20 ms·

The problems derive from the prohibition, which takes several forms. The forms add up for big profits and bad incentives, for which the consumer pays. FDA appr

The problems derive from the prohibition, which takes several forms. The forms add up for big profits and bad incentives, for which the consumer pays. FDA approval is the first layer of prohibition. Very expensive, this keeps a lot of competitors out. Lots of market (read: pricing) power is conferred to the winners. Great incentive is provided for regulatory capture. The second layer is patent protection. Again, competition becomes illegal, with outcomes similar to above. Third is scheduling it as a prescription drug. The incentives of the drug company are now to influence doctors, in ways that may be more or less overt. Docs get a cut of the outsize profits, de facto. The fourth layer is opiates being illegal in general. Competitors out. Of course there are legitimate reasons for prohibition, even if I don’t agree with them. One can make an argument for protecting people from harming themselves. But these arguments are naive and static. By “dynamically scoring” the cost of prohibition – following the incentives and the outcomes – we might choose differently.

arkades 10y ago
> Third is scheduling it as a prescription drug. The incentives of the drug company are now to influence doctors, in ways that may be more or less overt. Docs get a cut of the outsize profits, de facto. Hi! I'm a non-trad physician, with a history in health policy and managed care before moving onto the provider side. Please, tell me more about this, in a way that is more nuanced than the urban myth of "free golf trips and speaker fees for everybody!"
- allenz 10y ago
  Urban myth? This probably varies from place to place, but certainly all the physicians I'm close to are treated to very good food every day, and will accept occasional invitations to attend fun events with sales reps. Drug companies do their best to create an informal quid pro quo atmosphere. Many drug companies are involved, so they are clearly seeing returns from their physician influence. More overtly, drug companies pay for fancy physician association dinners, and a rep will give a presentation on their drug and hand out business cards and brochures.
  - arkades 10y ago
    First, and I want to make clear that I am strongly against any drug rep presence in any medical institution, and have advocated against it in institutions I've been affiliated with: let us draw a hard line between three levels of behavior, because conflating them is ... well, not ridiculous, not quite, but misleading. It's not ridiculous to group "slapping someone" with "beating them with a baseball bat," but it loses something. Additionally, I'm putting a firm "no" on "informal quid pro quo." Though you, I, and ever psych major on the planet knows better, most physicians firmly believe they're just being advertised to, but are not swayed by the pharmaceutical company ads. Very few of my colleagues believe they're susceptible to this sort of shenanigans. Very few would knowingly consent to partake in a "quid pro quo" arrangement of fringe benefits for prescriptions, and most would be earnestly outraged at any such suggestion. You can claim the outcomes are the same, but they're not - it speaks entirely different volumes of the characters of the people involved, and approach needed to reform. So, 3 levels: 1) Direct pay-offs from drug companies to docs This is something that has never been as commonplace as people seem to believe (eg, speaker fees), and is very nearly dead since physicians that get this money are now publicly monitored for it. It's always been rare, and remains so. So when we say "docs profit," which implies this level 1, well, let's not. 2) Physician frills paid for by drug companies This used to be quite common, and has grown much less so. It used to be "let us subsidize your trip to the bahamas for a 5-day medical conference (during which you will be pitched regularly)." That's been on the down-trend for about 2 decades, and is generally pretty rare these days. You're pretty much down to getting lunch brought to your office - and you had better believe this isn't ubiquitous, but depends on your practice (good private insurance practice of patients with lifelong autoimmune disease, and your co. has a new mAb out? Why, yes, lunch will be arriving soon. Standard PCP w/ 50% medicare, 20% medicaid, 30% private blend, general population of disease? eh, not so much). And, sure, occasionally dinner - subject to the above. Again, these have grown increasingly rare since these are now public numbers subject to scrutiny. No one wants to show up on that database, and definitely no one wants to be one of the docs that shows up in the local papers as one of the top 10 pharma whores for the year. More common is: 3) Drugs in the background Branded pens. Branded clipboards. Bullshit journals of carefully curated studies. Donations to org. meetings, which result in huge banners and the like. The chance to "educate" docs on new results: these are carefully put together study analyses meant to show the drug in its best light, not overt pitches. They're generally very well done studies earnestly presented, with their biases baked in deep in the fundamental study design (e.g., subject selection), so there's nothing for casual audience members to be able to nitpick at. It takes an old hand to catch the trickery here. 3 is really the big one. It's the tickle at the back of your brain; the easy prescription of familiarity, avoidance of the discomfort of getting that sad look from your local rep. But it's reasonably subtle, and unless you think docs are making bank on those free pens, it's not really what you'd call "profiting" in any meaningful sense. 1 & 2 are profiting, and inflammatory, and mostly a relic of the 80s and early 90s. They're also a shit-ton less effective than #3. In a transparent environment, advertising is a lot more effective than bribery. As a strong advocate for complete absence of pharma-to-MD relationships, I don't worry about the occasional bit steak lunch that most docs sit through playing on their phones; I worry about the never-ending barrage of advertisements. If you look at where pharma drops their big bucks, you'll see they share my priorities.
capote 10y ago
Can you explain more how competition, availability, and legality will stop the more addiction-prone (low-income, chronic pain among other health problem) parts of society in America from doing drugs and becoming addicted? If I read your argument correctly, it's that the pharma firms will not market it as much and not profit as much. In my mind that's not enough reasoning that people who simply have a bad situation won't reach out (to their doctor, guy next door with a prescription) and find the drug I see the experimental results in other countries that have taken steps forward on legalizing various drugs, but they also have a much better social welfare, schooling, and support system. I just don't see the connection between making a drug more available, making more versions of it, deregulating it and having less people taking it. Without your further explanation, that is.
- mwsherman 10y ago
  I don’t think legalization will reduce addiction (though would defer to empirical studies here). It would make the economic cost of addiction lower for the individual – one problem instead of two. More importantly, it would make doctors (and regulators) more honest participants. If a doctor wants to recommend opiates, it would largely remove their economic incentives for doing so. We don’t think of doctors having much economic incentive for prescribing acetaminophen or ibuprofen, by comparison.
  - SCAQTony 10y ago
    I have to agree! The bad floats with the good and likewise. From the New York Times: "Actually, Prohibition Was a Success By Mark H. Moore; Mark H. Moore is professor of criminal justice at Harvard's Kennedy School of Government." "... Second, alcohol consumption declined dramatically during Prohibition. Cirrhosis death rates for men were 29.5 per 100,000 in 1911 and 10.7 in 1929. Admissions to state mental hospitals for alcoholic psychosis declined from 10.1 per 100,000 in 1919 to 4.7 in 1928. Arrests for public drunkennness and disorderly conduct declined 50 percent between 1916 and 1922. For the population as a whole, the best estimates are that consumption of alcohol declined by 30 percent to 50 percent. Third, violent crime did not increase dramatically during Prohibition. Homicide rates rose dramatically from 1900 to 1910 but remained roughly constant during Prohibition's 14 year rule. Organized crime may have become more visible and lurid during Prohibition, but it existed before and after. ..." http://www.nytimes.com/1989/10/16/opinion/actually-prohibition-was-a-success.html http://www.nytimes.com/1989/10/16/opinion/actually-prohibiti...
hackuser 10y ago
> FDA approval ... patent protection ... scheduling it as a prescription drug ... opiates being illegal These things provide not only prohibition and costs, but also many essential services, a matter of life and death in some cases. The free market is a useful tool, but not the solution to every situation; not every issue is a nail for the free market hammer. I don't want to see how many of my neighbors die from a drug before I decide whether or not to take it.
pron 10y ago
> One can make an argument for protecting people from harming themselves. I don't have an opinion on legalization, but I don't think that's quite the argument against (even if some people express it in this way). Not all people are free to make choices in the same way, and drugs -- similarly to fast food -- hurt some communities more than others. Drugs have a social dynamics, they're not like choosing which toothpaste to use. Of course, prohibition may make matters worse instead of better, but as you say, that requires empirical study (I don't know the findings, which is why I don't have an opinion, except that the enforcement situation now is far from good).

arkades 10y ago

> Third is scheduling it as a prescription drug. The incentives of the drug company are now to influence doctors, in ways that may be more or less overt. Docs get a cut of the outsize profits, de facto. Hi! I'm a non-trad physician, with a history in health policy and managed care before moving onto the provider side. Please, tell me more about this, in a way that is more nuanced than the urban myth of "free golf trips and speaker fees for everybody!"

allenz 10y ago
Urban myth? This probably varies from place to place, but certainly all the physicians I'm close to are treated to very good food every day, and will accept occasional invitations to attend fun events with sales reps. Drug companies do their best to create an informal quid pro quo atmosphere. Many drug companies are involved, so they are clearly seeing returns from their physician influence. More overtly, drug companies pay for fancy physician association dinners, and a rep will give a presentation on their drug and hand out business cards and brochures.
- arkades 10y ago
  First, and I want to make clear that I am strongly against any drug rep presence in any medical institution, and have advocated against it in institutions I've been affiliated with: let us draw a hard line between three levels of behavior, because conflating them is ... well, not ridiculous, not quite, but misleading. It's not ridiculous to group "slapping someone" with "beating them with a baseball bat," but it loses something. Additionally, I'm putting a firm "no" on "informal quid pro quo." Though you, I, and ever psych major on the planet knows better, most physicians firmly believe they're just being advertised to, but are not swayed by the pharmaceutical company ads. Very few of my colleagues believe they're susceptible to this sort of shenanigans. Very few would knowingly consent to partake in a "quid pro quo" arrangement of fringe benefits for prescriptions, and most would be earnestly outraged at any such suggestion. You can claim the outcomes are the same, but they're not - it speaks entirely different volumes of the characters of the people involved, and approach needed to reform. So, 3 levels: 1) Direct pay-offs from drug companies to docs This is something that has never been as commonplace as people seem to believe (eg, speaker fees), and is very nearly dead since physicians that get this money are now publicly monitored for it. It's always been rare, and remains so. So when we say "docs profit," which implies this level 1, well, let's not. 2) Physician frills paid for by drug companies This used to be quite common, and has grown much less so. It used to be "let us subsidize your trip to the bahamas for a 5-day medical conference (during which you will be pitched regularly)." That's been on the down-trend for about 2 decades, and is generally pretty rare these days. You're pretty much down to getting lunch brought to your office - and you had better believe this isn't ubiquitous, but depends on your practice (good private insurance practice of patients with lifelong autoimmune disease, and your co. has a new mAb out? Why, yes, lunch will be arriving soon. Standard PCP w/ 50% medicare, 20% medicaid, 30% private blend, general population of disease? eh, not so much). And, sure, occasionally dinner - subject to the above. Again, these have grown increasingly rare since these are now public numbers subject to scrutiny. No one wants to show up on that database, and definitely no one wants to be one of the docs that shows up in the local papers as one of the top 10 pharma whores for the year. More common is: 3) Drugs in the background Branded pens. Branded clipboards. Bullshit journals of carefully curated studies. Donations to org. meetings, which result in huge banners and the like. The chance to "educate" docs on new results: these are carefully put together study analyses meant to show the drug in its best light, not overt pitches. They're generally very well done studies earnestly presented, with their biases baked in deep in the fundamental study design (e.g., subject selection), so there's nothing for casual audience members to be able to nitpick at. It takes an old hand to catch the trickery here. 3 is really the big one. It's the tickle at the back of your brain; the easy prescription of familiarity, avoidance of the discomfort of getting that sad look from your local rep. But it's reasonably subtle, and unless you think docs are making bank on those free pens, it's not really what you'd call "profiting" in any meaningful sense. 1 & 2 are profiting, and inflammatory, and mostly a relic of the 80s and early 90s. They're also a shit-ton less effective than #3. In a transparent environment, advertising is a lot more effective than bribery. As a strong advocate for complete absence of pharma-to-MD relationships, I don't worry about the occasional bit steak lunch that most docs sit through playing on their phones; I worry about the never-ending barrage of advertisements. If you look at where pharma drops their big bucks, you'll see they share my priorities.

capote 10y ago

Can you explain more how competition, availability, and legality will stop the more addiction-prone (low-income, chronic pain among other health problem) parts of society in America from doing drugs and becoming addicted? If I read your argument correctly, it's that the pharma firms will not market it as much and not profit as much. In my mind that's not enough reasoning that people who simply have a bad situation won't reach out (to their doctor, guy next door with a prescription) and find the drug I see the experimental results in other countries that have taken steps forward on legalizing various drugs, but they also have a much better social welfare, schooling, and support system. I just don't see the connection between making a drug more available, making more versions of it, deregulating it and having less people taking it. Without your further explanation, that is.

mwsherman 10y ago
I don’t think legalization will reduce addiction (though would defer to empirical studies here). It would make the economic cost of addiction lower for the individual – one problem instead of two. More importantly, it would make doctors (and regulators) more honest participants. If a doctor wants to recommend opiates, it would largely remove their economic incentives for doing so. We don’t think of doctors having much economic incentive for prescribing acetaminophen or ibuprofen, by comparison.
- SCAQTony 10y ago
  I have to agree! The bad floats with the good and likewise. From the New York Times: "Actually, Prohibition Was a Success By Mark H. Moore; Mark H. Moore is professor of criminal justice at Harvard's Kennedy School of Government." "... Second, alcohol consumption declined dramatically during Prohibition. Cirrhosis death rates for men were 29.5 per 100,000 in 1911 and 10.7 in 1929. Admissions to state mental hospitals for alcoholic psychosis declined from 10.1 per 100,000 in 1919 to 4.7 in 1928. Arrests for public drunkennness and disorderly conduct declined 50 percent between 1916 and 1922. For the population as a whole, the best estimates are that consumption of alcohol declined by 30 percent to 50 percent. Third, violent crime did not increase dramatically during Prohibition. Homicide rates rose dramatically from 1900 to 1910 but remained roughly constant during Prohibition's 14 year rule. Organized crime may have become more visible and lurid during Prohibition, but it existed before and after. ..." http://www.nytimes.com/1989/10/16/opinion/actually-prohibition-was-a-success.html http://www.nytimes.com/1989/10/16/opinion/actually-prohibiti...

hackuser 10y ago

> FDA approval ... patent protection ... scheduling it as a prescription drug ... opiates being illegal These things provide not only prohibition and costs, but also many essential services, a matter of life and death in some cases. The free market is a useful tool, but not the solution to every situation; not every issue is a nail for the free market hammer. I don't want to see how many of my neighbors die from a drug before I decide whether or not to take it.

pron 10y ago

> One can make an argument for protecting people from harming themselves. I don't have an opinion on legalization, but I don't think that's quite the argument against (even if some people express it in this way). Not all people are free to make choices in the same way, and drugs -- similarly to fast food -- hurt some communities more than others. Drugs have a social dynamics, they're not like choosing which toothpaste to use. Of course, prohibition may make matters worse instead of better, but as you say, that requires empirical study (I don't know the findings, which is why I don't have an opinion, except that the enforcement situation now is far from good).