In "honour" of 420 day a marijuana poll

[Richard Hakluyt]

The UK appears to have escaped this prescription opioid problem so far. I wonder if there are cultural factors at play or whether it will inevitably spread here?

More gatekeeping and rationing in healthcare is probably the biggest factor?

Yes, my suspicion is that there may be more acceptance of mediocre medical care and acceptance of unpleasant realities like pain....which in this case is actually helpful.

[Jacob]

The UK appears to have escaped this prescription opioid problem so far. I wonder if there are cultural factors at play or whether it will inevitably spread here?

I think it is less cultural and more about the healthcare system, marketing, and capitalism:

For decades, the Sackler family was known for its philanthropy and patronage of art galleries, museums and universities.

But bankrolling all that generosity was the family business for which the Sacklers have in recent years been in the headlines: Purdue Pharma, the company behind OxyContin, the drug considered at the heart of the opioid epidemic.

...

The opioid crisis has killed some 500,000 in the United States, and thousands in Canada, from both prescribed and illicit drugs. Last month, Purdue filed a restructuring plan to dissolve itself, while the Sackler family agreed to pay US$4.2 billion to resolve various civil claims.

For his book, Keefe takes a look at the family starting years before OxyContin was in development, when the patriarch Arthur Sackler and his two brothers began in pharmaceuticals, scoring their first big hit with the drug Valium and showing a particular marketing savvy.

"Arthur Sackler, the patriarch, he died before OxyContin was even created, but he was a pioneer in terms of how the drugs were marketed, and this was marketed directly to physicians," said Keefe.

https://www.ctvnews.ca/health/sackler-family-owners-of-company-behind-oxycontin-in-the-spotlight-in-new-book-1.5393453

[Admiral Yi]

Are NHS doctors allowed to have outside income?  I'm guessing the absence of pay to prescribe is a big part of it.

[Jacob]

As in, I think one of the key drivers of the opiod crisis is that there was a massive pharmaceutical company that generated billions in profits by producing huge amounts of opiods that they actively marketed as a mass market product, while claiming that their products (like OxyContin) were not addictive (in spite, apparently, of having evidence that it is).

You can call that "cultural factors" but IMO that's a poor combination of capitalism and a series of regulatory failures.

Years back I used to work in an office where my desk had a view of a back alley in the heart of the Vancouver opiod crisis. A not particularly uncommon sight was seeing what looked like an average suburban mom scoring pills off of some dubious looking dealer.

I reckon that eventually the OxyContin becomes insufficient to feed the addiction so - out of desperation - people graduate on to injections, to heroin, and/ or to fentanyl. Not that OxyContin can't fuck you up by itself, of course.

[Richard Hakluyt]

Are NHS doctors allowed to have outside income?  I'm guessing the absence of pay to prescribe is a big part of it.

They are but I believe it is fairly heavily regulated. There is no general advertising of prescription drugs in the mainstream media here either, so patients demanding the latest wonder pain-killer is unlikely.

[Jacob]

They are but I believe it is fairly heavily regulated. There is no general advertising of prescription drugs in the mainstream media here either, so patients demanding the latest wonder pain-killer is unlikely.

I'm not sure if the crisis was driven by marketing convincing consumers to request opioids on a wide scale, but rather by marketing (and incentives) to convince doctors to prescribe them on a wide scale.

I think the vector wasn't "I've heard these are the best pills, so I demanded them and now I'm addicted" but rather "the doctor prescribed me these pills and they're working pretty well, shit now I'm addicted."

[Sheilbh]

Are NHS doctors allowed to have outside income?  I'm guessing the absence of pay to prescribe is a big part of it.

So I don't think pay to prescribe exists in the UK or medical advertising - which is always amazing when we watch American TV.

And it wouldn't really work even if it did because a doctor would still need to prescribe within NHS rules and if there was a spike in prescriptions it would be investigated (not least because they are generally subsidised by the NHS). Not sure about outside income - I don't think there'd be an issue with that, GPs are private sector but I imagine there'd be conflict of interest rules.

On the other hand I got plenty of codeine when I left hospital last year

[Admiral Yi]

When I had my wisdom teeth pulled they gave me two goddamn fixes. Had to go back for more. 

[Richard Hakluyt]

Doctors in the NHS are encouraged to prescribe cheap generics whenever possible https://www.nhsbsa.nhs.uk/epact2/dashboards-and-specifications/medicines-optimisation-generic-prescribing and, as sheilbh said, I don't think there is any real financial incentive for them to dish out drugs.

I was shocked, on my first visit to the USA, to see a barrage of political and drugs adverts when I switched on the TV.

[OttoVonBismarck]

The opioid crisis had a fairly well documented origin story in the United States. Before about the mid-90s, people here were generally not prescribed narcotics very much for chronic pain management. Serious opioids were primarily used in hospital settings to handle extreme, acute pain, for brief periods of time. While you could get prescriptions for things as powerful as morphine, it was not common and even less common that someone would have a long running, frequently refilled prescription for something that strong.

It was common after sending you home for surgery that you might be given a one time prescription of x number of days supply of something like codeine, hydrocodone (vicodin) or such. People with terminal illnesses the standards might be relaxed a bit.

Meanwhile there were indeed lots of people who had chronic pain issues. They largely had to get by with NSAIDs and rehab and other things, some of which worked and for some people they didn't work. It was generally understood powerful opioids were not appropriate for long term prescription (again, there has always been some level of people who were able to finagle a long term prescription for Vicodin or even morphine, but this was quite rare and usually involved questionable medical decisions.)

Then in 1995 Purdue Pharma comes out with OyxContin, which is delayed release Oxycodone ( a drug that had been synthesized some 80 years earlier.) Purdue basically marketed it as a "miracle drug" for chronic pain. They claimed that because the product was formulated in a delayed release, it would help a patient manage chronic pain and was much safer than regular opioids. Absolutely none of these claims were true in any real way. However in the initial years of the OxyContin deluge, a lot of people did consider it basically a miracle drug. People who had been beset with genuine, crippling, horrible and permanent pain suddenly were pain free.

However the inevitable happens, the more you take OxyContin, the more addicted you become to the opioid. You start feeling worse because you need a higher dose, higher than your supply can satisfy. So you go to your doctor explaining that while it worked well to start with, now it isn't working so well. You doctor raises your prescription. This cycle repeats several times until you hit the limit of what a reputable doctor will prescribe. At this point is where pain clinics come in. Pain clinics were clinics, frequently operated in seedy areas (they were endemic in Appalachia), where a much less reputable MD would basically give anyone who came in just about as much fucking Oxy as they could carry. This is how you hear news stories about small towns in West Virginia where a pharmacy is processing more doses of OxyContin per week than there are people in the entire state let alone that town. People would come from out of state on buses to line up at the "good" pain clinics in states where regulations were cheap and doctors just looking to make $$$. A lot of people were gophers doing this to just accumulate pills for resale. The pharmacy system wasn't linked together back then either, so some people would do schemes to get the same rx filled at like 10 different local pharmacies as another way to multiply their access.

Meanwhile people are getting worse and worse in their addiction level. The terrible thing about this drug is once you're stuck on the addiction ramp, you perceive any loss of access to the drug as your "pain" coming back. What's actually happening is the drug is no longer really helping with your chronic pain, and you're just regularly feeling the horrible effects of early withdrawal if you aren't keeping supplied.

Some time in the mid-2000s a lot of the pain clinics get shut down, as we have this collective societal revelation that we just let the Sackler family make tens of billions of dollars pushing dangerous, addiction-causing opioids onto a big portion of the population through unsavory doctors and various shockingly inappropriate medical practices. OxyContin is also reformulated to make it a little harder to use recreationally (I don't know that this really changed much.) In a few years as easy ability to get legal opioids craters, suddenly we have a massive problem with people using illegal opioids, concentrated in the same exact areas where OxyContin use was extremely prevalent

[OttoVonBismarck]

Keep in mind even in the U.S. pay to prescribe has never been legal. This stuff was all done in shady ways to skirt the law. For example during Purdue's initial big marketing push, they started recruiting "pain management" doctors for their "Speakers Series", they would appear at events with other medical professionals and speak about how they were familiar with using OxyContin and using it to help patients treat pain. Purdue would pay them a hefty speaker's fee (legal), and while not directly pay to prescribe, what do you really think is going on there? There was also a prominent group of doctors that started lobbying in the 90s through a group they setup to treat pain as the new "Fifth Vital sign", and were making persuasive arguments in the medical community that doctors weren't worried enough about patient comfort and happiness, and were too reticent to prescribe opioids. If you trace the origins of this group, it was Purdue funded.

But it shouldn't be underestimated how much damage the pill mills were doing and what drove them. While Purdue created the environment in which they flourished, the way the pill mills worked is volume. The doctors running them were never paid directly by Purdue. Instead what would happen is they would charge a "Stat Fee" for every pain management consult. That might be $150. They would see 80 patients a day (way more than is appropriate), and that's going to approach $2m/yr if you average out that many patients a day for an average number of working days per year. The doctors couldn't directly make a ton of money just off writing a prescription or etc, and any insurance covered service they provided they had to deal with the negotiated rates of the insurance companies. It was the fact desperate people were willing to gravitate to these pain clinics to get their fix, and were willing to pay a non-covered, $150 upfront fee (sometimes more)

[Malthus]

That is all true, but it is only half the story. The way this is often described, it is said that the whole thing was a profit-driven scam by these shady companies.

The shady companies existed and they did over-promote (by lying about the addiction potential, offering various incentives to push their meds, etc.). They made money knowing full well what the impact of their practices would be (and are now getting sued by multiple states and provinces, to claw back some of that cash).

But what is often missed, is that even if they had not, the problem would likely have occurred anyway. The pill makers were just taking advantage of a genuine shift in medical practice, which saw pain management as significantly more important than it had been in the past (check out "pain as the fifth vital sign"). This wasn't done sort of self-interested marketing conspiracy, but a real compassionate movement centred on a change in philosophy of patient care. The unintended consequences were terrible.

Companies like Perdue took advantage of this to peddle their allegedly non-addictive opioid (that was just as addictive as any other) ... to take advantage of a medical system much more willing to use drugs to control pain. But they didn't create that willingness, that was created with the best of intentions by actual medical practitioners, who only wanted what was best for patients.

It is very tempting to make the whole scenario a morality tale of capitalism gone bad, which it is in part, but doing so risks missing some of the nuance.

[katmai]

Legal and smoke a few times a month.

[OttoVonBismarck]

That is all true, but it is only half the story. The way this is often described, it is said that the whole thing was a profit-driven scam by these shady companies.

The shady companies existed and they did over-promote (by lying about the addiction potential, offering various incentives to push their meds, etc.). They made money knowing full well what the impact of their practices would be (and are now getting sued by multiple states and provinces, to claw back some of that cash).

But what is often missed, is that even if they had not, the problem would likely have occurred anyway. The pill makers were just taking advantage of a genuine shift in medical practice, which saw pain management as significantly more important than it had been in the past (check out "pain as the fifth vital sign"). This wasn't done sort of self-interested marketing conspiracy, but a real compassionate movement centred on a change in philosophy of patient care. The unintended consequences were terrible.

Companies like Perdue took advantage of this to peddle their allegedly non-addictive opioid (that was just as addictive as any other) ... to take advantage of a medical system much more willing to use drugs to control pain. But they didn't create that willingness, that was created with the best of intentions by actual medical practitioners, who only wanted what was best for patients.

It is very tempting to make the whole scenario a morality tale of capitalism gone bad, which it is in part, but doing so risks missing some of the nuance.

No, I agree the Sacklers/Purdue aren't the sole villains and much of this would have happened without their existence. The conditions were ripe for the fire and it was probably inevitable, but they were an accelerant to the flame to be sure.

It's interesting how much the mentality is now changing back to the pre-90s norm, I've read op-eds by physicians in the last few years that advocate "teaching patients to understand that there is probably no magical fix to their pain, that pain often improves with rehab and specific exercise programs, but some pain is going to be chronic and they should find coping strategies." Which is a nice way of saying "learn to live with it."

[crazy canuck]

That is all true, but it is only half the story. The way this is often described, it is said that the whole thing was a profit-driven scam by these shady companies.

The shady companies existed and they did over-promote (by lying about the addiction potential, offering various incentives to push their meds, etc.). They made money knowing full well what the impact of their practices would be (and are now getting sued by multiple states and provinces, to claw back some of that cash).

But what is often missed, is that even if they had not, the problem would likely have occurred anyway. The pill makers were just taking advantage of a genuine shift in medical practice, which saw pain management as significantly more important than it had been in the past (check out "pain as the fifth vital sign"). This wasn't done sort of self-interested marketing conspiracy, but a real compassionate movement centred on a change in philosophy of patient care. The unintended consequences were terrible.

Companies like Perdue took advantage of this to peddle their allegedly non-addictive opioid (that was just as addictive as any other) ... to take advantage of a medical system much more willing to use drugs to control pain. But they didn't create that willingness, that was created with the best of intentions by actual medical practitioners, who only wanted what was best for patients.

It is very tempting to make the whole scenario a morality tale of capitalism gone bad, which it is in part, but doing so risks missing some of the nuance.

If the fraudulent claim that the pills were not addictive had not been made the pills would not have been prescribed in those numbers.  It is a nonsense to suggest it would have happened absent the fraud. 

Edit: the important take home here is that industry self regulation does not work.