
I was a drug rep and know how pharma companies pushed opioids - vo2maxer
https://www.washingtonpost.com/outlook/i-was-a-drug-rep-i-know-how-pharma-companies-pushed-opioids/2019/11/25/82b1da88-beb9-11e9-9b73-fd3c65ef8f9c_story.html
======
RupertEisenhart
I find it pretty terrifying how many people there are in here jumping to
defend opioids. Seems kinda off-topic for an article about how predatory
practices in marketing potentially harmful substances can be problematic.

I mean, nobody is suggesting that opiods shouldn't be used to treat pain, are
they? They are just saying that that misinformation campaigns run for the
purpose of increasing profit at the expense of human lives isn't a great
thing.

~~~
philwelch
> nobody is suggesting that opiods shouldn't be used to treat pain, are they?

If there's enough overreaction to opioid dependency, it _does_ impede the use
of opioids to treat pain. Making it harder to get opioids also, typically,
makes it harder to get opioids to treat pain. Bureaucratic systems, put
simply, suck.

Whenever you talk about the "opioid epidemic", a large part of what you're
talking about is people buying heroin and fentanyl from drug dealers. Making
it harder to get oxycodone does zero to stop people from buying heroin and
fentanyl on the street. It does a hell of a lot to stop the use of oxycodone
to treat pain.

~~~
shermozle
This is exactly what's happened in Australia. Over-the-counter opioids
(codeine, primarily) were banned last year. People were destroying their
livers and stomachs due to overdosing on the adulterants
(paracetomol/acetaminophen and ibuprofen) that were specifically put in to
stop people taking them in bulk.

Now ordinary people with ordinary aches and pains can't get effective
painkillers without visiting a doctor (or a quick trip to NZ where they're
still available).

~~~
adrianN
Ibuprofen always worked for my ordinary aches. I find it justified to require
a visit to a doctor if the pain doesn't react to Ibuprofen.

~~~
shermozle
Ibuprofen fucks my stomach. Paracetamol does nothing for me for pain (as
predicted by the literature). Mild opiates like codeine kill it dead. And
taking it once isn't an addiction problem.

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thrownjustnow
This may be completely unpopular opinion, but as a temporary user of pain
killers I am thankful I was prescribed them. I was experiencing chronic and
hard to diagnose pain. I was in a very dark and scary place and was constantly
wondering how people without access to these medicines continue their will to
live. I was having difficulty making it through a work day and as a desk
worker I was able to tolerate them during the day.

I am thankful my doctor was so willing to prescribe them for me. Looking back
on the experience in hindsight I would have preferred to stay on them longer
instead of transitioning to other medicines during physical therapy. There was
a lot of suffering during that time.

~~~
OnlineGladiator
First of all, I am not an expert on opioids nor am I a trained doctor. For
what it's worth, I have lived with chronic pain, so I do know what it is like
to suffer.

I do not think the problem is that opioids are evil, but that they were
clearly (to the point of obvious fraud) being sold in great quantities to
people to abuse for recreational purposes. Obviously it can be frustrating
because now people with legitimate medical pain have one less option for
dealing with their suffering (although based on studies I have read, opioids
are actually not the first choice for most users), and they are the victims of
the flagrant corruption of the pharmaceutical companies in question.

I am not saying doctors need to be perfect in diagnosing problems and always
knowing what to prescribe, and magically predicting when a patient will become
addicted (even if it is to treat a legitimate medical condition). I am saying
the corruption of overprescribing drugs for the obvious profiteering should be
stopped, and those found responsible should face legal consequences (I assume
something like 20 years jailtime, plus forfeiture of all assets gained
illicitly after thorough audits - when going after billions of dollars it is
easy to come up with the money for audits).

I am glad that opioids were able to help you and I am glad you were able to
get them when you needed! I understand there is a lot of villification of
opioids and in the outrage some people want them banned entirely and that
would likely be a loss (similar to what happened with marijuana, ketamine, and
other drugs that were always suspected to have real medical benefits and we
are now getting real clinical studies to support these hypotheses). But the
corruption is real, and the criminals need to be punished, and the overselling
needs to be stopped.

~~~
cortesoft
I think "recreational" is not the correct term to use for most of the people
taking opioids without a prescription.

So many addicts start out using for some pain, and become addicted. They then
buy from shady doctors or people who get drugs from shady doctors. Or they
might use them to feel numb because they are depressed.

I am just not sure that a majority of illegal opioid users are people who
started their habit by thinking "I am looking to have a good time to night,
let me take some opioids"

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vmurthy
Hmmm... this article seems like a real world demonstration of the principles
outlined in "Influence:The Psychology of Persuasion" by Robert Cialdini [0]

1\. Reciprocity - check 2\. Social Proof - check 3\. Authority induced bias -
check 4\. Scarcity - check 5\. Commitment and consistency - check

Damn scary how even highly qualified professionals fall prey to the same old
tactics.

[0]
[https://en.wikipedia.org/wiki/Influence:_Science_and_Practic...](https://en.wikipedia.org/wiki/Influence:_Science_and_Practice)

------
jdkee
The fact that so much effort and so many dollars are expended to "sell" drugs
to patients via the trust that doctors engender, illustrates just how broken
medicine is in the U.S.

------
philwelch
Isn't there a professional and ethical obligation to prescribe painkillers to
people who are in significant pain?

~~~
baxtr
I guess it depends. In other countries, like Germany, doctors have a very
different stance on people in pain.

 _“Pain is a part of life. We cannot eliminate it nor do we want to. The pain
will guide you. You will know when to rest more; you will know when you are
healing. If I give you Vicodin, you will no longer feel the pain, yes, but you
will no longer know what your body is telling you. You might overexert
yourself because you are no longer feeling the pain signals. All you need is
rest. And please be careful with ibuprofen. It’s not good for your kidneys.
Only take it if you must. Your body will heal itself with rest.”_

From: [https://www.nytimes.com/2018/01/27/opinion/sunday/surgery-
ge...](https://www.nytimes.com/2018/01/27/opinion/sunday/surgery-germany-
vicodin.html)

~~~
grabbalacious
Yes. When stubbing a toe I've historically employed two strategies for dealing
with it. In my youth I would shout and hop around the room, i.e. distract
myself. Nowadays I pay as much attention to the pain as is possible and
practical. Remarkably this approach does _seem to alleviate the pain_.

So my guess is that the function of pain is to direct attention to injury. Not
just for thinking about ways to avoid repeat injuries but purely and simply to
promote the healing response. Which is not to say that I wouldn't welcome a
painkiller if the pain was great enough. It's just that the suffering caused
does seems to increase with the efforts one makes to distract oneself from it.

~~~
Ididntdothis
There is a level of pain where it becomes totally debilitating and all
consuming. I can meditate over light headaches or other pain but from time to
time I get migraines where I either want to die or take anything that will
make it go away.

~~~
grabbalacious
With very severe pain I don't see why one couldn't adopt a dual strategy of
alleviating it both with drugs and by focussing on it during its most intense
moments.

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docdeek
> Since I left the industry in 2000...

That's a significant time to be out of the industry and still speak with
credibility about today's methods and practices. Not impossible to be entirely
on point, but it would be more credible from someone closer to practices in at
least the last decade.

~~~
mThumbnail
I suppose if it were "since I left Google/Microsoft .." you'd be more right,
but industry-wide practice is usually something that's relatively out in the
open especially for former insiders

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dwd
Back in the early 2000s I built a web app for a big pharma that was used to
compile doctor's responses to questions on survey cards that were mailed out.

These could be anything from multi-choice questions about awareness of drug
products, whether they prescribed particular drugs for specific treatments and
I think from memory there may have been incentives like prize draws like trips
to conferences for filling in the survey (return postage paid as well).

I can't imagine this having changing so much (maybe more online or in
partnership with clinic software) as it served as both promoting a drug for a
specific treatment and identifying individual doctors responsiveness to future
marketing.

~~~
noelsusman
Things have tightened up a bit since then, though not completely. My dad ran
hospitals for a living when I was a kid and we got tons of free tickets to
sporting events from various vendors trying to sell him stuff. He would have
to listen to a 10 minute pitch from some salesman (that he always made fun of
later) and in return he got a free night out with the family. I remember being
mad when that dried up in the mid-2000s. I later learned that CMS had
implemented some regulations cracking down on the practice.

These days, thanks to the ACA, you can look up exactly how much money your
doctor has received from medical device manufacturers or pharmaceutical
companies
([https://www.cms.gov/openpayments/](https://www.cms.gov/openpayments/))

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zarkov99
My 5 year old had to have surgery to repair a small abdominal hernea. Not a
big deal, most kids recover incredibly fast and are back to running around
within 2 or 4 days. We were given a prescription for enough opioids for 3
months at the maximum daily dosage. She needed one day, half the daily max.

~~~
riahi
There's a lot of anecdotes in this thread about people being prescribed "too
much".

What would your anecdote be if your child was in severe pain after the
surgery, occurring in the middle of the night, and you needed to get the meds
after hours?

What if you had to drive back in to get a paper script?

What if you had to wait 2 days?

I rarely (almost never as a radiologist now) write outpatient narcotic
prescriptions anymore, but when I did, I often prescribed in a pattern so I
could avoid people becoming uncomfortably symptomatic in an inconvenient time
for them (and us). I'm not sure what the best situation here is, other than
giving you the RX and telling you to not fill it?

~~~
zarkov99
There is a big difference between a reasonable margin of safety, say double
what was expected, and the 3 months which was 30x the expected need. Three
months is not an emergency contingency.

------
mcguire
" _When my patient’s loved ones ask how this could have happened, or start to
blame themselves, I think with anger about how, for years, drug companies
promoted the idea that addiction was not a common effect of the medication but
rather a personal failing of the addict._ "

Shouldn't that be, "...I promoted the idea..."

~~~
huffmsa
The author says they didn't sell the opioids. Your point is valid though.

------
hackermailman
It would be nice if actual statistics were floating around that identified
causes of drug addiction. I grew up surrounded by crack and heroin addicts,
anecdotally not a single one I met was pushed opiods by a doctor, they instead
had a lifetime of drug seeking behavior and pooled money with other drug
addicts, and whatever was cheap and available on the streets they took which
often was heroin (now synthetics like fentanyl). In that same country pushing
drugs by doctors was not common like it seems it is common in the US, yet we
still had an enormous out of control street addict problem with no end in
sight.

It would also be interesting to see Portugal research as they decriminalized
all drugs, if they still have an out of control street addict problem and
culture of drug taking, or Japan research why they don't have a drug taking
culture.

~~~
loeg
In 2005, the large majority of heroin addicts in the US were concurrent or
former pill opioid addicts, but as of 2015 or so, it's about 50%.[1]

[1]:
[https://www.ncbi.nlm.nih.gov/pubmed/28582659](https://www.ncbi.nlm.nih.gov/pubmed/28582659)

------
brenden2
Title should be "I was a drug rep. I know how pharma companies pushed
opioids.", as per the original article.

Here's a tl;dr of the article (quoted from the article itself) to save you a
click:

> Medical students and doctors didn’t just learn how to assess and pay
> attention to patients’ pain — they also internalized the idea that
> prescribing opioids was a professional, even an ethical, obligation.
> Exaggerating the clinical significance of pain drastically expanded the
> market for opioids, bringing them to populations with a high risk for
> addiction, like adolescents.

~~~
vo2maxer
The code of conduct changed around 2009 as the author points out. Prior to
that time it was a torrent of all kinds of expensive gifts, which were not
restricted to opioid prescriptions. The higher the number of “scripts” a
physician had, the more extravagant the giveaways.

Interestingly, prior to the opioid frenzy, the culture was one of great
restraint often leading to under medication of pain and unnecessary suffering
for patients. This was superseded by the conviction that pain had to be
eliminated if at all possible, it was a physician’s moral imperative to do so.
Now in hindsight, it’s clear that Pharma was driving a lot of this ethos.

