York State is $185,688!" When that's actually the per capita income over six years.
The 6 year scope is in the sentence immediately before, and it is clear that it means per capita over all the shipments (it says so!) and not per year/unit of time.
As a WV resident well aware of the drug problem (In the 'major' WV city I live next to, 28 people OD'd in one day recently), I'm wondering what this would look like if it DID in fact account for people that take none, myself included. I know of TONS of families around me that have been torn apart from opioid addiction. It is hard to describe the impact because to be an addict in this area especially, is to be stigmatized and essentially cast out from the society. I'm not sure if it's due to the prevalence of fire-and-brimstone religious folk in this area, but a lot of the folks around here would rather lose the drug addicts completely than rectify the problem and help them. The only input I can offer is that the current model of Rx drug abuse can't be sustained and is ruining lives while certain people/organizations are profiting greatly...
Just wanted to add the explosion in fentanyl and other synthetic heroin ODs in your community is also related. I'm not going to pretend the users are innocent, maybe they a teenagers who start off buying pills to get high -- point being that RX drugs are a very real and literal gateway drug to street narcotics, which are cheaper and far more dangerous.
I agree, it was never clearly divulged if the ~28 OD's were fentanyl-related (I assume the majority were), or for anything else - I can attest that the lion's share of people I have known to have opioid drug problems did start out with Rx abuse and progressed from there. As much as it pains me to say it, the culture around my area seems to perpetuate the idea that doctors generally do no wrong unless they botch a surgery, in which case, you sue.
Do you think every person, every man woman and child, has a legitimate need for 2-4 pills of narcotics each day?
Am I misunderstanding the figure? Instead of 2-4 a day per person, maybe you should calculate how many it is per person with a legitimate need for the drug.
I think you are misunderstanding the figure, it is 72 pill/year/person, so if an average person with a prescription is taking 2-4 (let's just use 3) they will need 365*3 = 1095 pills/year. That rate of consumption implies that 72/1095 = 6.5% of the total population is on a never ending prescription for opiates.
As a percentage of the population, that still seems really high, but WV is taking 0.2 pills/person/day not 2-4 pills/person/day
Chronic pain can use a lot of pills per year. One every couple hours perhaps.
I knew WV was a bit militaristic but some google results and some division imply 10% of the population are military veterans. Its almost believable given how many WV residents I met in the Army, generally extremely nice people BTW. So if no one in WV takes pain pills but military vets, then the vets get a whopping two pills per day and everybody else gets precisely zip nada nothing.
Yeah sure most vets are not taking pain pills. But the guy with no working knees or limbs blown off in an IED, he's probably taking more than two per day, the casualties from one IED explosion could make up for a whole retired company or even battalion of people not ever taking pills. And of course the general population has its own segments of people who have permanent physical problems, or temporary, or are painfully slowly dying of cancer, etc.
Here's another interesting depressing bottom up analysis. Lets say a third of people die of cancer after a year of horrific pain taking ten pills per day and they die on average at age 50 (think of all those heavy smokers and heavy drinkers with annihilated livers, plus the numbers are simpler and to one sig fig don't matter anyway). So if it takes 3650 pain pills per cancer death and a third of the population dies of cancer, that means the average dead took 1000 or so pain pills in the year before they died, and unless we suddenly become immortal that divided by 50 year lifetime means the average person is taking 20 pills per year over the course of their life, even if they never take a pill in their lives until the last year of life before a cancer death and 2/3 of them never take a single pill in their entire lives if they die in car accidents or whatever not from cancer. Now of course not every terminal cancer diagnosis takes an entire year to die and not all medical interventions including cancer in remission take zero pills and not everyone with terminal cancer takes ten pills per day, but none of these assumptions are more than an order of magnitude off on average.
Not really the season for depressing analysis like this, but math is math and the general public is utterly innumerate, so its relevant to the discussion...
I would suspect from this bottom up analysis that dozens of pills per person-year is not too far off from other states numbers and by playing games with careful selection of subgroups you can manufacture all sorts of crazy "surprisingly high" numbers that are anything but.
It's a shame that this journalist, trying to make a name for themselves, feels it's perfectly OK to manipulate the numbers so that it sounds like it's worse than it is. When people read this dramatic account, who don't bother examining the numbers get it in their heads that "something must be done!" it's the people who are in chronic pain that suffer.
Also, since this is coal country, I assume black lung plays a big part in the need for these scripts.
As an aside, I have a family member who had a horrific injury who is on a pain killer script. This person isn't allowed to take an extra pill on days when the pain is worse than normal because the DEA is cracking down so hard on this, her doctor is afraid to subscribe over the government imposed "limit." Pretty sad. Her doctor even suggested she go to a pain clinic because he is concerned about getting heat for total subscriptions.
Didn't we learn anything from the immensely stupid and still ongoing drug war? Fk this journalist.
'Instant' release pills usually last for 4 hours. There are also 'extended' release formulations that generally last 5-7 hours (despite the longer claims of manufacturers).
I'd be surprised if more than 5% (probably even less) of the population should be on heavy painkillers at any given time. I don't know statistics from other countries but we're talking about pills that are being used to treat severe pain, not just a headache.
2x Opiod pain pills a day every day for an entire year is a very serious amount of pain if legitimate.
If a state were to legitimately have 10% of its population that badly hurting, there should be a huge governmental investigation into what factor is causing that much crippling pain.
According to the article, the 780 million pills were hydrocodone and oxycodone pills. Those are highly powerful and addictive opioids. 72 of those per inhabitant of WV per year seems insane to me.
Look at it this way, 15% of the US population smokes. Let's say they smoke a pack a day, 20 cigarettes. If I presented that data to the population as a whole as this journalist is doing, it would be "The US population smokes up to 3 cigarettes per person per day," which is technically true based on the math applied, but grossly misleading.
15*20/100 = 3.
They are applying a number of a subset of the population to the entire population. It's very misleading.
Edit: This journalist is also citing per year statistics, so take my math and multiply by 365, so that would be, "the US population smokes up to 1,095 cigarettes per person per year." The larger number implies that it is much worse. To add a little spice, I could say, "The US population smokes 1,095 cigarettes per year for every man, woman and child," which is exactly the same data set, but it's now implying that children are 1/3 of the people who smoke. Also most people don't envision a 17 year old as a child, so it further implies that young children (say 5-12) smoke.
The saddest part of this whole story is that this is what we can expect from serious journalism in this day and age. Gotta have their clicks!
You're right, that makes sense. So the situation is probably that most of the people take nothing and 5% or so takes 6 a day and lives in a permanent state of sedation.
Sedatives are different. Also people who are on painkillers lose the "high" after a while, so for the most part, they are normal functioning people, which is the idea.
Also, as an aside, take into account that there are 5+ million car accidents a year. I would guess that is or at least is one of the leading causes of chronic pain in the US.
These are rational people making a decision for themselves if the pain relief is worth and side effects or other Iissues. Let the people of WV make up their own minds and let the market speak for itself.
Seriously though, 'rational' people can also be misinformed by a large corporation and a system which does not necessarily incentivize getting people healthy, and only wish to make their shareholders happy. The 'market' will always try to optimize for profits even at the expense of everything else.
I'm in favor of maximum MD power. I think they should be allowed to prescribe everything from cocaine to bleach, or any other chemical compound, as suits the patient care, if they know what they're doing.
But they should also bear maximum accountability for what they prescribe, including abuse potential.