Overall I agree with your point but I want to make a squabble with your example.
Purdue's marketing of Oxycontin definitely crossed my line of honesty, BUT there has been, historically, an enormous amount of untreated pain in the US (probably everywhere), because of the stigma around those drugs.
It's ok for someone to develop a tolerance and addiction to the drug if they have the actual pain issue. That is usually less disruptive to someone's life than living with crippling pain. In a way, getting opiate pain medication into the hands of more people is a good thing.
The problem was a little more complicated- 1) Perdue promoted Oxycontin in a misleading way. 2) This happened during an economic downturn with our post-manufacturing economy turning out tons of people on disability, and others without a clear future. 3) Legislators freaked out, making it harder for doctors to prescribe opiates without making it easier for them to prescribe opiate treatment pills like suboxone, which basically forces addicted users of pharmaceuticals onto the street to score heroin.
So it's a social, legislative, and corporate morality problem all at the same time.
I don't think they're being unfairly scapegoated. Oxycontin was an epidemic in itself. I've seen plenty of evidence from a variety of sources that their pills were aggressively and deceptively marketed as non-addictive, and that their wide availability led to an increase in opioid abuse. That includes knowing people who started on opioid addictions with brand name oxycontin and having heard countless anecdotes of the same. I'm having trouble understanding the motive for minimizing Purdue's role. The deception in marketing and all its consequences belong to them. It's difficult to imagine they merely made a mistake in trying to be effective marketers as opposed to knowingly misrepresenting what they sold in a way that was likely to harm the public.
All that said, I generally favor your stance that ending prohibition would yield the greatest harm reduction.
>I hope you're right and it's not the other way around.
Sadly, it is the other way around. Purdue spent millions of dollars advertising Oxycontin as a safe, less-addictive painkiller for chronic pain. Doctors were inundated with "FDA-approved" marketing info, telling them that this specific kind of heroin was an easy, twice-per-day way to deal with back problems, knee pain, arthritis, etc. It was so deceptive that three of their executives were found guilty of criminal charges, and the company was hit with a fine so high it was a record in the pharmaceutical industry.
After people had been prescribed what is effectively heroin on a regular basis for months or years, they were addicted.
Purdue was engaged in aggressive marketing of their opiate drugs to doctors who then prescribe them. Their marketing objective was to rehabilitate doctors’ then dim-view on opiates - and their marketing material went with unchallenged claims such as that they had developed new opiate formulations that weren’t addictive or otherwise had less addictive potential compared to older opiates - these claims have all since been debunked. I understand that the marketing executives at Purdue and others were aware that they were both being dishonest and that what they were doing would result in more OD deaths and ruined lives.
Charitably, it can be argued that making opiates more accessible to those who benefit from them who were previously denied them due to doctors’ reservations about opiates - despite increased OD deaths - would still result in a net improvement in overall disability-adjusted-life-years, but because Purdue’s leadership stood to personally gain from increased sales (and cynically: assured long-term sales due to iatrogenic addiction) we cannot assume they were simply acting in the public’s best interest and the increased revenue was just a pleasant side-effect. That is the problem.
I recommend checking-out the work of Ben Goldacre if you’re interested to find out more.
Pharma companies, of all sizes, manufacture drugs with very high addictive potential - no-one is angry at other companies for making generic fentanyl: those companies weren’t telling doctors it was somehow “safe”. (So I’m not saying it was only Purdue).
TL;DR: I think it is reasonable to blame Purdue for the reduced access to opioids we are now stuck with.
Purdue caused more addiction to occur, which in turn caused reduced access to the opioids that existed prior to the creation of Purdue's nuisance product.
Also, perverse incentives caused by the patent and licensing system motivated them to make OxyContin unnecessarily addictive in it's formulation and dosing schedule, in order to engage in patent "ever-greening" of an existing substance.
Oxycodone has been around for a long time, but was doesed and administered more safely in older products.
Purdue did some pretty perverse things to support their patent and regulatory rationale for OxyContin. To gain approval as a superior and patent-able alternative to the other extant gerneric hydrocodone and oxycodone products, it was claimed to require less frequent (but larger) doses. The result was that large numbers patients found that when taken as directed it provided superior pain relief, followed by a return of pain, in conjunction with hours of opioid withdrawals until the next dose. Early on in the product's life cycle doctors were encouraged to increase the dose but not the dosing schedule when patients complained, in part because the alternative would have undermined the rationale for the existence of the product.
Although this was probably an undesired side effect from the point of view of Purdue, they could hardly have designed a better way to cause drug addiction. Millions of people took this product and many became addicted. Purdue went far out of their way to publicize people as criminals rather than address the fundamental problem with the way the product was administered. It seems to be evidenced that the more effective administration schedules of other already existing products cause less addiction, so at the margin, Purdue caused many more drug addicts to exists than would have otherwise.
If they had not done this, or had been willing to adequately address the problems, we would probably still have easier access now to the opioids that already existed. The problem has grown to such a scale that it is now very hard to "put the genie back in the bottle."
legalization is really an orthogonal issue. opioid painkillers are a very useful class of drugs that also have serious potential for addiction. doctors understand this and must balance the risk/benefit trade off. the problem here is not that purdue sold addictive drugs, it is that the company intentionally deceived the public about how addictive their formulation is. even if all drugs were fully legal, it still ought to be illegal to misrepresent your product this way.
Purdue had a financial interest in selling more Oxycontin. They knowingly pushed doctors to prescribe the medication in a manner that encouraged addiction. They knowingly misled patients and doctors as to how addictive the medication was.
Cutting the supply off without any alternatives absolutely caused harm. However, that only serves as evidence that safe and legal means of procurement are better than illegal ones.
If there had been a network of state dispensaries to provide safe regulated doses and support, over-prescription could have been stopped without leaving the victims to fend for themselves.
Purdue mislead doctors, and the public, in several different ways.
They said that their medication was unlikely to lead to addiction if used to treat pain. They said their medication was less likely to lead to addiction than other opioids. They knew some doctors were prescribing vast quantities of opioids - far more than even Purdue recommended as treatment for pain. They used a variety of marketing to doctors and to members of the public, and some of that was designed to evade regulation of marketing. They used stealth marketing methods such as employing physicians to speak at conferences without disclosure. They interfered with the creation of treatment guidance. They used front groups. They targeted vulnerable and wealthy populations. They concealed what they knew about the addictiveness of their product. They concealed what they knew about the efficacy of their product (people may tolerate an addictive medication if it increases function. Purdue knew their meds didn't increase function for many patients.)
There's a huge list of absolutely scumbag behaviour from that company, and we need to recognise their part in driving death and misery to millions of Americans.
The makers of OxyContin have been losing lawsuits [0, 1] for aggressively and misleadingly marketing (saying that it wasn't addictive) the drug for pain management leading to the levels of opioid addiction that we see in cities around North America. I think pharma, particularly Purdue, deserves the lion's share of the blame in this.
Problem here is that doctors pushed highly addictive painkillers on anyone and anything, while Purdue did everything they could to increase sales and disguise the risks associated with opioids.
> If you rob a bank you can't just give the money back if you get caught, and you certainly can't just give half of it back.
How much less oxycontin do you think they'd have sold if their advertising was less reprehensible?
Notably, Purdue produced some of the first extended-release opioid formulations on the market, which does have some real value even without exaggerated sales. It developed MS Contin (XR morphine) in 1984 and OxyContin (XR Oxycodone) in 1996. (CONTIN™ is Purdue's extended-release drug delivery system developed in the 70s.)
OxyContin was also the first "Abuse-deterrent Formulation" (ADF) approved by the FDA, for whatever value that has[1]. Today, ten such formulations are approved and of those, five are actually available.
So tl;dr, I don't think your metaphor is especially apt. They should be punished for their sales tactics, which were outrageous, but there seems to be this mentality that all opioid manufacture is evil, and I don't believe that.
You've missed the point. There would be precious few who would deny narcotics to those who really need them. They are often the only effective line of pain relief for severe pain and they are on WHO's list of essential drugs!
You seem to have not considered these points:
(a) The intrinsic nature of narcotics requires them to be managed with great care. This means the dose has to be accurately titrated sufficient to kill pain and no more or addiction results. These facts have been known by the medical and pharmaceutical industries for over 100 years, also the FDA knew this but seems to have forgotten when it was lobbied. (I'm oversimplifying the facts here but it'll have to do.)
(b) Sacklers/Purdue were fully aware that intrinsic nature of narcotics requires them to be managed with great care. As this info is in almost every medical text on the planet that deals with the subject, similarly every pharmacopeia text on the subject. (Check for yourself.)
(c) Sacklers/Purdue deliberately ignored these well established medical facts about narcotic addiction so as to proffer from drug sales. They willfully pushed OxyContin use to levels well in excess of that recommended by medical best practice. Thus, it hugely increased the numbers of opiate addicts than there would otherwise have been.
(d) As I've said above, many medicos were complicit with Purdue and deserve to lose their license to practice.
(e) As I also said above 'before OxyContin, there were any number of narcotic painkilling drugs from those that have to be injected to ones that can be swallowed as a tablet or capsule that are made by more reputable drug companies (and have been for decades). OxyContin didn't offer anything over these earlier drugs.' Doctors, pharmacists and the FDA knew this too, yet they deliberately threw away their Hippocratic Oath and 'mistreated' their patients for a few cheap shekels.
Yeah. I think the underlying story is that doctors used to be more apprehensive about prescribing opioid painkillers, and when they did they prescribed lortabs or something like that for acute cases and they wouldn't put refills on or rewrite the scripts when asked. Then, along comes Purdue with a claim that OxyContin, because of its unique formulation, is a big addiction concern and is safe to prescribe for chronic pain. Then they (and a couple other manufacturers) basically conducted a successful campaign to convince doctors that undertreatment of chronic pain was widespread and they were basically letting their patients suffer, strongly suggesting that this may be considered malpractice in the future if they do not start prescribing more opioids. This campaign was very smart and even reached the doctors who refuse to take incentives from drug manufacturers. Essentially, in the way that Pfizer created a new category of concern in the mind of patients with Viagra, Purdue did the same in the mind of doctors with OxyContin.
Lo and behold, people are addicted to OxyContin, some start looking for more immediate-relase formulations of opioids because they don't feel right even on 80mg Oxy tablets, and hundreds of thousands who otherwise would have been alive with chronic pain are now dead of overdose. Meanwhile, research is showing that opioids are not very good for chronic pain and other approaches, usually multimodal approaches, are better, including NSAIDs, gaba-ergic drugs like gabapentin and pregabalin, ketamine, physical therapy, psychological retraining, meditation, acupuncture, etc.
"I find these two positions very hard to re-conciliate"
Same as per vmception's comments.
Also, what you need to realize is that opiate drugs are almost unique amongst drugs. There are staggering numbers of them in different classes - oral, injectable, short/long-acting etc.
The tragedy is that they're all addictive and the degree of their addictiveness is directly proportional their effectiveness at reducing pain (see Burroughs's perceptive quote in my post).
Thus, titrating the right dose and determining the period for which the drug should be given becomes a very difficult tightrope act, especially so if a long period is involved. Give too little and the patient suffers pain, give even a little too much and addiction is very likely the result. It's a nightmarish problem.
Opiates are the Janus of drugs - one face shows a miracle drug - the other is unmitigated pain and tragedy - and often death.
The issue here is that Purdue deliberately peddled oxycontin, a drug that can be taken by mouth, in ways that encouraged patients to easily slip into the 'too much' side. That this should never happen without supervision is a longstanding axiom of opiate management and has been known and well understood for over one hundred years.
In essence, Purdue and the Shacklers deliberately chucked away years of best practice which then benefited them financially but to the patients' devastating expense.
The matter of what drugs should be legalized etc. is somewhat different matter (which others have covered well so I won't address it except to say that they're not logically in conflict as they address different things).
Please remember that Purdue were the ones who marketed Oxycontin on the premise of one dose for 12-hour pain relief.
When they learned doctors were prescribing it for eight hours, they tried to "re-train" them to use the "proper" (read: their) dosing recommendation, because there were cheaper drugs with six of eight hour doses.
Sure, the doctors made the prescriptions, but you, and I, and everyone who thinks honestly about it for two and a half seconds realizes that no matter what the recommendation is, enough people who are in bad enough pain to be prescribed oxy will take it when they need it, recommendation be damned, that to have issued that recommendation in the first place was an act of bad faith.
They marketed the drug on a lie in order to get doctors to prescribe it, which fueled — if not created — an epidemic, which has killed tens of thousands of people. Their hands are not clean, here.
"Apart from their addictive designs" is the key phrase here.
Purdue only created OxyContin for legitimate pain management but they knew full well the level of abuse because of their profits
I'd rather live in a society where the creators of these things take some responsibility for effects of whatever they've created, whether intentional or not
I don't think that's the case, unless you go back many decades.
Purdue was in part so effective because they spent millions 'educating' (and bribing) doctors and making up a '5th vital sign' in order to push huge quantities of drugs. This was on purpose. Those face in pain posters you see still originally came from Purdue.
This always comes up in these threads, that perhaps we've swung too far in the direction of limiting access to pain meds for legit patients.
Which definitely has merit.
But that doesn't take away from what Sacklers and Kappor et al did.
from my understanding long term prescription of opiates in modern medicine wasn't really a thing before Purdue's marketing (and still isn't outside of late stage cancer in most countries).
So that's what I was getting at in responding to 'other opiates having been stigmatized in previous moral panics,' I think you'd have to go back to prohibition to find a similar time of heavy long term use 'medically'
Purdue aggressively marketed OxyContin as having a very small rate of addiction to doctors who weren't pain specialists and thus had little experience with controlled medications, while providing a dosing regime that was almost designed to cause addiction. (It's sole advantage was as a timed-release medication; if pain returned before time for the next dose, doctors were instructed (strongly) to raise the dosage rather than increase the number of doses per day.)
Do you really honestly believe that anyone that became addicted really listened intently to Purdue Company marketing and made an informed decision based on that? That if the marketing was more cautious, they would have made a rational decision not use Oxycontin instead? Because I, to put it politely, don't think that's really how human behavior works.
I mean, we have 500+ years of human history where people have become addicted to hard drugs without a marketing campaign. Including many in that same heroin/opium/morphine family. Maybe Occam's Razor is that people would've done the oxys regardless of what the Sacklers disclosed about the chemical compound....?
Purdue Pharma is still doing pretty damn well. The problem isn't in using opiates to treat pain - it is Purdue's marketing actively lying about the addiction potential of OxyContin.
Purdue's marketing of Oxycontin definitely crossed my line of honesty, BUT there has been, historically, an enormous amount of untreated pain in the US (probably everywhere), because of the stigma around those drugs.
It's ok for someone to develop a tolerance and addiction to the drug if they have the actual pain issue. That is usually less disruptive to someone's life than living with crippling pain. In a way, getting opiate pain medication into the hands of more people is a good thing.
The problem was a little more complicated- 1) Perdue promoted Oxycontin in a misleading way. 2) This happened during an economic downturn with our post-manufacturing economy turning out tons of people on disability, and others without a clear future. 3) Legislators freaked out, making it harder for doctors to prescribe opiates without making it easier for them to prescribe opiate treatment pills like suboxone, which basically forces addicted users of pharmaceuticals onto the street to score heroin.
So it's a social, legislative, and corporate morality problem all at the same time.
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