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Ohio Sues 5 Major Drug Companies For 'Fueling Opioid Epidemic' (npr.org)
491 points by CrocodileStreet on May 31, 2017 | hide | past | favorite | 349 comments

I think I've seen this movie before. This looks like it's headed down the path of the Tobacco Master Settlement Agreement [0].

Here's the playbook:

1) A.G.s and private lawyers start filing lawsuits.

2) Defendants realized there is potentially catastrophic liability here and start negotiating a master settlement agreement ("MSA") whereby the states agree not to sue in the future in exchange for a set payment schedule to the plaintiffs.[1]

3) States A.G.s realize this is a great publicity opportunity to leverage their career into other elected office and governors realize this a real revenue stream.

4) So, interests aligned and there is a settlement.

5) Lawyers make a TON of money on their fee schedule set forth in the MSA. So much so, the Tobacco MSA lawyers were securitizing their future fees in private markets.

6) Bankers swoop in and start pitching states on the securitization of MSA payments for states to cover current deficit shortfalls.

7) Bankers make a point or two on the securitization deal proceeds ($10s or $100s of millions).

8) States leverage their future payments under the MSA to fill budget gaps where ever possible. Some allocate a small portion of the proceeds to the victims of the malfeasance but many do not because there are better ways to get future votes.


Full disclosure: I was once a young public finance analyst working 80-100 hour weeks building financial models to securitize Tobacco MSA payments...slight grudge still held.

[0] https://en.wikipedia.org/wiki/Tobacco_Master_Settlement_Agre...

[1] Tobacco stocks jumped on news of the settlement because a large known liability is much better than an unknown one.

EDIT: slight clarification.

There's a missing epilogue:

9) The states themselves, as well as a large interest group formed by the purchasers of whatever deals were securitized, are now financially interested in the continued financial health of the malfeasors.

In other words: the opioid producers now have the states and bondholders rooting for them to continue selling opioids.

(In fairness: if the pharmas are not pure plays this will not be as dismal as it was with tobacco. But in the tobacco case, it was pretty clearly laid out that the continued payment streams were secured only by MSA revenues based on continuing cigarette sales. So the states, or the bondholders, were rooting for continued cigarette sales.)

Ohio AG Mike DeWine is running for governor next year. He's Quite the opportunist. Consider this suit a campaign soft-launch. Don't know if he'll get a settlement before the election, but there will be plenty of quid pro quo cash to go around.

Their could be an opportunity here to launch some websites and drum up public interest against such deal being made, wait for the tickers to drop and settle off, then go long, wait for the inevitable settlement, then dump post settlement spike?

And to think of the bonds that will come from this that will be tied to tax revenue from such products that will probably decline as patients and doctors avoid using them, probably a way to get exposure to short positions on those as well.

I came in ready to blab about what a pointless, impotent move this is to address the issue of opiate abuse.

Instead, I found a new perspective that helped me to see that this isn't about opiate abuse at all. It's about cashing checks.

It's always about cashing checks.

What difference does the motive of individual participants make? There's a system in place which incentivises people to sue to stop this kind of abuse and punish the companies doing it. I'd much rather that's done for money than waiting and hoping for a good Samaritan to come along and save people out of the goodness of his heart.

Except in this case the payouts won't exactly stop or truly punish the offenders, and the payouts also might not go to help the victims..

@sbarre what makes you think that the payouts will not punish the offenders? are the pharma, not one of the categories of offenders in this case? Just curious.

I mean real meaningful punishment (for the companies and the individuals responsible for the decisions), not just a settlement payout that represents a fraction of the profits they actually made by causing this tragedy, or "the cost of doing business" as you often hear in these situations..

Corporations exist to protect the investors and the executives but they can only be punished monetarily.

This is why CU undermines Democracy.

Citizens United has nothing to do with why we rarely charge people who break the law while working for a corporation with charges that carry significant jail time.

Perfect is the enemy of good. Isn't pharma losing some of their ill gotten profits better than them losing one?

> Perfect is the enemy of good.

Yes, and that's why you prefer perfect ;).

> Isn't pharma losing some of their ill gotten profits better than them losing one?

The problem here is that when such a thing occurs again and again, people start to treat it as a business model. Punishments are meant to deter, by giving only a slap on the wrist and calling it sufficient punishment, they'll be further legitimizing the whole strategy as a viable business model.

I don't think there is going to be the same level of liability. In the tobacco case, people who started smoking Marlboros were dying from smoking Marlboros. With OxyContin, this isn't the case. E.g.:

- User switches to heroin or some other generic opiate because it's too hard to get a legal prescription and dies.

- User mixes drug with alcohol or benzodiazepines and dies.

- User dies from APAP poisoning, which the government requires to be added.

There might be 50,000 opiate-related deaths per year or whatever, but the actual number of accidental opiate ODs on solely OxyContin is no more than the number of deaths from Tylenol or Ibuprofen.

The Supreme Court already ruled that drug manufacturers can't be held responsible for the safety of generics. So even if Purdue is held entirely responsible for the rise in opiate addiction, there are enough mitigating factors in terms of the actual harms of addiction that I think it will be hard to see a tobacco-style settlement.

Would this be affected by the marketing of Oxycontin as a 12-hour pain medication, when it was known that it wears off earlier than that for a significant fraction of the population? Not a lawyer, and so I have no idea how that would affect liability.


I think that's good for around a billion dollars in fines and maybe a few prison sentences, but not for 100+ billion.

The basic issue is that even if they purposely got millions of Americans addicted to opiates, being addicted to opiates isn't especially dangerous or harmful in and of itself. If most of the harms come from unrelated government policies then there's only so much damages you can pin on the Pharma companies.

Super interesting insight, and fascinating walkthrough of the finance side..

However, you paint the whole thing as a corrupt failure. Hasn't smoking use dropped dramatically? Sure, lots of people got paid/power along the way, but we did make a large dent in the problem.

As a part of the deal, the tobacco companies were "exempted from private tort liability regarding harm caused by tobacco use". A much more just settlement would have allowed everyone who was harmed by tobacco (at least the ones who started smoking in the period between when the tobacco companies knew that tobacco was harmful, and when the publicly acknowledged it) to sue the companies for the cost of their harm.

This would of course have immediately bankrupted every tobacco company.

The perverse outcome of the tobacco MSA was that state's payments were tied to tobacco usage. So if tobacco usage went down, so did their payments.

This pretty much obligated the states to transfer their interests to investors of the securitizations in order to reduce the obvious conflict of interest.

Yes, my rant tag was trying to be a subtle admission of the bias.

I'm sure there were some good aspects of the MSA that I failed to mention. The restrictions on marketing is one that comes to mind without a lot of thought.

I think the biggest problem (that I remember) was money getting allocated to pay for things other than programs to help the original victims.

That's probably why it's so successful. Pockets get lined and the deal is seen publically as a moral victory.

It would be politically hard to oppose the arrangement without looking pro-Tobacco, or at least without getting smeared that way by the beneficiaries...

Fascinating! With your unique experience, do you see opportunity at any stage to tip that playbook onto a better course?

Global nuclear wipeout. Humans are, and always will be, incurably greedy. Give some other species a chance instead.

Other species are the same and would do the same given the opportunity - they're just not as capable as we are.

We do not know that.

Yes we do. Evolution selected for the greedy. An exception might be organisms who're newly introduced into an environment and there are still too many resources for their needs so they can sit around not trying hard to get whatever they can. Once populations stabilize though, they have to fight to survive.

While that is true, different species could have different thinking patterns, and therefore different propensity to prioritize their own greed before other interests and motivations when making choices.

I'm just spitballing here, but the fact is that until we meet some other similarly advanced species and get to know their psychology, we can but theorize.

Man, the grudges you hold after you have to dig into an industry, deep enough to model it.

But this is also in light of the recent MA RICO conspiracy charges, which from my understanding is not really a...small deal, right? From what I've read, RICO is usually reserved for the likes of the mafia and even still is rarely used due to the overwhelming burden of proof required. Definitely despicable behavior though, with doctors taking bribes in exchange for breaking their Hippocratic oath

Source: https://www.justice.gov/usao-ma/pr/pharmaceutical-executives...

After watching a 30 year old female overdose in a parking lot and not being able to be saved by first responders or emergency responders I've realized this problem is far more prevalent then most of us realize. This is a epidemic that is playing out under our very noses all across America.

This is just as dangerous as terrorists or any other think that goes bump in the night - it will destroy this country if not stopped.

Not sure what the solution is but this looks to be a good start to push for controls needed.

There were less than 150 terrorist deaths in the US this decade [1] and tens of thousands of opioid deaths every year in the US [2]. Terrorism is closer to the threat posed by crush deaths from vending machines [3].

[1] https://en.wikipedia.org/wiki/Terrorism_in_the_United_States...

[2] https://www.drugabuse.gov/related-topics/trends-statistics/o...

[3] http://journals.lww.com/jorthotrauma/Abstract/1992/06000/Sod...

> Terrorism is closer to the threat posed by crush deaths from vending machines

This is a fallacy. In the case of terrorism "past performance is not an indicator of future results".

An attack with e.g. a biological weapon could cause, on a single day, 1000x the cumulative number of deaths we had over the past decade.

There is no possibility of the number of crush deaths from vending machines rising like that.

> An attack with e.g. a biological weapon could cause, on a single day, 1000x the cumulative number of deaths we had over the past decade.

Perhaps. But it's virtually a certainty that opioid overdoses will kill tens of thousands of people in the US this year. (The most reliable recent figure I can find was ~30k in 2015.) Meanwhile, a terrorist attack in the US that kills hundreds of people -- let alone tens of thousands -- is a relatively low-probability event...

You'd need quite a lot of biological weapons. 1000 x 100 terrorism deaths is still on the order of magnitude of the number of road deaths in 10 years. So a 100,000 people killing bomb in the US every few decades isn't really that bad.

You have to acknowledge that someone abusing opiods doesn't infringe on another's freedom but a terrorist attack does.

Not saying we shouldn't do anything about this drug epidemic but your comparison is fundamentally unsound.

That seems like a veiled sort of victim-blaming to me. The entire premise that "someone abusing opioids doesn't infringe on another's freedom" ignores the role of the medical system (and of the drug companies named in this lawsuit!) in leading patients into opiate addiction through poorly handled pain management.

Moreover, addiction is fundamentally a disease which acts upon the sufferer's ability to make free, rational decisions. In a very real sense, the addiction itself is "infringing on the freedom" of the addict, even if it hasn't killed them yet.

Unless you are injected against your will or force fed then you still had the freedom to not take it in the first place. Everyone knows how addicting these things are. There are alternative pain relieving options available too. Nobody cares about smokers getting addicted although they do care about public smoking because it infringes on their right to clean air.

> Everyone knows how addicting these things are.

No, the point of the lawsuit is that they don't (or didn't). The article makes that clear through quotes such as: "We believe that the evidence will show that these pharmaceutical companies purposely misled doctors about the dangers connected with pain meds that they produced."

> Nobody cares about smokers getting addicted although they do care about public smoking because it infringes on their right to clean air.

Public smoking is a focus of conversation today, but the analogous 1990s big tobacco lawsuits centered on the medical costs of treating smokers. See wikipedia: https://en.wikipedia.org/wiki/Tobacco_Master_Settlement_Agre...

The lawsuit might contend people don't know they are addicting but that's not reality.

You make a good point. Surely there's a way statistics account for this "damage potential". How do statistics treat things like nuclear incidents, etc?

They're called "black swan events."

Apart from writing difference of books and publishing hundreds of papers on the subject (see Nassim Talib), the tl;dr is economists and sociologists still really have no way of truly accounting for them besides being cognizant of their existence.

Good to reference Black Swan, but Taleb would call these events gray swans, not black swans.

A true black swan is something that's basically inconceivable before it occurs. It is outside the mental model used to evaluate outcome probabilities. Black swan events include things like:

---Your enemy in a war invents the nuclear bomb and drops it on your cities (this happened to Japan in 1945)

---You are a turkey. The farmer comes, as he does every day. Instead of feeding you, he slaughters you (something which you've got no experience or conception of).

---It's 1994 and you own Blockbuster Video, a solid earning company. Then someone invents the Internet...

Biological warfare attacks are quite well-known as a concept, making them gray swans. Also in the gray swan category are asteroid strikes, supervolcanoes, etc etc.

I try to spread this distinction because if we start calling gray swans black swans, that will hide from us the most important part of Taleb's argument, which is that true black swans are the most important events. The idea of the black swan is hard to keep in your mind (how do you keep in mind the inconceivable?) so it's very easy for a pretender concept to sneak in and steal the label.

Thank you for the correction. I truly appreciate the importance of this distinction.

In that case the cause of the credit crunch that the 2007 financial crisis was a grey swan. The risk models on subprimereal estate were clearly being interrupted incorrectly...

Good to know!

Nukes have also been a very well-known concept, then have been theoretically invented in 1939 and by 1941, it was well-proven that one can be made. If anything in nukes was a black swan event it was the isotope mix of reactor-produced plutonium which made detonation of plutonium bomb without a fizzle incredibly difficult - something which no one had an idea before it happened and it almost doomed the project - in 1941, making the bomb looked a lot easier than it proved to be.

It was also well-known that U.S. is the world leading scientific and industrial power, that it absorbed huge number of well-educated Jews fleeing Nazis, and it was least affected by ongoing WWII of all major powers.

So if anyone was to make a bomb it was U.S., every rational actor should have expected it to happen. Only 'if' was timing.

I think the big black-swan event with nukes was dropping one on a city. It's a pretty big mental leap from "Yes, nuclear fission is possible" to "Our enemies have achieved it in practice, turned it into a weapon, and are about to drop it on one of our cities." Even among the top physicists working on the Manhattan project, it was uncertain if detonating the bomb would ignite the whole atmosphere and kill off all life on earth.

Wormholes, for example, have been theorized for decades. Nevertheless, "The earth is about to fall into a wormhole and end up in another dimension" would probably fall into the category of black-swan events.

> it was uncertain if detonating the bomb would ignite the whole atmosphere and kill off all life on earth.

This was known before it was dropped on a city. The Trinity test happened about three weeks prior to dropping the first bomb on Japan. The second bomb was dropped with full knowledge of the potential casualties after the devastation of the first.

We Americans always justify these bombs, but really, there is no justification.

>We Americans always justify these bombs, but really, there is no justification.

So you'd have volunteered to be the first wave on the beach?

You presume that a beach landing was necessary. By this point in the war, the US had air superiority (the fire bombing of Tokyo...), and all sea lanes under control. The US had other options.

The best explanation for why the US wanted to have a swift end to the war with Japan was to deny the USSR the option of dividing Japan like was Germany.

There is no good way to justify killing civilians during the war, and it's impossible to say what would have happened if these bombs were not dropped and some other path was taken.

From a purely strategic perspective, the potential to avoid a costly land invasion must have seemed much more tangible than the at the time hypothetical and uncertain PR fallout (no pun intended) that would result from use of the new weapon.

Arguably keeping the USSR out of the islands may well have caused less misery over time for the Japanese people, from the purely utilitarian perspective of looking at how populations under Soviet rule fared.

Given the amount of food which Japan had been importing prior to the war, wouldn't blockading the sea lanes mean you're still killing civilians?

It really wasn't a black swan though because bombings of industrial cities were well established at that point; it is even possible that the bombing of Tokyo killed as many as the two atomic bombs combined (estimates of deaths for each have very broad ranges).

Earlier than that on the European front, there was Dresden, which killed about a third of as many that as the atomic bombing of Nagasaki.

Really, once the US established control of the air, they were capable of wiping out Japan's cities with conventional weapons.

The number of deaths can be both meaningful and irrelevant. For example, we can drop 1 regular bomb that kills 10000, or we can drop this new type of bomb that slowly eats the flesh off of 100 people, before they die very terribly (and unstoppably) a week later.

The second, just by its gruesomeness factor remains a black swan, irrespective of the number of deaths.

In the same vein the nuke might not be as deadly as all the bombings before it, but at the same time it was one new weapon (ie. a singular drop from a single plane) that did something totally new and horrific, thereby making it a black swan.

I actually took an entire class in business school about this exact topic -- "Catastrophic Risk Analysis". Great class, the teacher was a former astronaut (among many other things).

And you're right, you basically can't predict things like this -- but a great many catastrophic risks that can be prevented are ignored because the event seems much less likely than it is due to the scale of the impact being so large as to be unimaginable by many. Climate change is a chief example; but there are plenty others throughout history in business, warfare, and science.

>no way of truly accounting

No way to predict, sure. But if my memory serves me correctly, the entire theme of Taleb's Black Swan was about accounting for such events. For example, financial hedging; you won't know what event might manifest itself and cause a huge financial disruption (the cause), but you can anticipate "it" happening, in some form, and preparing for it by buying long shot hedges (accounting for the effect).

My understanding is that you multiply the cost by the probability, or use a power of the cost (since the impact of a huge liability or disabling disaster is usually more than the accounted-for direct damage).

Problem is that it's virtually impossible to estimate the probability of a black-swan event, since, by definition, they are events that have never happened before and nobody has foreseen them possibly happening. A priori, your probability is zero, and yet they happen anyway.

We can be fairly certain that something unexpected will happen in the future, but predicting what that something is or with what likelihood it will occur is still the domain of fortune-tellers.

Do we do that for various financial endeavors and shut them down due to the economic risk posed? Cost of 9/11 was rather large, but it was not that large simply due to terrorism, it was that large due to the failure of various measures meant to prevent it... all aligning into a perfect storm.

And therein lies the problem. How do you calculate the probability in the first place? For some things (asteroids) this is possible, for others (catastrophic rapid climate change or terrorism) we don't have the predictive tools.


Large-scale, high-consequence, strongly systemic or correlated events are difficult to model and describe.

Death-by-asteroid is one of the more interesting cases. That would be a bad day for you (or your descendants), but also, quite likely, many others, when it happens. The days aren't frequent, but they're big.


More generally, there's a lot summary statistics don't tell you.


I'm not entirely sure, but models typically don't. Nassim Taleb wrote a book called Black Swans about these types of events.

A black hole swallowing our planet whole would have an even larger death toll, I think.

The point is that past performance gives a baseline that can used to judge both possibility and probability of such outcomes.

I think the OP means black swans happen. And so terrorism should be considered a black swan sort of risk. But if we're doing that then shut down all the various financial institutions that may cause such risk as they have been shown to do more than once in the past. However, thus far the black swan risk from terrorism seems to be a few thousand people in the time frame of around two to three decades... globally. The cost seems to be in the trillions but that has little to do with the terrorists, and much to do with the management of the response to terror... and also management of the risk posed by it.

Globally? No, that's a very USA-centric view. Terrorism has killed hundreds of people globally this month alone. It has destabilized (if not outright destroyed) many countries over the past 2-3 decades.

Terrorism has not destroyed countries across the past 2-3 decades.

Civil wars did. Many of them have either been started by, or fueled by American foreign policy.

So, yes, your country being destabilized by a civil war is a real threat if you live in the global south. In America? It's not going to happen because of a few mouthbreathers decided to cook some bathtub C4.

Globally speaking, USA imperialism is bigger threat than the terrorism with regards to the body count metric.

Yeah it has killed hundreds this month mostly again due to mismanagement of response to terror and management of the prep for terror. It's a significantly different thing to compare terrorism in 3rd world countries who are routinely targets of both non-State and State sponsored terror because lack of control mechanisms and terror in developed countries or countries with stable governance systems.

Fat vs thin tails. Namsayin?

Why is a hypothetical massive terrorist attack more scary than hypothetically polluting all fresh water than humans need to live?

There is no possibility of the number of crush deaths from vending machines rising like that.

Not unless some terrorist rogue scientist invents nano machines that turn everything into vending machines. Some bizarre gray goo scenario.

This is a good point. The annual stats for terrorism looked very different in 2001 vs 2000. And the nature of terrorism presents an unknown level of threat that could make the events of 2001 look like a firecracker in comparison. Your biological weapon example is excellent, there are those who have the will and only lack the way to make it happen today.

As an average citizen I bunch events into the categories of 1 "Things I Can Prevent" and 2 "Things I Cannot Prevent". Opioids fall into category 1. I refuse to take any opioids even when prescribed because I do not want to go near such dangerous substances. However terrorist attacks, mass shootings, crazy people, etc fall into category 2. Category 2 frightens me quite a bit more than category 1. I'm willing to bet that a ton of people feel the same way as me. And that's probably why issues like terrorism get a ton of air time and issues like opioids get very little.

Many people who end up taking opioids say the same thing you say, and swear them off. It's easy to say that you won't take them until you're in pain that makes you feel as if you're dying, then it's a different story.

yeah but not all the people taking them are in that sort of pain. most are just ordinary drug addicted people

Source? From what I have read the major cause of the opioid crisis is doctors prescribing opioids for pain [0]. Even 2 week prescriptions have 25% chance of creating an addict [1]. Remember originally these were marketed to doctors as non-addictive.

[0] - https://en.wikipedia.org/wiki/Opioid_crisis

[1] - https://arstechnica.com/science/2017/03/with-a-10-day-supply...

And the major cause of doctors prescribing opioids for pain is: Purdue Pharma propaganda and bribes. [0][1]


[1]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/ title: "The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy"

Opoid issues get quite a bit of press in midwestern newspapers. In my experience it gets more press than terrorism.

How can you prevent crazy people?

I'm asking because I often wonder what price we're willing to pay to make to make the chances of killed by another person 0%. Is there anyway to acheive that without creating a police state with zero privacy and zero possibility of dissent? If we start editing people's genes so they aren't "crazy" who decides what the legalized normative behaviour is?

I'm not sure labeling as "crazy" is fair or helpful. These substances are addictive and many people got them prescribed by their doctor whom they trusted.

Lab experiments with rats might be pointing is towards what we have to do to mitigate this at least somewhat. Experiments showed that rats in a healthy social environment are much less prone to opioid addiction than ones living in isolation or having lived in isolation. See https://en.m.wikipedia.org/wiki/Rat_Park. I finds it easy to imagine that the same is true to some degree for humans. I wouldn't be surprised if the effect was even stronger on humans. We are very social animals after all.

> I'm not sure labeling as "crazy" is fair or helpful. These substances are addictive and many people got them prescribed by their doctor whom they trusted.

I'm pretty sure the person you're replying to was using the word "crazy" in reference to terrorists, specifically the ones of a suicide variety, not your garden variety person who ends up addicted to prescription drugs.

Whoops. I was only using the word crazy as a quote from the person I was responding too. I think the word crazy only exists in a perjorative sense and is used to do discredit a set of individuals.

Most people have a broader conception of the word "crazy".

"My life was great before I got addicted" said no drug addict ever.

You don't know many addicts right?

Especially in the US the opioid addiction epidemic is caused mostly by doctor.

Last year less than 1% of the population tried heroin or opium poppy. A bit more than 5% of the population tried opioids.


'Opioids' are the prototype solution to human pain.

Have you never had surgery, a massive fever, or a broken bone?

Morphine and its analogs are probably up there with HVAC, internal combustion engines, and carbohydrates with respect to human progress.

Especially in the US the opioid addiction epidemic is caused mostly by doctor.

And doctor prescription is caused mainly by drug company.

I don't know any opiod addicts, but I know several alcoholics who would definitely say that.

Prince. That shit killed Prince.

In your hypothetical example where personality editing is possible, the consequences would be much more wide-ranging. Much of human suffering is due to human shortcomings and weaknesses. Therefore, if it becomes possible to edit minds, the incentive to make everyone resilient, jovial, agreeable, patient, extroverted... etc. would be strong enough that a natural normative standard would put itself into place by the action of market forces. Having a diverse set of personalities helps society but every parent would want to give their kid the traits most conducive to fitting in and being happy.

And then begins the real beginning of homo financus.

I have a hard time imagining anything except a real monoculture of individuals would emerge from such a possibility.

Where do road accidents fall? Do you just avoid being on roads?

Personally I feel the majority of road accidents fall into category 1. As long as you are very careful and aware of your surroundings you can avoid a huge number of accidents. This is probably why experienced drivers get huge discounts on car insurance. I've managed to actively avoid many more accidents than I have been involved in and I've never caused an accident (beyond giving a car a scrape while parking just after getting my permit). Sometimes there's no winning though. Like waiting at a stop sign and someone rear ends the truck behind you (so you can't see anything behind the large truck) hard enough to send the truck into your car and almost send you into speeding cross traffic. When that happened it really freaked me out. That was definitely a category 2 event.

Living in a large dense city where cars move slowly and most people use rapid transit goes a long way towards this. (And also costs you.)

If you don't need a lot of space, i.e. you don't have kids and you can handle having roommates, then it doesn't really cost more to live in a big city. Sure, the rent is more, but not having to pay for an auto loan/gasoline/insurance saves a good amount too.

Source: I moved from the suburbs of DC in MD to Manhattan, I track my spending pretty religiously on Mint, and my spending only went up a few $K per year -- which is way, way less than my salary did from the move.

I work on Manhattan and live in Brooklyn, with family and kids. I still reap most of the benefits of a dense city (subway, nearly everything within walking distance, variety of options in food, etc), while spending < 20% of my income on rent.

Are you saying the engineering / dev salaries in NYC are outpacing DC?

I see DC creeping up to $160K-$170K or so for senior devs that can negotiate.

What are you seeing in Manhattan?

I'm earning over double that in Manhattan as a senior SWE (at the big G). We have no real eng presence in DC.

Maintaining situational awareness is the difference between an accident and a close call the vast majority of the time, not just when driving.

I'm sure you already know, but it's completely irrational to fear the things out of your control. There's literally nothing to be accomplished by doing so.

> it's completely irrational to fear the things out of your control.

Fear is the foreknowledge of (or of the risk of) something unpleasant happening to you. Foreknowledge of our inevitable death, over which we have no control (sure, we can try to prolong life a bit, or end it early, but the ultimate result is the same), induces fear, ranging from anxiety to terror, in large numbers of people - perhaps even the majority.

To me, it's irrational to fear events that are highly improbable, but in view of our survival instinct as humans, it's quite rational to fear something horrible that is absolutely going to happen to you, and there's nothing you can do about it - for example, being scheduled for judicial execution the next day.

A: Most things are not completely out of our control so it is possible to mitigate those risks.

B: People are not perfectly rational.

However, I totally agree with your main point.

But terror attacks aren't out of your control.

For example, on a policy level, Japan never has them. They just don't immigrate any of the religious group who might commit terrorist attacks. So it's a non-issue.

And on a personal level, you can mitigate terror attack risks. Just avoid gatherings of people, basically. You can go as far as you want with this - living off-grid in the forest makes you pretty much fully insulated from terrorist attacks.

So the only question remaining on a personal and policy level is what the cost/benefit is for various things you could do to prevent terrorist attacks.

This is a common mistake. People like to think that some options are impossible, or some gains are free. Thinking this way makes decisions easier; it makes you feel more secure in your opinions. In reality, everything is possible, and everything costs.

I wonder if the reason Japan doesn't have terror attacks is because their military does not deploy outside of their own country (other than UN peacekeeping and humanitarian efforts) and therefore doesn't create terrorist level animosity towards their country and people?

There is still significant animosity towards Japan by several other Asian nations due to atrocities committed during WWII.

This is regularly triggered by various disputes about commonly claimed territory and things such as politicians visiting shrines that house the Japanese war dead (including war criminals). It often leads to rioting and destruction of perceived Japanese things (cars, restaurants, etc) in China.

Still no terrorist attacks in Japan committed by Chinese though despite Japan allowing in large numbers of Chinese visitors, students and workers.

Japanese people live in abject fear of terrorism outside Japan. There have been a few attacks in southeast Asia against venues that Japanese frequent and, owning that the country is extremely safe, it has been completely blown out of proportion.

I have a Japanese friend that has been road-tripping Europe for some time in his vacations and has been unable to convince any (Japanese) friend to go with him. In the last one, he was almost coming with a guy, but at the last moment, that guys mother convinced him to cancel the trip, and this was before the Paris attacks.

Lack of immigration. But that didn't prevent a Sarin attack either.

A number of countries have been hit by terrorist attacks despite having no intervention in the Middle East, Sweden and Spain for example.

Japan has absolutely had terror attacks.


I wouldn't say they never happen in Japan - after all, one of the most sophisticated terror groups/cults in modern history was from Japan (https://en.wikipedia.org/wiki/Aum_Shinrikyo). They were even able to synthesize VX and sarin gas.

I remember being a kid living in Japan, and watching the subway attacks on TV. It was scary.

But to your point, I agree, statistically, Japan is about the safest country there is in terms of human on human violence.

Oh, come on.

Terrorism killed 160 people/year in the US over the past two decades. [1]

Terrorism killed 33,000 people globally in 2014. [2]

Vending machines deaths in the US are 2-3/yr. [3]

There's hardly a comparison.

[1] https://en.wikipedia.org/wiki/Casualties_of_the_September_11...

[2] http://www.dailymail.co.uk/news/article-3322308/Number-peopl...

[3] https://www.quora.com/Fact-Vending-machines-kill-4-times-as-...

3,000 deaths from September 11th 2001.

33,000 from opioid overdoses in 2015 [1].

That's like 11 9/11's every year. I'm not afraid of terrorists. I am worried if I take opioids after a root canal I'll become a drug addict [2].

[1] - https://www.cdc.gov/drugoverdose/

[2] - https://arstechnica.com/science/2017/03/with-a-10-day-supply...

Opioids (like driving) have some benefit to wider society. Terrorist attacks don't.

I agree they are not identical situations.

Driving is not a good analogy either. A 2 week prescription gives you a 25% chance of becoming an addict. That is Russian roulette odds.

Driving everyday all year has about a 1 in 10,000 chance of death.

Driving is a necessity in most places. Opioids are not.

The vast majority of the global death toll attributed to terrorism in the article is in anarchic countries plagued by (civil) war -- Afghanistan, Syria, Iraq, Nigeria.

And hundreds of thousands if not millions due to car accidents, drinking-related, smoking-related, and obesity-related illnesses.

I've never seen a society destabilized by car accidents, smoking, obesity or drug abuse. I have seen societies destabilized by terrorism.

If you'd like to see a society destabilized by drug abuse, visit some of the... Less well-off reservations. Or these days, anywhere in Appalachia.

Oh? Drugs are not the source of their problems? Well, neither is terrorism. It doesn't happen in a vaccum. The kind of terrorism that destabilizes societies takes place in the middle of civil wars. If you are in the middle of a civil war, terrorism is not your problem.

You're right. We should just all get used to terrorism now, a few dead a year is the best we can do.

You are more likely to be struck by lightning, then killed by a terrorist. That doesn't mean that we should spend billions of dollars on outfitting every man, woman, and child, with a Faraday cage.

If you do insist on spending billions of dollars to deal with terrorism, though, perhaps you could look at dealing with the root causes that breed dejected, anti-social, and radicalized young men (Who tend to either join terror cells, or an army.) As a bonus, you'll also probably save quite a lot of people from opiates.

First thing is, people worried about terrorism aren't really worried about terrorism as it is now. They're really worried about what terrorism and ethnic conflict will be like in a few decades when, for example, Muslims are majority in some European countries. Muslim majorities are predicted in several major European countries, using basic conservative demographic projections, this century. How will that be to live in? For a prototype of that, you can look to Lebanon, or how Christians have been faring in Egypt in recent decades.

Here you have to make the distinction between the steady problem and the unlimited-growth problem.

The steady problem is "homegrown" terrorism. While there is always some level of terrorism coming from all groups, that should be addressed with the usual deradicalization and politics programs. Those approaches solved the issue with, for example, IRA terrorism. Which is a good thing, because we have to live with our own people.

The real issue is the one that will grow without limit due to ongoing demographic replacement in the West by Muslims. That's what people are worried about, because people understand that unlike homegrown terrorism, the Islamic terrorism problem can become infinitely bad, and you can end up like the Christians in Egypt. No magical historical force prevents French or Germans or British from ending up living under such deadly tyranny. Sadly, the only real way to stop this is to cease Muslim immigration until some of these data [1] start looking a lot more promising (which will take a century at least). There's certainly no shortage of people wanting to move West from places like India and China, so I see no problem with choosing immigrants who will create better outcomes (and we do that anyway).

If we're willing to discriminate on age and education, we can discriminate on religion - especially when a religion's core beliefs, as interpreted in all its mainstream schools of thought, explicitly opposes the basic egalatarian democratic values of our society.

[1] http://www.pewresearch.org/fact-tank/2017/05/26/muslims-and-...

What does a Muslim majority population have to do with terrorism? I've lived in many Muslim majority neighbourhoods and the closest I've gotten to terrorism is watching it on the news. In fact there was far more terrorism (daily almost) on the news as i was growing up in Ireland. 'Christians' blowing the shit out of each other.

Practically all of the recent Muslim immigrants in Europe are running away from terrorists not becoming them. Fear of a Muslim majority is completely irrational.

It's not. Muslim majority countries worldwide have an appalling human rights record.

Many (most?) have criminal punishment for blasphemy, apostasy and homosexuality. Capital punishment for any of the above is common, and legal in many majority-Muslim states.

There are clear examples of social regression to point to as well. Both Iran and Turkey used to be far more secular and liberal.

True, it's not terrorism. The oppression is usually legal, and at the behest of the majority of the population. But it's reasonable to fear it, especially if you happen to be kuffar, female, or gay.

Europe is not going to introduce Sharia law or anything remotely similar. Pretty sure the gay Muslims I met in Berlin moved there to escape persecution, not mete it out.

Indeed - that's been my experience too. Literally every Muslim immigrant I've known has been fleeing the crazy.

But you're ignoring my point - almost every majority Muslim country has a rights-violating Sharia based Government.

So no. Europe certainly won't enact Sharia law, provided their Muslim population remains a minority.

Muslims/Islam != terrorism.

Do you know many muslims? I happen to live in a muslim majority area of a major European city. No problems. They're people just like me and you and like most religious people they keep their views to themselves and get on with their lives.

Oh and the area I live in has a muslim politician in charge (and their closest competitor is a Imam) - both have very liberal policies.

Your reasoning seems to be: muslim majority == now they have the power to implement strict religious laws via the democratic process. Well that's absolute nonsense when it's only a tiny minority of them that have these extremist views. I could very easily look at some fundamentalist Christian groups and come to the same conclusions you have but I know that not all Christians believe the crazy crap that some fundamentalists do.

I'm actually terrified reading your comment because you've taken the uneducated bullshit arguments given by people and political parties on the verge of racism/sectarianism and polished it to look like it's intellectual and backed by evidence when that's clearly not the case.

I live in a European city/country with a lot of muslims and they are nothing but a problem - generally speaking (this one cool muslim guy you know is not a rebuttal), they refuse to assimilate, are an enormous burden on the welfare state and are overrepresented in crime. Demanding similar anecdotes from the OP however is an appeal to authority.

You only have to take off your rose tinted blinders and look at the state of affairs in muslim majority countries to see what happens when they are significant in numbers. Even in a "moderate" muslim country like Indonesia gays get arrested. Do you think these societies are a result of their geographic location or the culture/religion? What do you think happens if you only change the location of the people and they keep their culture/religion?

It's far from a "tiny minority" that holds extremist views - there are plenty of polls (check out those from Pew Research Center) that attest to that. You are gravely mistaken if you believe all religions are the same and equally compatible with western ideals.

Correct. If we as a society could somehow "get used to terrorism" it would be no more of a threat than falling vending machines, as pointed out above.

Plus, we'd save billions of dollars and countless hours of productivity.

Not that I'm expecting this to happen, but one can imagine...

I do generally agree that terrorism isn't a threat worth changing our lifestyles over.

However, I wonder if it's a little unfair to average out the probabilities and compare to something closer to an actual random event, like falling vending machines; surely, a terrorist attack is significantly more likely to occur in a place like New York than Middle America, no?

I'd really like to see something like what's the probability of being killed by a "falling vending machine" IN NEW YORK vs a terrorist attack IN NEW YORK, than something country wide.

FYI, getting killed by falling vending machines isn't a random event. It happens because people are rocking vending machines back and forth, either to knock loose a stuck purchased product or just to try to steal from them. If you get killed by a falling vending machine it's because you were doing something stupid.

So long as you never rock vending machines, and you shouldn't!!, you are way more likely to be killed by a terrorist, even though the odds of that are incredibly low (one in many, many millions).

Well... yes, because if we got used to terrorism, it would break the media cycle and cease to terrorize, and people would stop doing it!

Are you talking about successful destabilization efforts by terrorists, or societies destabilizing themselves as a reaction to threats of terrorism? Maybe they're the same?

> or drug abuse.

I'm no expert but isn't China known for having suffered from opium for a long time? If so it's quite relevant here since we're precisely talking about opioids.

That was about money, not opium.

You're not entirely wrong. Opium reversed the flows of silver specie that was the lifeblood of the China Trade. Before opium, most of the European trade was Mexican or Peruvian silver for tea, or china, or what have you. After opium, it was those Chinese products, or silver, for opium.

Opium addiction ravaged China (although by the point it really became a public health problem, domestic opium production had exploded). But the wild swings in the price of silver fucked the Qing economy, that had a bimetallic currency between silver taels and copper cash.

The point was reaching destabilization through drug use, which seems to have happened in China, despite the reason. i.e. Chinese are not more susceptible to being drug addicts than any other grouping, so it's noteworthy that policies resulted in such widespread addiction. Therefore, the policies are worth studying as they serve as a red flag for all future generations.

There are pretty ample examples of societies destabilized by drug abuse. See eg. the Opium Wars in China or the usage of methamphetamines in Nazi Germany.

But what destabilizes it, if it remains a statistical anomaly, is irrational, disproportionate terror. Putting other threats in perspective helps prevent that.

Drug abuse isn't that hard. See the Qing dynasty.

China was certainly destabilised by opium addiction over 100 years ago.

What societies were destabilized by terrorism?

The comparison of terrorism to the opioid epidemic (which is both heartbreaking and underreported) or vending machines deaths breaks down when one factors in nuclear weapons, attacks on critical infrastructure, etc. Violence from terrorism has fat tails.

But, of course, multiple things can be bad at once.

The odds of a terrorist group detonating a nuclear weapon are, for all intents and purposes, zero.

The odds of a terrorist group detonating a dirty bomb are not, but the casualties from one will be much, much lower then what they can accomplish with an equivalent effort put into bathtub explosives.

The danger of nation-states using their arsenal of nuclear weapons against each-other is at least two orders of magnitude greater. If those two nation states are the US, and Russia, the death toll will also number in the hundreds of millions.

If you really want to optimize for 'not dying in a nuclear explosion', you should be clamoring for immediate, unconditional disarmament, instead of worrying about orcs from Mordor carrying out Hollywood suitcase nuke plots.

The irrational fear about "terr'ists" the parent post is getting at, though, seems to rarely have anything to do with cataclysmic events like nuclear weapons these days. I literally hear people I know talk about keeping their guard up around Muslims because they're afraid of knife attacks, or you see the TSA freaking out about people pulling their clear plastic bag containing travel size toothpaste out of their suit case when this particular airport doesn't require you to do that. Statistically, individual acts of terrorism like that are indeed exceptionally unusual.

Well, the opioid epidemic is arguably a subset of a broader problem including poorly managed antibiotics and pesticides. Genetic engineering is part of the fat tail here.

I'm constantly amazed, as vulnerable as we are, that in 20 years, there has only been one significant terrorist action within the United States.

I'm sure the victims of the insignificant terrorist actions within the US take comfort from your categorization.

because charged emotional responses are always the best responses

Terrorist plots are foiled on at least a daily basis. If we didn't try as hard as we do, we'd see a lot more success.

How about averaging the number of deaths over the past 2 decades instead? I bet you'd get a different result [0].

[0] https://slatestarcodex.com/2016/08/31/terrorists-vs-chairs-a...

Average them over the past 2 decades and terrorism is still at ~1/100 the level of opioids.

Many US citizens still die overseas in terrorist attacks, for instance, 11 American souls were lost this week due to a suicide bomb in Kabul. Not to mention the whole black market economy that surrounds terrorism, along with human trafficking and other dark criminal activity that coalesce together. Quantifying these operations that seek to undermine the integrity and saftety of our societies (sometimes successfully) doesn't really do any favors, especially when putting the staggering amount of hidden costs that we don't know of today into play.

You should probably include most US combat deaths in the terrorism category because, no matter how little Iraq had to do with 9/11, we wouldn't have been in a war there or Afghanistan without terrorism. Veteran suicides and overdoses can probably also be attributed to terrorism as they followed from the wars. War casualties are only in the thousands over the entirety of the war, but there's about 20 veteran suicides per day, so the deaths indirectly attributable to terrorism are actually quite a bit higher than your number.

Veteran suicide rates are comparable to civilian suicide rates, and even including all combat and terrorism deaths in the last 20 years together we're at around 10,000, compared to 35,000 opioid deaths in just 2015.

And honestly, the Iraq war is as related to terrorism as vending machine crush deaths. That was our dumb fault. That was a military industrial complex power grab.

> the Iraq war is as related to terrorism as vending machine crush deaths

This is just wrong. Iraq had nothing to do with 9/11, but 9/11 provided the political cover that the Bush administration needed to take the country to war. Absent that terrorist act, there's no way that the American public and the international community would have stood by and allowed the US invasion to take place the way that they did because of 9/11.

>> this decade...

I think that's known as carefully picking your sample population to get the result you want.

Yes, it was a convenient (one nice block of the table) and admittedly not statistically honest sample.

That said, even if we include the whole of US history (that whole wiki article) it's still an average of roughly 1/100 as many people dying each year of terrorism compared to opioid deaths. Even if we include the whole of US history terrorism deaths, it's still about 1/10 the number of terrorism deaths than opioid deaths just in 2015.

By the numbers yes, but terror alters behavior of society as a whole. But I do agree the overall impact is lower, but at what cost to society? How much resources does it take to keep the impact as low as it is?

Opioids also alters the behavior of society as a whole, to a larger degree than terrorism (albeit in a less flashy manner). When people can't get their addictive painkillers legally, illicit trade and overdosing permeates society, causing cascading side effects to society such as homelessness and crime. This is not normal.

Yes and it goes beyond homelessness and crime. Social services, never built to handle an epidemic like this, are overrun. https://www.theguardian.com/us-news/2017/may/17/ohio-drugs-c...

Hospitals are ill-equipped to handle addicts and the tangled web of birth, opiates, and crime that comes with it. The result: kids die. http://www.reuters.com/investigates/special-report/baby-opio...

The mere aspect of caring for a child born with what they call neonatal abstinence syndrome e.g. babies addicted to opiates is too much for the current system. Lily's Place in West Virginia is one response, but it's a drop in the national bucket. http://wvpublic.org/post/lilys-place-continuing-care-addicte...

Now picture a school in a community overrun by this trying to contend with children born addicted to opiates, and parents who merely shrug when social services takes their children away. Portsmouth, Ohio is one that has been hard hit by the opioid epidemic. There is no safety net for this sort of thing, and it's crushing the institutions that it touches while wrecking the community. https://www.theguardian.com/society/2017/may/17/drugs-opiod-...

I can feel the anger in this post but please know it's not directed at you or HN. I see this up close and the hopelessness of it all, makes me feel impotent to meaningfully help, and subsequently, angry.

That is probably the most depressing hn comment ever.

I didn't disagree, but it isn't fair to compare only deaths. Terror can destroy the economy suddenly. Cause huge societal shifts. Opoid epidemic is a horrible and slow wasting. There is a definite "terror isn't a big deal, barely kills anyone" bias on HN. I do agree it is very hard to quantify and endlessly used to abuse authority and gain new authority that doesn't solve real terror problems. And there are real problems. They just get co-opted by politicians.

Anyway, I have direct familial experience with relatives becoming addicted to prescription painkillers, so I don't need to be convinced, I grew up in the deep south, and have seen the impact first hand. Folks go from opiods to alcohol and meth. Their body is cooked by 40. It breaks families and is a quietly suffered epidemic. Terror is flashy and in your face. No one cares if your uncle died when you were 15 addicted to alcohol and meth. You get all sorts of patriotic platitudes about heroism if your relative is killed by a terrorist.

Edit: It informs life choices in interesting ways. When that tough on his luck guy comes over, smelling like a still at 11am, I can relate to where that guy is. So I let him pet my dog on our walk and treat him with kindness, because not many others will. It is about as hopeless a problem as you can find when a family member is in deep. Anyway, we do other things, but everyone has a hard go at it in life, some people just have it harder and deserve compassion. We do other things to help, but everyone loves petting dogs.

But terrorists are people, not natural events. IMO this is a dangerous line of thinking, since there exist ways to kill millions of people at a time.

Just as dangerous as terrorists? According to this https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm, in 2014 alone, there were 28,647 deaths from opioids in the US.

In the last /decade/, it depends on how you do the math, but it was less than 100 people. http://www.politifact.com/truth-o-meter/statements/2015/oct/...

edit: I see I was beaten to the punch here.

Sorry, but I'm going to take a different perspective. This will not destroy society if not stopped. We've had opioid epidemics in the past. Drug choice changes over time. Not long ago meth was the scourge of the land. It will ebb and flow.

Humans have always wanted to use mind altering drugs. What makes that a problem is prohibition. What's nice is I think society is slowly realizing that and turning to harm reduction. The safe injection sites and prescribed heroin are a couple good examples of that.

I'm curious if you have any personal experience with someone addicted to opioids? I think anecdotal evidence is actually relevant in this case, saying people have always done drugs and it's cyclic as if it's a fashion fad does a disservice to what's really going on here. The changes to the strength and how people are being introduced to the drug is far different than the past. You also speak of meth as if it has become less of a problem, while it has done nothing but continue to increase. I agree that humans have always pursued mind alteration even if it was only spinning in a circle until dizzy. The thing is, I'm not sure if harm reduction will be enough as long as new addicts are being created at this pace. It's going to take a multi pronged approach that requires acknowledging just how bad this whole thing has gotten.

One of the big drivers in this has been the quadrupling in opioid prescriptions in the US since 1999.


Opioid pain prescriptions used to be very limited and carefully monitored because of the perceived risk of addiction. The prevailing wisdom on this danger was changed because of some low quality papers on the risk that were pushed by drug companies.

Another big driver has been a more effective opioid selling due to some Mexican drug sellers. Interestingly, these sellers are much less violent than previous opioid sellers.

These reasons are outlined in the excellent book 'Dreamland'


Long interview podcast (~1hr) with the author to listen to or read the transcript of here:


Regardless of how we respond, a considerable amount of damage has already been done. From the article, it is estimated that the number of current addicts in Ohio is equivalent to the population of Akron, one of Ohio's bigger towns. This has already wrought havoc on the communities - it's unclear to me whether they would recover even if we could snap our fingers and dispel everyone's addiction instantly. Family members have died, social ties have been altered or destroyed, jobs lost, credit ruined, savings spent, homes foreclosed, and so on.

Thank you. The solution is, paradoxically, to increase access to opiates so nobody has to buy on the black market.

That's what really kicked this epidemic into high gear. The government decided to "crack down" on pills and now all the people who were hooked switched to heroin, which is harder to gauge dosage because it doesn't say right on the bottle.

I don't think our government is humble enough to admit the mistake, so many more people will die.

humble enough to admit the mistake

So many of the worst tragedies in life seem to be caused by this. Arrogance, shame, saving face, covering your ass. Humans can be so cruel to each other when we try to do the right thing. We bow to peer pressure when we're 16 and end up wrapping mom's sports car around a tree. Ahhh, damn.

This is my cue for a Tolstoy quote:

> “I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives.”

I agree completely. I also feel for all the pain patients out there that are now being targeted for needing medication. The crazy restrictions the DEA has placed and the fact that virtually every doctor is now terrorized into refusing to prescribe any sort of opioid is hurting real people. We are going about this the wrong way.

> What makes that a problem is prohibition.

No what makes it a problem is the debilitating addiction. It doesn't matter if you buy heroin from a dealer or from Walgreens, it's probably going to ruin your life.

But, by then treating the addiction as a medical condition rather than as criminal activity, that makes it much easier to overcome, and it's easier to intervene with someone performing a legal vs an illegal activity. Portugal experienced a lot of positive results with its decriminalisation of drugs, with the number of heroin users having significantly dropped since that was introduced.

It doesn't magically stop being dangerous, but prohibition clearly doesn't work for any substance.

Prohibition isn't perfect but it certainly can work and one glance at drug use rates in Sweden and Singapore will tell you that.

I'd argue that this is much more dangerous than terrorism.

Most things are. The main danger of terrorism is that we injure ourselves.

I think "just as" was being use colloquially to mean "at least as".

People need to be able to replace opioids with safer alternatives. Cannabis, kratom, etc. Not going to work for everybody of course but many people will probably be saved that way.

This is something Ive been tracking in the US for a few years even though I live in Australia.

It's painfully obvious why it's been suppressed for so long. All you need to is look at who the top advertisers with news organisations are, then imagine why they very rarely cover negative stories about drug companies.

Hell just to name 1 big example, the elderly couple who were passed out in the car with their grandchild in the back. When it went viral, the claim was they were doing illegal opioids and days later when it settled down it was found out to be prescription meds.

It is already worse than the AIDS epidemic ever was in the US (although that too might come back). It's become a significant factor in declining life expectancies in the US among certain demographics.

Lets by realistic, this is far more dangerous day to day than terrorism.

Neither are going to destroy the country. These drugs are going to destroy a lot of lives though.

"accuses the companies of engaging in a sustained marketing campaign to downplay the addiction risks of the prescription opioid drugs they sell and to exaggerate the benefits of their use for health problems such as chronic pain."

This is very relevant, from the article. This is the accusation. I have seen very generic comments in this thread that don't take this information into account.

Maybe this will turn into a tobacco moment for the industry.

Of course it will, big pharma has deep pockets. Why go after the doctors prescribing the drugs? They don't have any money.

And in the end what will happen is that people that legitimately need pain killers will be told "sorry, you might get addicted, just tough it out". Not a world I want to live in.

I started encountering many doctors who blanket refuse to prescribe anything addictive, under any circumstances, about 1-2 years ago.

what about stuff like cortisone? It's addictive (you build a tolerance, you have to taper the medicine at the end), but it very far from the issue of heroin.

I am asking in good faith: I used to be prescribed cortisone, and managing the end of the treatment was a pain, I just decided to stop worrying treating my rashes altogether, because that was getting ridiculous. I am wondering if some doctors also threw the towel on that one.

Under what context, can you say? I assume not all your own doctors, etc.

exactly. This has already happened to me. I had surgery and was sent home for several days of agonizing pain with "extra strength tylenol." I was informed that it was now hospital policy not to prescribe take-home opioids due to the "opioid epidemic." ftr I have never had a problem with opiates before, and I've had them in the past when I broke my arm, and when I had my wisdom teeth removed.

I believe the solution to this isn't "let more people have opioids", it's very hard to determine abuse, and requires monitoring. Reducing the number to monitor is one way increasing safety. Long term I believe the solution will move to "let's find a safer alternative to opioids".

Based on research canibis is promising http://jamanetwork.com/journals/jamainternalmedicine/fullart... With a 25% reduction in opioid abuse by allowing patients access (not necessarily prescribing).

Kratom is an even better candidate in my opinion. It works very well for pain management and anxiety relief, and it’s both less dangerous (e.g., no respiratory depression) and less addictive (although still certainly habit-forming) than synthetic opiates. People use it to help kick addiction to opiates because it contains mild opioid receptor agonists. The DEA considered banning it late last year, but there was considerable backlash, and I doubt the new administration is going to move on it for a while.

Kratom is saving lives. When Alabama banned it, opiate overdose deaths shot up 30% (no pun intended). It really is one of the premier solutions to the country's opiate epidemic.

Yup. It’s been a massive help to me for managing anxiety, insomnia, some minor chronic pain, and a predisposition to alcohol abuse. It’s not a wonder-drug but it comes about as close as I personally could ask for.

This is exactly the same situation I am in. I found kratom in 2010 while looking for some solution to my back pain and arthritis which wasn't also a recreational drug. It ended up helping me with anxiety and depression associated with PTSD, chronic pain, and even helped me stop drinking altogether. I felt like marijuana was a pretty amazing thing before, but it isn't even on the same planet as kratom.

You're not going to get addicted from one prescription to manage short-term pain for a few days, e.g. wisdom teeth or surgery recovery.

The people who got addicted, and the subject of the lawsuit, were prescribed opioids for long-term pain management. Of course you're going to get addicted if you take them every day for weeks or months. It's the nature of the drug, and the drug companies are being sued because the purposefully downplayed that.

Out of curiosity, was the wisdom teeth removal an especially complex operation? My last wisdom tooth removal took 20 minutes for the whole visit, after which the dentist neither prescribed any painkillers whatsoever nor did I get a day off from work.

Many wisdom teeth removals involve "digging them out" where the gums need to be cut open and stitched back together. I was put under general anesthesia and given Oxycodone for a few days, and was very glad to have it because it hurt like hell.

If the teeth have come in enough though, they can be treated like regular extractions. They are still painful, but generally much less invasive / potentially complicated.

Yep, this is exactly what happened to me.

Or they will get properly informed of the risks and have their dosages monitored by a doctor who is properly informed of the risks.

Instead of getting handed opiates like they are harmless because the doctors believed the drug companies who tried to pass them off as safe for unmonitored use.

It's not mentioned in the article, but were the people who are addicted initially prescribed opioids for pain relief? Or did they initially try them recreationally?

I read that the amounts recommended by producers are often such that the effect reliably wears off before the next dose is due. This is a sure way to form an addiction.

Re: How this forms addiction - the levels prescribed are for a 12 hour period, but since the drug only lasts 8 hours, a patient is getting a dose above the recommended level that it should last.

Marketed: 120mg over 12 hours or 80mg over 8 hours

Reality: People that take the 120mg over 12 hours realize it only lasts 8 hours thus they are taking 40mg more than they should be on the schedule that makes sense to them to avoid pain.

Well, the reality seems to be even worse.

Rather than taking 40mg at the end of the day, the drugs companies caution doctors to prescribe more medication initially rather than give any indication that the drug only lasts for 8 hours.

They care more about their approach to marketing, than the efficacy of the prescription schedule.

It's this that creates addicts: the extreme high of the unneeded extra initial dosage, followed by a lower low when the drug runs out.

What nine_k meant is that 120mg is too much, so the person gets a tiny buzz at first. But instead of acclimating with a consistent dose as you suggested, they wait 12 hours until the drug has worn off, causing a crash. Then they repeat the high/low cycle, causing an addiction.

why would that form an addiction?

Psychologically. Instead of constantly feeling okay (the pain is gone, you keep getting a prescribed amount and no more), you are reminded every few hours that with the drug the life is good, and without it the life is miserable. But you cannot alleviate the pain unless you break the rules (the prescription).

Once the prescribed regime is broken, and the psychological restraint is broken, too, there's little left to stop the usage from spiraling up, to an overdose.

because you experience repeated cycles of pain, take pills, then relief, then pain, take pills, then relief.

Yes, very much so. It's resulted in a multi-fold increase in opioid addiction and consequently opioid deaths in the US over the last about 15 years or so. The general trajectory is: person gets prescribed opioids for pain, person's life falls apart due to addiction or they hit some hiccup that causes them to lose their health insurance, then they traverse a downward spiral as they become unable to hold a job and switch to heroin (same fix, easier to get), and because heroin doesn't have consistent dosing the chance of OD'ing is much higher.

Remember 9/11? Imagine that many people dying from a preventable tragedy every 4 weeks in the US. Because that's what happened in 2016 with opioid addiction.

If drugs are over prescribed in such a number that mass diversion is possible, does it matter? This is more than stealing from grandmas pill bottle, the drug companies knew how many pills they were selling to pill mills for example.

This is exactly it, and people who are complaining about access are missing the point. There is absolutely no way you can count the cash you make from the volume of these pills and think "this is roughly in proportion to the number of people dying of stomach cancer".

It's a serious problem that is killing people, and it's worth taking a shot at without being shouted down every time by someone who thinks you're trying to take their pills away.

There's this weird thing in the US where ads can say "ask you doctor for <drug brand>".

That's incredibly stupid and illegal in all but one other country in the world.

asking your doctor for oxycodone, even in the US, is a very easy way to be shown the door

Perfectly legal in Canada. Don't be hyperbolic, it doesn't help anything.


My apologies if I was wrong. I believe I got it from the nytimes article on the topic published a few months ago.

Would you care to update Wikipedia (and cite your source)? They only list the US, NZ, and Brazil.

https://www.nytimes.com/2016/02/28/sunday-review/ask-your-do... https://en.wikipedia.org/wiki/Direct-to-consumer_advertising

The pharma companies have some liability, but there was a perfect storm

The "war on drugs", and the racially motivated moral panic about crack cocaine and addiction created a social attitude that casts addiction as a moral failing

Inadequate safety net healthcare provisions lead people to the cheapest treatment option, generic opiates fit this bill

Our current healthcare system says, hey, if you're poor/out of work/disabled, here's some cash to buy dangerously addictive opiates that will short-term make you feel better. What could go wrong?

Here's some blog posts arguing the ACA actually increased the severity of the opioid crisis:



I'm (nevertheeless) pro-universal healthcare, but our idea of healthcare should probably not include these drugs in any but the most extreme and limited circumstances (like, I'm lying in a hospital bed). They're too dangerous.

Having doctors actively prescribe them, under incentives from pharma companies to sell them, seems to me predatory in the same way we think of street dealers stalking schoolyards as predatory.

Chris Arnade has done a great job documenting the crises at a personal level. I highly recommend checking out some of his articles and tweetstorms. It's gut-wrenching stuff (and obviously the problem goes way deeper than simple access).

But pharma/doctors/govt pushing drugs isn't helping, and is probably making it much worse.

Do you believe a person has the right to acquire and consume whatever drug they want to as long as it does not lead to criminal behavior? Or do you believe we should treat citizens like children who can't be trusted to make their own decisions? Because this is a completely separate issue from overprescription of opiates.

Let me say upfront: I'm pro-legalization of recreational drugs. Even the ones I wouldn't personally do. I truly believe that with access - especially to things like pot and hash - will seriously help with opiate abuse.

And honestly, the correct answer (in my opinion) is that one should do both. As much as I'd like to believe better in society, the truth is that not everyone thinks things through. Not everyone gains information before they do stuff.

Some drugs should have restrictions. Age limits are prudent, for example. I don't trust folks to take most prescription drugs correctly. Antibiotics and most treatment-only drugs are like this.

I'd rather folks do opium than heroin or opiate pills. If there is still a market for them after legalisation, I'd rather the opiate pills that are available to the public be the mild variety. Push folks to do occasional cocaine rather than crack. Avoid meth if possible, mostly because it is hard on folks. Heroin or anything else that one injects are only available at a clinic, where you have to consume there.

And above all, drug addiction treated like a medical condition... and free of charge.

I'm certainly opposed to prohibition, but we're at the other extreme when we're using tax dollars to get people hooked on drugs pushed by large, profitable corporations.

It's an incredibly difficult problem to solve. Ultimate freedom for the responsible citizen, without allowing the general population to be brainwashed into unhealthy consumption habits.

I hate this argument.

1. Crack has a lighter sentence than meth does despite meth being a "white" drug and crack being a "black" drug.

2. America has always casted failure as a moral failing. Its the basis of Calvinism. It has nothing to do with the war on drugs.

3. The epidemic is new. In the 40s, 50s, 60s, when healthcare was much worse, you didn't see this level of addiction to opiates. Easier access to opiates means better access to healthcare which is the problem.

Thank you. Your 2 is an aspect I hadn't thought of at all. In reference to sentencing disparity, I was referring to the 100:1 (pre 2010, now only(!) 18:1) difference in sentencing for crack vs coke

#3 isn't quite true.

Yes, this epidemic is new, but drug epidemics aren't. This one is likely more widespread because of widespread use.

But this is most pronounced in the US. Other countries with good-or-better access to healthcare don't have nearly the same problems as the US [1]. I think it lies more in the way we treat folks when they are sick: Turning to opiods instead of other drugs (a combination of ibuprofin and paracet/tylenol is a pretty standard pain treatment here). Not actually giving folks time off when they are sick and injured. Sure, you have the FMLA, but that doesn't exactly let folks pay their bills. We (the US) could also do things like talk to patients and/or their families about ways to handle the pain, what to do if the pain relief wears off, prescribe differently so that it isn't wearing off. We could make sure to have realistic conversations about addiction. And the drug companies could be upfront about this. Lastly, we could provide addiction help, treating it with time off in a manner similar to simply being sick.


In regards to #1, the war on drugs has been going on for decades now, whereas I believe you're only referring to the current situation. It was certainly true that, for decades, crack as a "black drug" was being treated way more harshly than other "white drugs", with hugely aberrant sentences. And now under Jeff Sessions we might well be reverting back to that.

We can conjecture all we'd like, but Sam Quinones wrote a rather definitive history of the opioid epidemic in America. https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidem...

Sam ran the podcast circuit awhile back if you want to listen to his story. I found out about it via Russ Roberts' Econ Talk. http://www.econtalk.org/archives/2017/01/sam_quinones_on.htm...

Maybe but even if all of that were true it has no bearing on pharmaceuticals encouraging irresponsible over-prescribing and over use of their opioid based medication.

The "war on drugs" has little to do with our opioid epidemic. These are people who were given "medicine" (mostly painkillers) and got hooked.

I disagree. Look at Portugal, which decriminalized opioid use and started viewing it as a treatable medical condition. They went from the highest to one of the lowest rates of opioid use in Europe.

Portugal didn't have pharma companies and doctors selling opioids as being safe to regular people.

That is what makes the USA unique - it's almost impossible to be prescribed strong opiates anywhere else in the world, let alone to be told that they're safe.

I'm pretty sure we're the only country that has commercials for "Opioid Induced Constipation" drugs as well.

You know something is prevalent when the drugs to treat its side effects are worthy of prime time advertising.

> I'm pretty sure we're the only country that has commercials for "Opioid Induced Constipation" drugs as well.

Well, we're one of only two countries in the world that allow direct to consumer advertising for drugs at all, so your statement is probably true.

(New Zealand is the other one for those curious, with Canada having some limited things they allow).

As a kiwi myself, I'm genuinely curious about what drugs are advertised in NZ. I can't recall any such advertisements, apart from maybe flu pills that contain pseudo-ephedrine?

We don't have many - panadol & ibuprofen combos, viagra generics, branded asthma drugs. Generally they purchase ad spots outside of prime time (and likely with more regularity on channels like One & Prime, where there's a slightly older audience.

My hypothesis there would be, those people are prequalified—the fact that they're consuming opioids means that they 1. have money and 2. are willing to spend that money on drugs to fix their suffering. Selling them an add-on drug that relieves the suffering from the first drug seems like "easy money."

Or commercials for pharmaceuticals at all.

European doctors didn't prescribe the same stuff American doctors prescribed, and unlike the US if you did get something prescribed it was easier to keep the prescription (so you didn't turn to heroin, etc).

One of the few things that makes me proud of my country.

I am mostly with you on that and think this is a separate issue of big pharmacy pushing unsafe drugs, but there probably is some truth to GP's statement as well. The social stigma of addiction treated it as something that happened to morally deficient people, and probably lead to defunding and demphasizing public health approaches to solving it.

In theory, its hard to say addicts don't have treatment options. If you're ensured the same guys will give you methadone, and public clinics exist. If you fall off the grid its much harder, especially because public treatment options which are mostly free, do require tedious screening. In that case its a matter of implementation. The real issue is that many treatments have a poor success rate.

I disagree. If we want to get into numbers sure there is some percentage who first had a prescription. I'm also sure there are plenty of people who started using when they were flowing freely and cheaply as a recreational drug. I know where I grew up, plenty of people were using without having it prescribed. It was incredibly easy to get bulk amounts across the country, for example Florida: http://www.nytimes.com/2011/09/01/us/01drugs.html

What the other poster is talking about is the reaction to someone being hooked, looking the other way and/or not treating it as a mental health issue and putting them in rehab instead of jail.

Then, imo, if you really want to get into it, destabilization in Mexico has created the actual heroin epidemic we see now, as the pill mills and doctors involved have had their operations closed.

The numbers suggest the majority started with a prescription. The number of people given these prescriptions was staggering around 4 times as many people got hooked (2.1 million) than are using Heroin (0.4 million). https://www.drugabuse.gov/about-nida/legislative-activities/...

"By 2002, death certificates listed opioid analgesic poisoning as a cause of death more commonly than heroin or cocaine."

No. The war on drugs means that when people "fall out" of civilized society due to opioid addiction they are forced to turn to street drugs. Drugs of questionable composition and strength, making dosing dangerous. The result is 100 deaths from opioid overdoses every. Single. Day.

If those people were on methadone instead, for example, hundreds of thousands of people who are now dead would still be alive.

Drug companies don't write scripts. That falls entirely on doctors.

I know people who died of opioid overdoses, and they were never prescribed it. If you take away the medical pills, they just go get heroin and OD on that.

I know people who died of opioid overdoses, and they were always prescribed it.

Also if you read "Dreamland" 80% of heroin addicts started addiction with prescribed drugs.

My wife was facing a burnout at the work. She was needlessly scared and suffered panic attacks. It is something I have gone through too and coped. But in her case because I love her more than I love myself I decided to take her to a doctor who then refereed her to a psychologist who then prescribed her drugs which on quick research appeared to be his plan to keep her on those forever. My expectation was that the doctor would suggest her some mild drugs and ask to take up Yoga or some other hobbies and assure her that everything is in fact alright with her.

He on other hand made a big deal out of whole thing.

We decided to trash all the medicines and lived happily without any issues.

My doctors have given me opioids so many times and I typically throw them out. Why take a substance like that if pain is bearable ?

To address your final question: patients are strongly pushed to take prescribed medications at the prescribed intervals.

You decided your didn't need anything extra for your pain. That is good. Many people have difficulty toughing it out, maybe they had it worse. Perhaps some got an infection from their wisdom teeth removal (or they failed to follow directions and got dry socket leading to extreme pain). Given the prior doctor instructions (and perhaps not understanding why they are currently in pain) patients take their drugs at the maximum (or in some cases, above) the prescribed rate.

This isn't too say your choice was wrong, but that many others aren't as fortunate to avoid addiction, add once they are: their choices can no longer be considered rational, but as those made by an addict in pain who had been told opioids will help.

I live in France and the approach here to pain relief is very gradual, I was in a hospital with severe headaches, the nurse came every time I rang her and gave me mild pain medicines (alternating sometimes because it didn't work).

I am glad they didn't bring in the big guns, I am a bit worried about morphine and heroin stuff we read on the internet.

In most European countries, opioid painkillers will only be administered in hospitals when pain is so strong that you can't fight it with Ibuprofen or Aspirin (e.g. after surgeries).

I don't know a single person here in Europe who got a recipe for opioids by a GP or after leaving the hospital. That's not because pain is not treated but because doctors realise how dangerous opioids are.

In the most European countries co-codamol is OTC without a prescription.

I think it's quite common to get co-codamol or dihydrocodeine from a GP in the UK. However, this is really weak in comparison to the high-dose oxy or hydrocodone that US doctors seem to prescribe.

CO-Codamol has a comparably low codeine content which would likely make it less addictive (only guessing, not a doctor). It's a prescription drug in the UK.

Will probably depend on the doctor but the GPs I have seen in the UK have preferred Ibuprofen if it can treat the pain.

It's not a prescription drug. You can get up to 12mg/500mg OTC at a pharmacy.

FWIW you can also get 8mg/500mg dihydrocodone without a prescription OTC in the UK.

Anything containing codeine is prescription afaik in Belgium. Pure paracetamol-based painkillers is OTC.

This is probably where cannabis would help, but I don't think even most medical states include anxiety/mild depression on their list of conditions for referral. Very few allow for pain without very specific parameters. Nah, instead we'll hit people over the head with hard drugs. Forever.

While Cannabis could help, what's wrong with Ibuprofen? It's the go-to drug for most doctors in Europe and used for the vast majority of patients with pain. Unless you had surgery or have been in an accident, pain is rarely that strong that you need opioids.

Taking ibuprofen for your pain today is perfectly acceptable. Taking it everyday in an attempt to treat chronic pain is not. There are heart and liver disorders linked to long term ibuprofen use.

Long term use of ibuprofen is linked with heart and liver issues, if I recall. I know I'm not citing a source here, just something I remember my wife telling me she read in a study, the best kind of evidence :)

FWIW, I've found ibuprofen to be the absolute best for my post-surgical pain. The issue is that it's 600-800mg every 6 hours to remain effective, and that's pushing some limits on dosage. Doctors have always told me fine in the short term, but bad longer term.

I know I'm saying this with a clear mind and pain free body right now, but I'm entirely unwilling to fill an opioid prescription in the future. The small amounts I've taken in the past for surgery were just too memorable - nothing should stick in your brain like that years after and be considered safe.

But cannabis can also be highly addictive IMO and can definitely cause anxiety/panic attacks in some people (especially with too high a dose in an inexperienced user).

Addictive in what sense? Opioid withdrawal can kill you. My understanding is cannabis is only mildly addictive and essentially results in short term irritability and a small rise in blood pressure for a few hours to a few days.

Anecdotally, the biggest potheads I know can take a month off without impact to their lives.

Regarding anxiety and panic attacks, I'm sure that's possible, but people don't die from it. An extra cup of coffee would do something similar for a longer period of time.

I don't think we've studied cannabis enough to truly know the negatives, but even heavily discounted historical and anecdotal evidence would suggest it's less harmful than opioids. That potential for harm might be low enough that you simply try it first for pain management, before moving on to stronger things that carry their own sets of risks. I'm not a doctor (or a cannabis enthusiast), just what I think I think.

How is your opinion informed on the highly additive nature of cannabis? As with any substance cannabis can be abused and can have negative consequences; however to say that is it highly addictive is highly misleading.

I agree that anxiety can be an issue especially with novice users, but those effects vary person to person and strain to strain.

Cannabis can help many conditions including anxiety but because of its long history of demonization it has not been standardized and requires a lot of work on the part of the patient to zero in on the correct dosage. This is starting to change with products like tinctures being more and more available that provide the ability to easily have lower / long lasting dosages.

What are the long-term health insurance related issues if they find out you didn't follow the doctor's prescription?

The wouldn't know as I got the medicines and trashed them.

Also, if they are any smarter they should lower the premiums of people who did not such painkillers.

For some people it can be clinically dangerous to try to bear through pain.

Not only that, if someone has a leg injury and works doing roofs or tiles or is a plumber, it helps them get back to work faster. We have nearly zero safety net in the US.

I focused on the accidental in my review of the cause, thank you for reminding me that for some, not working, and the threat of no income can push them to push them themselves with opioids to fall into the trap of addiction

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