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> 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 gam

> 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.
worik 2y ago
> Either something is a clearly articulated, written, rule with an enforcement mechanism, or it's fair game. No. There are many legal and bad things. Laws are a boundary, that few of us need. Laws are not a target
- thegrimmest 2y ago
  I would argue that fiduciary responsibility mandates that corporate leaders do everything right up to the legal boundary in pursuit of their shareholders interests. In fact profitably violating regulations would also be the right thing to do in this case. Certainly most shareholders seem to appoint executives that do exactly that.
  - worik 2y ago
    > corporate leaders do everything right up to the legal boundary in pursuit of their shareholders interests. Yes, that happens Those are evil, short sighted people, sociopaths, who should not be emulated
    - thegrimmest 2y ago
      Sociopaths and other dark triad types have been the driving force in unifying and leading people since prehistory. It takes exactly that kind of person to unite tribes of strangers in order to go conquer, subjugate, and murder your neighbours. "Evil" is immaterial. Markets and society are ecosystems, and the optimal patterns of behaviour in ecosystems are as ruthless as they are predictable.
      - worik 2y ago
        > "Evil" is immaterial. No. Never
- jjk166 2y ago
  Taboos are not simply undesirable things, they are rules which carry severe penalties if you break them. The difference is that rather than going through the effort of getting society on the same page and agreeing what is okay and what isn't, you instead leave ambiguity that harms the well meaning and benefits the malicious. If something is bad enough that it should be banned by an unwritten rule, it's bad enough to be banned by a written rule. If you aren't willing to ban something by law, then it ought to be permissible.
  - worik 2y ago
    I am not a lawyer. I am from a legal family (three generations) and I understand jurisprudence > you instead leave ambiguity that harms the well meaning and benefits the malicious. Two points 1. Law advantages those with access, and often benefits the malicious and harms the good. Case in point: Drug law. Another is IP law 2. Law is not objective. The words that form it are in black and white, but there are courts and judges because the application of the law is subjective. The boundary cases are numerous and important More generally.... > If something is bad enough that it should be banned by an unwritten rule, it's bad enough to be banned by a written rule. Sotp, just stop! This is the idea that we must punish and scantion people into being good. I think of things that are good (like treating drug addicts as ill, not criminal or imoral). I think not of "bans". They accomplish little. Permissible, impermissible, these are blunt concepts that are not very useful. We can be, and should be, aspirational and collegial not judgemental and competitive
    - jjk166 2y ago
      > Sotp, just stop! This is the idea that we must punish and scantion people into being good. You're not understanding what this conversation is about. Taboos punish and sanction people into being good. We are in full agreement that this is undesirable. There are some things that should be banned, and if they should be banned, they should be banned explicitly. There are many other things that should not be banned, and if it should not be banned it should not be a taboo, which is a form of ban. You give a perfect example for my argument - treating drug addiction as an illness that should be treated instead of a moral failure to be punished. Where drug use is a taboo, you can't treat it; eliminating the taboo and accepting that these are people in need of help is, in my and many other people's opinion, the correct course of action. Most would agree that making drug use legal but ostracizing drug users would be an absurd strategy. Taboos are fundamentally about what is permissible and impermissible, there is no other framework in which to talk about them.
mcguire 2y ago
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.) "The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/) "The Family That Built an Empire of Pain" (https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain https://www.newyorker.com/magazine/2017/10/30/the-family-tha...)
- thegrimmest 2y ago
  Blindly listening to a company trying to sell you something has never been a good idea. Doctors doing just that despite the clear, obvious, conflict of interest is their failure, not Purdue's. Thinking that an individual or organization with a vested interest will not bullshit you at every turn is absurdly naive. This is why third-party testing, accreditation, certification, and audits are a thing. > doctors who weren't pain specialists Then they should have insisted on third party, board approved, usage guidelines; especially when it became obvious that OxyContin is highly addictive. It doesn't take that long. Doctors have not however been held responsible for their abject failure towards their patients, and continue to prescribe a month's worth of Oxy for minor issues. This will continue until doctors start losing their licenses.
  - mcguire 2y ago
    Everyone in every industry that I know about relies on true information from their suppliers, from software to produce. They're the ones who know about the products, after all. In fact, pharmaceuticals are the one industry most likely to treat suppliers at adversaries, with FDA regulations continually attacked as too stringent. Purdue was actively lying about their drugs. "Purdue trained its sales representatives to carry the message that the risk of addiction was “less than one percent.”50(p99) The company cited studies by Porter and Jick,51 who found iatrogenic addiction in only 4 of 11 882 patients using opioids and by Perry and Heidrich,52 who found no addiction among 10 000 burn patients treated with opioids. Both of these studies, although shedding some light on the risk of addiction for acute pain, do not help establish the risk of iatrogenic addiction when opioids are used daily for a prolonged time in treating chronic pain. There are a number of studies, however, that demonstrate that in the treatment of chronic non–cancer-related pain with opioids, there is a high incidence of prescription drug abuse. Prescription drug abuse in a substantial minority of chronic-pain patients has been demonstrated in studies by Fishbain et al. (3%–18% of patients),53 Hoffman et al. (23%),54 Kouyanou et al. (12%),55 Chabal et al. (34%),56 Katz et al. (43%),57 Reid et al. (24%–31%),58 and Michna et al. (45%).59 A recent literature review showed that the prevalence of addiction in patients with long-term opioid treatment for chronic non–cancer-related pain varied from 0% to 50%, depending on the criteria used and the subpopulation studied.60" "The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/) "Purdue has known about the problem for decades. Even before OxyContin went on the market, clinical trials showed many patients weren’t getting 12 hours of relief. Since the drug’s debut in 1996, the company has been confronted with additional evidence, including complaints from doctors, reports from its own sales reps and independent research. "When many doctors began prescribing OxyContin at shorter intervals in the late 1990s, Purdue executives mobilized hundreds of sales reps to “refocus” physicians on 12-hour dosing. Anything shorter “needs to be nipped in the bud. NOW!!” one manager wrote to her staff." "‘You want a description of hell?’ OxyContin’s 12-hour problem" (https://www.latimes.com/projects/oxycontin-part1/ https://www.latimes.com/projects/oxycontin-part1/) From what I've seen (women sent home days after a c-section with Ibuprofen as the only pain medication; all of the doctors near me displaying signs saying they will not treat chronic pain), pain medication may well be under-prescribed at this point.
darawk 2y ago
> Prescribing doctors are responsible for the opioid epidemic. Doctors failed in their duty of care to patients. Doctors 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? This is a nice idea, but most Oxycontin is not prescribed by someone's doctor (it is prescribed by a doctor, but it is power-law distributed, most of it is sold by dealers). There are a small number of doctors in the country at any given time that prescribe almost all of the supply. This is not something you can readily fix with responsibility at the doctor level. It may seem like you can, because you could just prosecute "those doctors", but the problem is that the incentives are too concentrated. That isn't to absolve these individuals of responsibility. They are responsible, and we should prosecute them legally. The problem is that we already do and always have. We should keep doing it, but I don't expect it to fix anything. EDIT: To be clear I'm not necessarily for or against this settlement. There was a time that we might have stopped the opioid crisis at the corporate or pharmaceutical level, but that time has long since past. We could criminalize all opioids tomorrow and it would make almost no difference. Most opioid addicts use fentanyl now, and most fentanyl is produced/sold illegally. Heroin, for instance, has been Schedule I forever - the only thing that reduced its popularity was a cheaper substitute in fentanyl. If we are going to bother prosecuting or civilly charging Purdue or its principals, it would have to be for purely punitive reasons. Corporate behavior unfortunately does not matter anymore.
- thegrimmest 2y ago
  The on-ramp from minor pain or surgery; to a massive, blindly-renewed, over-prescription of Oxy; to an opioid addiction that spirals into street drugs is still mediated by doctors. Until these doctors start losing their licenses for their clear and obvious breaches in their duty of care, this on-ramp will remain open. > a small number of doctors in the country at any given time that prescribe almost all of the supply The fact that medical boards allow these doctors to retain their licenses is the core of the issue. > we already do and always have I am only aware of a handful of the most obvious, blatant, and egregious pill mill operators being prosecuted. Regular doctors who simply cannot be fucked to care for their patients, and prescribe them pills so they leave their office, have yet to be held accountable.
burnished 2y ago
Taboos are part of how a society functions. Taboos can prevent the 'tragedy of the commons' in a way that rules and laws cannot. Think about it - people break the law all the time. They rarely break taboos.

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.

worik 2y ago

> Either something is a clearly articulated, written, rule with an enforcement mechanism, or it's fair game. No. There are many legal and bad things. Laws are a boundary, that few of us need. Laws are not a target

thegrimmest 2y ago
I would argue that fiduciary responsibility mandates that corporate leaders do everything right up to the legal boundary in pursuit of their shareholders interests. In fact profitably violating regulations would also be the right thing to do in this case. Certainly most shareholders seem to appoint executives that do exactly that.
- worik 2y ago
  > corporate leaders do everything right up to the legal boundary in pursuit of their shareholders interests. Yes, that happens Those are evil, short sighted people, sociopaths, who should not be emulated
  - thegrimmest 2y ago
    Sociopaths and other dark triad types have been the driving force in unifying and leading people since prehistory. It takes exactly that kind of person to unite tribes of strangers in order to go conquer, subjugate, and murder your neighbours. "Evil" is immaterial. Markets and society are ecosystems, and the optimal patterns of behaviour in ecosystems are as ruthless as they are predictable.
    - worik 2y ago
      > "Evil" is immaterial. No. Never
jjk166 2y ago
Taboos are not simply undesirable things, they are rules which carry severe penalties if you break them. The difference is that rather than going through the effort of getting society on the same page and agreeing what is okay and what isn't, you instead leave ambiguity that harms the well meaning and benefits the malicious. If something is bad enough that it should be banned by an unwritten rule, it's bad enough to be banned by a written rule. If you aren't willing to ban something by law, then it ought to be permissible.
- worik 2y ago
  I am not a lawyer. I am from a legal family (three generations) and I understand jurisprudence > you instead leave ambiguity that harms the well meaning and benefits the malicious. Two points 1. Law advantages those with access, and often benefits the malicious and harms the good. Case in point: Drug law. Another is IP law 2. Law is not objective. The words that form it are in black and white, but there are courts and judges because the application of the law is subjective. The boundary cases are numerous and important More generally.... > If something is bad enough that it should be banned by an unwritten rule, it's bad enough to be banned by a written rule. Sotp, just stop! This is the idea that we must punish and scantion people into being good. I think of things that are good (like treating drug addicts as ill, not criminal or imoral). I think not of "bans". They accomplish little. Permissible, impermissible, these are blunt concepts that are not very useful. We can be, and should be, aspirational and collegial not judgemental and competitive
  - jjk166 2y ago
    > Sotp, just stop! This is the idea that we must punish and scantion people into being good. You're not understanding what this conversation is about. Taboos punish and sanction people into being good. We are in full agreement that this is undesirable. There are some things that should be banned, and if they should be banned, they should be banned explicitly. There are many other things that should not be banned, and if it should not be banned it should not be a taboo, which is a form of ban. You give a perfect example for my argument - treating drug addiction as an illness that should be treated instead of a moral failure to be punished. Where drug use is a taboo, you can't treat it; eliminating the taboo and accepting that these are people in need of help is, in my and many other people's opinion, the correct course of action. Most would agree that making drug use legal but ostracizing drug users would be an absurd strategy. Taboos are fundamentally about what is permissible and impermissible, there is no other framework in which to talk about them.

mcguire 2y ago

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.) "The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/) "The Family That Built an Empire of Pain" (https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain https://www.newyorker.com/magazine/2017/10/30/the-family-tha...)

thegrimmest 2y ago
Blindly listening to a company trying to sell you something has never been a good idea. Doctors doing just that despite the clear, obvious, conflict of interest is their failure, not Purdue's. Thinking that an individual or organization with a vested interest will not bullshit you at every turn is absurdly naive. This is why third-party testing, accreditation, certification, and audits are a thing. > doctors who weren't pain specialists Then they should have insisted on third party, board approved, usage guidelines; especially when it became obvious that OxyContin is highly addictive. It doesn't take that long. Doctors have not however been held responsible for their abject failure towards their patients, and continue to prescribe a month's worth of Oxy for minor issues. This will continue until doctors start losing their licenses.
- mcguire 2y ago
  Everyone in every industry that I know about relies on true information from their suppliers, from software to produce. They're the ones who know about the products, after all. In fact, pharmaceuticals are the one industry most likely to treat suppliers at adversaries, with FDA regulations continually attacked as too stringent. Purdue was actively lying about their drugs. "Purdue trained its sales representatives to carry the message that the risk of addiction was “less than one percent.”50(p99) The company cited studies by Porter and Jick,51 who found iatrogenic addiction in only 4 of 11 882 patients using opioids and by Perry and Heidrich,52 who found no addiction among 10 000 burn patients treated with opioids. Both of these studies, although shedding some light on the risk of addiction for acute pain, do not help establish the risk of iatrogenic addiction when opioids are used daily for a prolonged time in treating chronic pain. There are a number of studies, however, that demonstrate that in the treatment of chronic non–cancer-related pain with opioids, there is a high incidence of prescription drug abuse. Prescription drug abuse in a substantial minority of chronic-pain patients has been demonstrated in studies by Fishbain et al. (3%–18% of patients),53 Hoffman et al. (23%),54 Kouyanou et al. (12%),55 Chabal et al. (34%),56 Katz et al. (43%),57 Reid et al. (24%–31%),58 and Michna et al. (45%).59 A recent literature review showed that the prevalence of addiction in patients with long-term opioid treatment for chronic non–cancer-related pain varied from 0% to 50%, depending on the criteria used and the subpopulation studied.60" "The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/) "Purdue has known about the problem for decades. Even before OxyContin went on the market, clinical trials showed many patients weren’t getting 12 hours of relief. Since the drug’s debut in 1996, the company has been confronted with additional evidence, including complaints from doctors, reports from its own sales reps and independent research. "When many doctors began prescribing OxyContin at shorter intervals in the late 1990s, Purdue executives mobilized hundreds of sales reps to “refocus” physicians on 12-hour dosing. Anything shorter “needs to be nipped in the bud. NOW!!” one manager wrote to her staff." "‘You want a description of hell?’ OxyContin’s 12-hour problem" (https://www.latimes.com/projects/oxycontin-part1/ https://www.latimes.com/projects/oxycontin-part1/) From what I've seen (women sent home days after a c-section with Ibuprofen as the only pain medication; all of the doctors near me displaying signs saying they will not treat chronic pain), pain medication may well be under-prescribed at this point.

darawk 2y ago

> Prescribing doctors are responsible for the opioid epidemic. Doctors failed in their duty of care to patients. Doctors 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? This is a nice idea, but most Oxycontin is not prescribed by someone's doctor (it is prescribed by a doctor, but it is power-law distributed, most of it is sold by dealers). There are a small number of doctors in the country at any given time that prescribe almost all of the supply. This is not something you can readily fix with responsibility at the doctor level. It may seem like you can, because you could just prosecute "those doctors", but the problem is that the incentives are too concentrated. That isn't to absolve these individuals of responsibility. They are responsible, and we should prosecute them legally. The problem is that we already do and always have. We should keep doing it, but I don't expect it to fix anything. EDIT: To be clear I'm not necessarily for or against this settlement. There was a time that we might have stopped the opioid crisis at the corporate or pharmaceutical level, but that time has long since past. We could criminalize all opioids tomorrow and it would make almost no difference. Most opioid addicts use fentanyl now, and most fentanyl is produced/sold illegally. Heroin, for instance, has been Schedule I forever - the only thing that reduced its popularity was a cheaper substitute in fentanyl. If we are going to bother prosecuting or civilly charging Purdue or its principals, it would have to be for purely punitive reasons. Corporate behavior unfortunately does not matter anymore.

thegrimmest 2y ago
The on-ramp from minor pain or surgery; to a massive, blindly-renewed, over-prescription of Oxy; to an opioid addiction that spirals into street drugs is still mediated by doctors. Until these doctors start losing their licenses for their clear and obvious breaches in their duty of care, this on-ramp will remain open. > a small number of doctors in the country at any given time that prescribe almost all of the supply The fact that medical boards allow these doctors to retain their licenses is the core of the issue. > we already do and always have I am only aware of a handful of the most obvious, blatant, and egregious pill mill operators being prosecuted. Regular doctors who simply cannot be fucked to care for their patients, and prescribe them pills so they leave their office, have yet to be held accountable.

burnished 2y ago

Taboos are part of how a society functions. Taboos can prevent the 'tragedy of the commons' in a way that rules and laws cannot. Think about it - people break the law all the time. They rarely break taboos.