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I understand people who think the Sacklers are villains who destroyed lives, Purdue should be shut down, and we should transform the legal regime around opioids

I understand people who think the Sacklers are villains who destroyed lives, Purdue should be shut down, and we should transform the legal regime around opioids. I understand people who think Purdue should continue, the status quo is OK, and the Sacklers are not [simply] villainous. I don't understand people who think the Sacklers are villains who destroyed lives, but Purdue should continue operating more-or-less as-is. Which is, I think, the conclusion from this settlement. If this is you, can you help me understand? Do you think there is/was a realistic way to prescribe opioids routinely and safely?

legitster 2y ago
The settlement was not at all about Purdue operating as is. Purdue was going to be turned into a legal fund and treatment provider as part of the settlement agreement.
- shawndrost 2y ago
  Under the bankruptcy settlement, Purdue will continue to sell opioids. The ownership will change (profits will be used to fund the causes you listed) but the operations will not. Right?
  - legitster 2y ago
    You know I can't actually find a lot of details about what the "new" Purdue was supposed to operate like - my understanding was that it was going to turn into a receivership under the court. But that's kind of the weirdness of all of this - at no point was OxyContin itself banned or been made illegal.
yostrovs 2y ago
I understand there's fraud and bribes and such, but it seems to me that in the end it is doctors and the medical system, with a bit of help from government regulators, that decide prescriptions, dosages, limitations and such. Purdue could have been making pure poison, but they don't prescribe anything.
- mcguire 2y ago
  Is it fraud if the pharmaceutical company falsely claims that the addiction rate is very low? If the company aggressively pushes a dose regimen that is almost designed to produce addiction?
cheeze 2y ago
Here is a good resource on it [1]. My understanding is that Purdue pushed hard for marketing, including paying doctors to market for them. This paragraph sums up most of it. > “Purdue admitted that it marketed and sold its dangerous opioid products to healthcare providers, even though it had reason to believe those providers were diverting them to abusers,” said Rachael A. Honig, First Assistant U.S. Attorney for the District of New Jersey. “The company lied to the Drug Enforcement Administration about steps it had taken to prevent such diversion, fraudulently increasing the amount of its products it was permitted to sell. Purdue also paid kickbacks to providers to encourage them to prescribe even more of its products.” Is purdue solely at fault here? Absolutely not. Does it seem that Purdue likely knew what was happening, but put profits above public health? In my opinion, yes. [1] - https://www.justice.gov/opa/pr/opioid-manufacturer-purdue-pharma-pleads-guilty-fraud-and-kickback-conspiracies https://www.justice.gov/opa/pr/opioid-manufacturer-purdue-ph...
- shawndrost 2y ago
  I understand the contents of the link; that judgement prompts my question rather than answering it. The DOJ found that old Purdue's problem was illgal marketing, kickbacks, etc. I understand that as a legalistic thing. But as far as human judgement goes: I thought the problem here was opioid addiction, which is continuing to rise in the "new Purdue" regime. We all think old Purdue should not have been doing the illegal stuff. But was the illegal stuff the real problem here? It seems like the "new Purdue" reforms are not affecting the growth of the opioid epidemic.
vikramkr 2y ago
That's not the settlement. The settlement is that purdue pays 8+ bn and shuts down, but the sacklers are immune personally. The supreme court threw out that deal saying that the sacklers can't be given immunity as a part of the deal.
Mistletoe 2y ago
I mean I have been prescribed opioids many times and I just take them as prescribed and they help the pain of the surgery or whatever. I don’t even take the whole bottle. What will replace the opioids if we don’t allow them to be prescribed?
- michael_vo 2y ago
  Could you have recovered without pain killers? Or maybe used a pain killer that is much weaker that doesn't kill all the pain but is much safer like marijuana? Are there scientific studies that shows that opioids help patients recover quicker?
  - suslik 2y ago
    Why is this question important? The primary purpose of pain medication is not to facilitate recovery, but to reduce suffering and increase quality of life.
    - michael_vo 2y ago
      Exactly! Opioids increase suffering and ruin the quality of life for hundreds of thousands of Americans. 80k+ yearly overdose deaths, plus a percentage of those using opioids for recovery become addicted to it. Is that a worthy tradeoff? I presume (could be wrong) but we did fine recovering with surgical operations 80 years ago without opioids.
      - bonzini 2y ago
        Most countries do without them now and have always done without them except in special cases such as palliative cures. You get opioids during recovery in the hospital, but not once you're discharged. You might get codeine rarely, but that's it.
      - philipkglass 2y ago
        Morphine was commonly administered for post-surgical pain 100 years ago: "The after-treatment of surgical patients, by Willard Bartlett and collaborators." (1925) https://babel.hathitrust.org/cgi/pt?id=mdp.39015071056918&seq=62 https://babel.hathitrust.org/cgi/pt?id=mdp.39015071056918&se... One of the first complaints made by the postoperative patient on returning to consciousness is pain. This if due to the actual operative procedure should be at once relieved. William J. Mayo taught us long ago to give morphine during the first twenty-four hours for the pain which we make; viz., by cutting, retracting, suturing, etc. The discomfort caused by such procedures is relieved best by this drug and it is given by us if there be no contraindications for its use, regardless of the amount until full relief is experienced or its physiologic effects obtained.
doublet00th 2y ago
I think there's a misunderstanding in what the settlement is about. As part of Purdue's bankruptcy, the Sackler family is voluntarily providing 6 billion dollars to help settle claims opioid victims have brought against Purdue Pharma. As a condition to provide the 6 billion dollars, the Sackler family has asked the bankruptcy judge to not even allow any new suits against the Sacklers related to the Opioid epidemic. This is something bankruptcy courts do regular for the company Purdue Pharma, but it is irregular when it comes to the Sackler family (this is not the entity going bankrupt!) This is the issue that went up to the Supreme Court, and the Supreme Court ruled that the protection given to the Sackler family is not something that can be given by a bankruptcy judge during the bankruptcy of Purdue Pharma. Matt Levine has a much better explanation here: https://www.bloomberg.com/opinion/articles/2024-06-27/purdue-s-bankruptcy-went-too-far https://www.bloomberg.com/opinion/articles/2024-06-27/purdue...
- brookst 2y ago
  +1 for Levine's explanation. As usual he is insightful, great at communicating a complex topic, and just fun to read.
  - ProjectArcturis 2y ago
    Matt Levine is a treasure. He is tied only with Derek Lowe for being a fantastic writer who makes complex topics understandable, interesting, and enjoyable.
- monetus 2y ago
  https://archive.ph/Co2A1 https://archive.ph/Co2A1
- Terr_ 2y ago
  To try to illustrate the (bad) principle with a starker hypothetical: 1. Scrooge McDuck owns a thousand different corporations that are restaurants and eateries. 2. A one-taco-stand company is in bankruptcy court, after recklessly inflicting severe food-poisoning on a dozen customers. 3. Scrooge McDuck says: "Out of the goodness of my heart, I will charitably donate $X of my personal funds to help these poor unfortunates... If you give me personal immunity to any lawsuits somehow involving recent food-poisoning problems anywhere." 4. The dozen hospitalized taco-eaters are puzzled but OK with this, since they'll at least get something. The judge shrugs and things move forward. 5. Meanwhile a million other customers of other restaurants see the news on their phones, which they have out because they're stuck on their toilets with raging diarrhea. Plus maybe a few whistleblowers that can't get work anywhere because Scrooge blacklisted them. 6. All of them are justifiably outraged that their rights to seek justice/compensation have been (partly) signed-away in the bankruptcy of some unrelated tiny taco stand case that they didn't--couldn't--participate in.
feoren 2y ago
Loaning money at 8% interest to informed parties is OK. Loaning money at 200% interest to vulnerable people is usury and should be illegal. Where in the middle is the right line to draw, legally? Does the intent of the lender matter? Does it matter if the lender is intentionally trying to keep people uninformed and vulnerable? These are hard questions, but that doesn't change the basic facts at the extreme ends of the spectrum. Clearly the Sacklers' behavior was in the realm of exploiting vulnerable people as much as possible in order to create a cycle of dependence. I think they're villains who destroyed lives. I don't think that means no pharmaceutical companies should be allowed to sell opioids, or that Purdue should be shut down for that reason. Clearly giving birthing women access to epidurals (fentanyl!) is OK. Clearly bribing doctors to over-prescribe addictive opioids to vulnerable people is villainous and should be illegal. It's a hard problem to find the exact right line in the middle, but it's a problem worth attempting. Obviously it involves a lot of regulatory oversight.
- thegrimmest 2y ago
  > Loaning money at 200% interest to vulnerable people is usury and should be illegal Stop with the patronizing. Any transaction between consenting parties (backed by bankruptcy protection) should be allowed. We're all grown ups, let people make their own decisions. Setting upper limits on interest rates simply makes it so that high-risk borrowers are unable to access credit. This harms those borrowers more than anyone else, by limiting their opportunities. Regarding the Sacklers, they never prescribed any drugs to anyone. Doctors did. Why aren't we holding them responsible? It is doctors who have a duty of care to their patients, not pharmaceutical companies.
  - ClumsyPilot 2y ago
    > Stop with the patronizing. Any transaction between consenting parties (backed by bankruptcy protection) should be allowed. Any? Can I sell my kidney? You are arguing an extreme minority opinion, consumer protection laws exist because it is not possible for an average consumer to understand all safety implications of vehicle design, house construction or a medical procedure.
glitch13 2y ago
The ruling was only about whether or not a bankruptcy court has the legal authority to declare that the individual members of the Sackler family are immune to being sued directly, which is an agreed-upon condition of the bankruptcy settlement. SCOTUS ruled that it did not, so the settlement as it stands is dead. Purdue is not going to be operating in any capacity regardless of this ruling (except as a bank account holding the settlement funds).
wesselbindt 2y ago
The only way is if it is done without a profit driven system incentivizing their overprescription. But this requires a gigantic systemic overhaul of healthcare to a nationalized system. And there seems to be a lot of peer reviewed evidence in favor of such a system, and there seems to be broad popular support for such a system. Yet we never manage to get there. It's almost like there's a group of people who simultaneously benefit from its existence and have the capital to influence legislation in their favor. Feels almost undemocratic.
fnordpiglet 2y ago
1) I don’t think this is an accurate read of the situation but others discuss that 2) a company is a set of processes and infrastructure, with some legal rights to employ people etc. The decisions of a driver of a car are the drivers fault not the cars. The car itself may be unsafe and should be adjusted if it’s possible. But there is no point in destroying the car if it has utility with different drivers and safety. Revenge isn’t a good reason to dismantle infrastructure. Revenge can only be taken on humans. 3) yes if you know people with chronic pain opioids are the difference between a full life and an early suicide. The consequence of all this is all opioid use is treated as potentially criminal by everyone involved from pharmacies to doctors to patients. This isn’t a feature this is a flaw. And the lack of legal opioid access is leading chronic sufferers into fentanyl from the street.
nonethewiser 2y ago
> I don't understand people who think the Sacklers are villains who destroyed lives, but Purdue should continue operating more-or-less as-is. Which is, I think, the conclusion from this settlement. If this is you, can you help me understand? Do you think there is/was a realistic way to prescribe opioids routinely and safely? This is an extremely easy answer that doesn’t require any details of the case. The supreme court clarifies what the law is, not if the Sacklers are villains and if Purdue should continue. So the people who think the the Sacklers are Villains and that Pursue should continue are people who believe the settlement is not legal and dont believe in legislating from the bench.
darawk 2y ago
Yes of course there are realistic ways to prescribe opioids routine and safely. Purdue did not invent opioids, what they did is patent a particularly strong formulation, and then work to undermine the cultural taboo in medicine around their use. That last thing was their crime. There isn't, at this time, any other way to treat serious pain (in all cases). Opioid prescriptions will continue to be an unfortunately necessary feature of our medical system until we invent painkillers strong/good enough to replace them. I say this as someone who was personally addicted to opioids in general and Oxycontin in particular and feel very lucky to have only one dead friend as a result. Opioids can't be banned until we can replace them with something equally generally effective. But what we should do is reinstate the taboo around prescribing them, and probably stop offering take home fentanyl prescriptions at all (it's still useful for anaesthesia, in hospitals). Perhaps more importantly, I think the cat is kind of out of the bag on prescriptions. I haven't been around that world for a long time, but it seems to me like pharmaceuticals aren't the primary entrypoint to opioid addiction anymore - people just start with fentanyl. Dealing with fentanyl seems to me to be basically impossible. One kilogram of pure fentanyl is ~2,000,000 doses, for someone without a tolerance. This is impossible to interdict at the border. It is also fully synthetic, with no great choke point on synthesis routes. I have heard that there are other, even more dangerous, compounds like https://en.wikipedia.org/wiki/Etonitazene https://en.wikipedia.org/wiki/Etonitazene that are also even easier to synthesize. I don't really know if there is a good way out of this other than doing the slightly less impossible thing, which is curing addiction.
- thegrimmest 2y ago
  > That last thing was their crime Taboos are bullshit. Either something is a clearly articulated, written, rule with an enforcement mechanism, or it's fair game. Prescribing doctors are responsible for the opioid epidemic. Doctors failed in their duty of care to patients. Doctors massively overprescribed, failed to track their patient's medication usage, and failed to spot addictive behaviour. Why aren't we holding them responsible? Simply because that's hard to do?
  - doctorpangloss 2y ago
    Nobody is forcing you to see any doctors for any of your problems. That's pretty reductive, right? Well so is what you are saying.
ninetyninenine 2y ago
Here's a way to help you understand. Let's say I gave you 1 million dollars to help you understand. Then would you understand? That's likely how other people started understanding the situation. Something along those lines. Something this obviously wrong, some sort of coercion or bribery or some other shady thing has got to be a part of it.
ClumsyPilot 2y ago
> I don't understand people who think the Sacklers are villains who destroyed lives, but Purdue should continue operating more-or-less as-is I’ve got a friend that’s the same in Afghanistan - he thinks it was right to go in, and it was right to abandon it - which to me sounds like moral myopia. Surely it was either wrong to begin with, or you have to stick around.

legitster 2y ago

The settlement was not at all about Purdue operating as is. Purdue was going to be turned into a legal fund and treatment provider as part of the settlement agreement.

shawndrost 2y ago
Under the bankruptcy settlement, Purdue will continue to sell opioids. The ownership will change (profits will be used to fund the causes you listed) but the operations will not. Right?
- legitster 2y ago
  You know I can't actually find a lot of details about what the "new" Purdue was supposed to operate like - my understanding was that it was going to turn into a receivership under the court. But that's kind of the weirdness of all of this - at no point was OxyContin itself banned or been made illegal.

yostrovs 2y ago

I understand there's fraud and bribes and such, but it seems to me that in the end it is doctors and the medical system, with a bit of help from government regulators, that decide prescriptions, dosages, limitations and such. Purdue could have been making pure poison, but they don't prescribe anything.

mcguire 2y ago
Is it fraud if the pharmaceutical company falsely claims that the addiction rate is very low? If the company aggressively pushes a dose regimen that is almost designed to produce addiction?

cheeze 2y ago

Here is a good resource on it [1]. My understanding is that Purdue pushed hard for marketing, including paying doctors to market for them. This paragraph sums up most of it. > “Purdue admitted that it marketed and sold its dangerous opioid products to healthcare providers, even though it had reason to believe those providers were diverting them to abusers,” said Rachael A. Honig, First Assistant U.S. Attorney for the District of New Jersey. “The company lied to the Drug Enforcement Administration about steps it had taken to prevent such diversion, fraudulently increasing the amount of its products it was permitted to sell. Purdue also paid kickbacks to providers to encourage them to prescribe even more of its products.” Is purdue solely at fault here? Absolutely not. Does it seem that Purdue likely knew what was happening, but put profits above public health? In my opinion, yes. [1] - https://www.justice.gov/opa/pr/opioid-manufacturer-purdue-pharma-pleads-guilty-fraud-and-kickback-conspiracies https://www.justice.gov/opa/pr/opioid-manufacturer-purdue-ph...

shawndrost 2y ago
I understand the contents of the link; that judgement prompts my question rather than answering it. The DOJ found that old Purdue's problem was illgal marketing, kickbacks, etc. I understand that as a legalistic thing. But as far as human judgement goes: I thought the problem here was opioid addiction, which is continuing to rise in the "new Purdue" regime. We all think old Purdue should not have been doing the illegal stuff. But was the illegal stuff the real problem here? It seems like the "new Purdue" reforms are not affecting the growth of the opioid epidemic.

vikramkr 2y ago

That's not the settlement. The settlement is that purdue pays 8+ bn and shuts down, but the sacklers are immune personally. The supreme court threw out that deal saying that the sacklers can't be given immunity as a part of the deal.

Mistletoe 2y ago

I mean I have been prescribed opioids many times and I just take them as prescribed and they help the pain of the surgery or whatever. I don’t even take the whole bottle. What will replace the opioids if we don’t allow them to be prescribed?

michael_vo 2y ago
Could you have recovered without pain killers? Or maybe used a pain killer that is much weaker that doesn't kill all the pain but is much safer like marijuana? Are there scientific studies that shows that opioids help patients recover quicker?
- suslik 2y ago
  Why is this question important? The primary purpose of pain medication is not to facilitate recovery, but to reduce suffering and increase quality of life.
  - michael_vo 2y ago
    Exactly! Opioids increase suffering and ruin the quality of life for hundreds of thousands of Americans. 80k+ yearly overdose deaths, plus a percentage of those using opioids for recovery become addicted to it. Is that a worthy tradeoff? I presume (could be wrong) but we did fine recovering with surgical operations 80 years ago without opioids.
    - bonzini 2y ago
      Most countries do without them now and have always done without them except in special cases such as palliative cures. You get opioids during recovery in the hospital, but not once you're discharged. You might get codeine rarely, but that's it.
    - philipkglass 2y ago
      Morphine was commonly administered for post-surgical pain 100 years ago: "The after-treatment of surgical patients, by Willard Bartlett and collaborators." (1925) https://babel.hathitrust.org/cgi/pt?id=mdp.39015071056918&seq=62 https://babel.hathitrust.org/cgi/pt?id=mdp.39015071056918&se... One of the first complaints made by the postoperative patient on returning to consciousness is pain. This if due to the actual operative procedure should be at once relieved. William J. Mayo taught us long ago to give morphine during the first twenty-four hours for the pain which we make; viz., by cutting, retracting, suturing, etc. The discomfort caused by such procedures is relieved best by this drug and it is given by us if there be no contraindications for its use, regardless of the amount until full relief is experienced or its physiologic effects obtained.

doublet00th 2y ago

I think there's a misunderstanding in what the settlement is about. As part of Purdue's bankruptcy, the Sackler family is voluntarily providing 6 billion dollars to help settle claims opioid victims have brought against Purdue Pharma. As a condition to provide the 6 billion dollars, the Sackler family has asked the bankruptcy judge to not even allow any new suits against the Sacklers related to the Opioid epidemic. This is something bankruptcy courts do regular for the company Purdue Pharma, but it is irregular when it comes to the Sackler family (this is not the entity going bankrupt!) This is the issue that went up to the Supreme Court, and the Supreme Court ruled that the protection given to the Sackler family is not something that can be given by a bankruptcy judge during the bankruptcy of Purdue Pharma. Matt Levine has a much better explanation here: https://www.bloomberg.com/opinion/articles/2024-06-27/purdue-s-bankruptcy-went-too-far https://www.bloomberg.com/opinion/articles/2024-06-27/purdue...

brookst 2y ago
+1 for Levine's explanation. As usual he is insightful, great at communicating a complex topic, and just fun to read.
- ProjectArcturis 2y ago
  Matt Levine is a treasure. He is tied only with Derek Lowe for being a fantastic writer who makes complex topics understandable, interesting, and enjoyable.
monetus 2y ago
https://archive.ph/Co2A1 https://archive.ph/Co2A1
Terr_ 2y ago
To try to illustrate the (bad) principle with a starker hypothetical: 1. Scrooge McDuck owns a thousand different corporations that are restaurants and eateries. 2. A one-taco-stand company is in bankruptcy court, after recklessly inflicting severe food-poisoning on a dozen customers. 3. Scrooge McDuck says: "Out of the goodness of my heart, I will charitably donate $X of my personal funds to help these poor unfortunates... If you give me personal immunity to any lawsuits somehow involving recent food-poisoning problems anywhere." 4. The dozen hospitalized taco-eaters are puzzled but OK with this, since they'll at least get something. The judge shrugs and things move forward. 5. Meanwhile a million other customers of other restaurants see the news on their phones, which they have out because they're stuck on their toilets with raging diarrhea. Plus maybe a few whistleblowers that can't get work anywhere because Scrooge blacklisted them. 6. All of them are justifiably outraged that their rights to seek justice/compensation have been (partly) signed-away in the bankruptcy of some unrelated tiny taco stand case that they didn't--couldn't--participate in.

feoren 2y ago

Loaning money at 8% interest to informed parties is OK. Loaning money at 200% interest to vulnerable people is usury and should be illegal. Where in the middle is the right line to draw, legally? Does the intent of the lender matter? Does it matter if the lender is intentionally trying to keep people uninformed and vulnerable? These are hard questions, but that doesn't change the basic facts at the extreme ends of the spectrum. Clearly the Sacklers' behavior was in the realm of exploiting vulnerable people as much as possible in order to create a cycle of dependence. I think they're villains who destroyed lives. I don't think that means no pharmaceutical companies should be allowed to sell opioids, or that Purdue should be shut down for that reason. Clearly giving birthing women access to epidurals (fentanyl!) is OK. Clearly bribing doctors to over-prescribe addictive opioids to vulnerable people is villainous and should be illegal. It's a hard problem to find the exact right line in the middle, but it's a problem worth attempting. Obviously it involves a lot of regulatory oversight.

thegrimmest 2y ago
> Loaning money at 200% interest to vulnerable people is usury and should be illegal Stop with the patronizing. Any transaction between consenting parties (backed by bankruptcy protection) should be allowed. We're all grown ups, let people make their own decisions. Setting upper limits on interest rates simply makes it so that high-risk borrowers are unable to access credit. This harms those borrowers more than anyone else, by limiting their opportunities. Regarding the Sacklers, they never prescribed any drugs to anyone. Doctors did. Why aren't we holding them responsible? It is doctors who have a duty of care to their patients, not pharmaceutical companies.
- ClumsyPilot 2y ago
  > Stop with the patronizing. Any transaction between consenting parties (backed by bankruptcy protection) should be allowed. Any? Can I sell my kidney? You are arguing an extreme minority opinion, consumer protection laws exist because it is not possible for an average consumer to understand all safety implications of vehicle design, house construction or a medical procedure.

glitch13 2y ago

The ruling was only about whether or not a bankruptcy court has the legal authority to declare that the individual members of the Sackler family are immune to being sued directly, which is an agreed-upon condition of the bankruptcy settlement. SCOTUS ruled that it did not, so the settlement as it stands is dead. Purdue is not going to be operating in any capacity regardless of this ruling (except as a bank account holding the settlement funds).

wesselbindt 2y ago

The only way is if it is done without a profit driven system incentivizing their overprescription. But this requires a gigantic systemic overhaul of healthcare to a nationalized system. And there seems to be a lot of peer reviewed evidence in favor of such a system, and there seems to be broad popular support for such a system. Yet we never manage to get there. It's almost like there's a group of people who simultaneously benefit from its existence and have the capital to influence legislation in their favor. Feels almost undemocratic.

fnordpiglet 2y ago

1) I don’t think this is an accurate read of the situation but others discuss that 2) a company is a set of processes and infrastructure, with some legal rights to employ people etc. The decisions of a driver of a car are the drivers fault not the cars. The car itself may be unsafe and should be adjusted if it’s possible. But there is no point in destroying the car if it has utility with different drivers and safety. Revenge isn’t a good reason to dismantle infrastructure. Revenge can only be taken on humans. 3) yes if you know people with chronic pain opioids are the difference between a full life and an early suicide. The consequence of all this is all opioid use is treated as potentially criminal by everyone involved from pharmacies to doctors to patients. This isn’t a feature this is a flaw. And the lack of legal opioid access is leading chronic sufferers into fentanyl from the street.

nonethewiser 2y ago

> I don't understand people who think the Sacklers are villains who destroyed lives, but Purdue should continue operating more-or-less as-is. Which is, I think, the conclusion from this settlement. If this is you, can you help me understand? Do you think there is/was a realistic way to prescribe opioids routinely and safely? This is an extremely easy answer that doesn’t require any details of the case. The supreme court clarifies what the law is, not if the Sacklers are villains and if Purdue should continue. So the people who think the the Sacklers are Villains and that Pursue should continue are people who believe the settlement is not legal and dont believe in legislating from the bench.

darawk 2y ago

Yes of course there are realistic ways to prescribe opioids routine and safely. Purdue did not invent opioids, what they did is patent a particularly strong formulation, and then work to undermine the cultural taboo in medicine around their use. That last thing was their crime. There isn't, at this time, any other way to treat serious pain (in all cases). Opioid prescriptions will continue to be an unfortunately necessary feature of our medical system until we invent painkillers strong/good enough to replace them. I say this as someone who was personally addicted to opioids in general and Oxycontin in particular and feel very lucky to have only one dead friend as a result. Opioids can't be banned until we can replace them with something equally generally effective. But what we should do is reinstate the taboo around prescribing them, and probably stop offering take home fentanyl prescriptions at all (it's still useful for anaesthesia, in hospitals). Perhaps more importantly, I think the cat is kind of out of the bag on prescriptions. I haven't been around that world for a long time, but it seems to me like pharmaceuticals aren't the primary entrypoint to opioid addiction anymore - people just start with fentanyl. Dealing with fentanyl seems to me to be basically impossible. One kilogram of pure fentanyl is ~2,000,000 doses, for someone without a tolerance. This is impossible to interdict at the border. It is also fully synthetic, with no great choke point on synthesis routes. I have heard that there are other, even more dangerous, compounds like https://en.wikipedia.org/wiki/Etonitazene https://en.wikipedia.org/wiki/Etonitazene that are also even easier to synthesize. I don't really know if there is a good way out of this other than doing the slightly less impossible thing, which is curing addiction.

thegrimmest 2y ago
> That last thing was their crime Taboos are bullshit. Either something is a clearly articulated, written, rule with an enforcement mechanism, or it's fair game. Prescribing doctors are responsible for the opioid epidemic. Doctors failed in their duty of care to patients. Doctors massively overprescribed, failed to track their patient's medication usage, and failed to spot addictive behaviour. Why aren't we holding them responsible? Simply because that's hard to do?
- doctorpangloss 2y ago
  Nobody is forcing you to see any doctors for any of your problems. That's pretty reductive, right? Well so is what you are saying.

ninetyninenine 2y ago

Here's a way to help you understand. Let's say I gave you 1 million dollars to help you understand. Then would you understand? That's likely how other people started understanding the situation. Something along those lines. Something this obviously wrong, some sort of coercion or bribery or some other shady thing has got to be a part of it.

ClumsyPilot 2y ago

> I don't understand people who think the Sacklers are villains who destroyed lives, but Purdue should continue operating more-or-less as-is I’ve got a friend that’s the same in Afghanistan - he thinks it was right to go in, and it was right to abandon it - which to me sounds like moral myopia. Surely it was either wrong to begin with, or you have to stick around.