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Tens of thousands of US drug users (victims) get jailtime. Citizen traffickers (perps): serious jailtime. Corporate traffickers (perps) get fined for 'nuisance'.

The Arthur Anderson firm got deep-sixed for felony obstruction of justice. Enron's Ken Lay was convicted of 10 counts of wire and bank fraud. (Skilling just got out of jail.)

Tens of thousands of dead Americans: 'nuisance'? I can think of only a couple of 'justifications' for the disparity.

Arthur Anderson and Enron harmed wealthy, powerful people.

Corporate pusher's victims were just Regular Joes. Who the law protects and who the law binds aren't always in sync.

> Arthur Anderson and Enron harmed wealthy, powerful people.

Not true. Probably the biggest losers for Enron were the rank-and-file employees of the company. Not only did they lose their jobs, but more than half of the Enron employees' 401k was invested in Enron stock.

And Enron happened to freeze the 401k plan at the time where the stock started to drop and people could have sold.


It is true, lots of people were harmed, including the rank and file. But “rank and file” usually calls up images of honest, blue collar folks and factory floors. According to Smartest Guys In The Room, the rank and file of Enron were mostly MBAs in thousand dollar suits with a reputation for utter ruthlessness and extravagant pay. The electrical utility employees in that article were not truly Enron employees.

That they harmed rank-and-file is besides the point. The important point is they harmed wealthy, powerful people.

> Corporate traffickers (perps) get fined for 'nuisance'.

One of the worst cases is probably https://www.cnn.com/2014/04/02/justice/delaware-du-pont-rape...

> Though Robert H. Richards IV was convicted of rape, the wealthy heir to the du Pont family fortune was spared prison by a Delaware court in 2009 because he would "not fare well" behind bars,

The term is https://en.wikipedia.org/wiki/Affluenza. It is surprising how blatant and obvious it is.

Yeah $500M out of $80B in revenue is pocket change, about 0.6%.

What is exactly is it that you believe qualifies as criminal behavior? Opiates are a legal, and medically necessary, component of the healthcare system. Unless you want patients to suffer horrendously, somebody has to manufacture and sell opiates.

Opiates are also a fun and addictive drug. As long as they exist and are generally available, some percent of the sub-population will abuse them. We can try our best to keep them only for medical use, but once the prescription leaves the pharmacy there's not much you can do. You can't blame the legal manufacturer when that happens, if they took all required steps to keep their drugs in the legal channels. Maybe you think that's true, but that the opiate manufacturers have used their power and influence to over-prescribe their products. That assumes that opiates are over-utilized in American healthcare. And that's a narrative that simply isn't borne out by the data.

Only 0.19% of opiate-treated chronic pain patients without a prior history develop any form of abuse or addiction[1]. And remember these are chronic-pain patients who take tolerance-escalating doses over years or even decades. Virtually no one develops an opiate addiction from following their medically prescribed treatment regiment.

The death rate from prescription opiates has not budged since 2006[2]. The vast majority of opiate overdoses in America are not prescription opiates, but illicit fentanyl, and to a lesser extent heroin and methadone. Nor do chronic pain patients face any major risk of overdose. The fatal overdose mortality rate for long-term opiate-prescribed patients is 17 per 100,000[3]. And that number doesn't exclude the subset of the population engaged in abusive behavior like mixing with alcohol, snorting pills, or hoarding medication.

Finally the sizable majority of prescription drug abusers in this country do not source from a doctor or the healthcare system at all. The vast majority get their drugs either from the black market or a friend or relative. On the National Drug Use Survey only 18% of prescription drug abusers report doctors as their primary source. And among street prostitutes (a high at-risk group) only 5%[4].

All of this goes to show that there is very little evidence of any sort of over-prescription of opiates in America. To begin with the vast majority of the opiate crisis has to do with fentanyl, not prescription drugs. But even when it comes to prescription drug abuse, the intersection with medical users is vanishingly small.

However what there is a major problem in America is untreated chronic pain. 50 million American suffer chronic pain[5]. And 20 million suffer high-impact chronic pain which severely impairs normal life function. More than 10% of suicides are linked to chronic pain[6]. High-dosage opiates are absolutely essential for this group to live any sort of normal life. As long as there are such massive numbers of legitimate pain patients, the law of large numbers guarantees a large supply of diverted opiates. Even under the tightest controls. There's simply no way around that except by denying most of the legitimate patients treatment for their debilitating conditions.

[1] https://www.ncbi.nlm.nih.gov/pubmed/18489635 [2] http://www.ncsl.org/portals/1/documents/health/APeeples0118_... [3] https://annals.org/aim/article-abstract/745518/opioid-prescr... [4] http://sci-hub.tw/https://www.tandfonline.com/doi/abs/10.108... [5] https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm [6] https://www.ehidc.org/sites/default/files/resources/files/Ch...

> What is exactly is it that you believe qualifies as criminal behavior? Opiates are a legal, and medically necessary, component of the healthcare system. Unless you want patients to suffer horrendously, somebody has to manufacture and sell opiates.

The criminal behaviour was aggressively selling something that already sells itself.

> Only 0.19% of opiate-treated chronic pain patients without a prior history develop any form of abuse or addiction.

Your cited meta-analysis looked at nonmalignant chronic pain patients receiving chronic opiate therapy: There is not a strong indication for this therapy in that group.

When they looked at all recipients, the abuse/addiction rate was 3.27%.

" In the urine toxicology grouping, there were five studies (15,442 CPPs exposed). Here, 20.4% of the CPPs had no prescribed opioid in urine and/or a nonprescribed opioid in urine." In other words, 20% were clearly diverting to non-prescribed users, and/or already supplementing their opioids.

How could the authors suggest that there was only 3% demonstrated abuse/addiction or aberrant behaviour when 20% were diverting their entire RX or supplementing????

> When they looked at all recipients, the abuse/addiction rate was 3.27%.

The 3% figure includes includes those patients with a pre-existing history of addiction/abuse. Now it's debatable whether previous addicts should get opiates for chronic pain conditions, it's irrelevant to the specific question of opiate prescriptions create new addictions. Because by definitions those with a history already had a pre-existing addiction.

Regardless 3% is still an extraordinarily low percent for chronic pain patients treated for years at a time. For reference 3% is less than or on par with the abuse/addiction rate of long-term prescribed ADHD medication[1].

> In other words, 20% were clearly diverting to non-prescribed users, and/or already supplementing their opioids.

Your characterization of the findings are mis-leading. Opiates frequently metabolize to another active opioid inside the body. Morphine commonly metabolizes to hydromorphone[2]. Codeine metabolizes to morphine[3]. Oxycodone metabolizes to oxymorphone[4]. Hydrocodone metabolizes to hydromorphone[4].

Furthermore many of these metabolic pathways are only just recently discovered (like morphine to hydromorphone). The reality is that our current understanding and technology is not advanced enough to tell from urine toxicology which specific opiates were consumed and which are the byproducts of metabolism.

[1]https://slatestarcodex.com/2017/12/28/adderall-risks-much-mo... [2] https://www.ncbi.nlm.nih.gov/pubmed/16620524 [3] https://www.ncbi.nlm.nih.gov/books/NBK100662/ [4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704133/

> Your characterization of the findings are mis-leading. Opiates frequently metabolize to another active opioid inside the body. Morphine commonly metabolizes to hydromorphone[2]. Codeine metabolizes to morphine[3]. Oxycodone metabolizes to oxymorphone[4]. Hydrocodone metabolizes to hydromorphone[4].

I’m pretty sure the authors were accounting for that. Otherwise they’re not investigating anything of value. Especially if they’re lumping them in with a group that didn’t have any opiates in their screen.

> Opiates are a legal, and medically necessary

This is finally being questioned by studies. Multiple studies have recently come out that show non-opioid pain killers are as effective and sometimes more effective than opioids in both chronic and acute pain. Now, I don't think opioids need to be made illegal because they do have their uses, but they are clearly over-prescribed when more conservative options may work.



I agree that opiates are an important medical tool. But from what I've read I get the impression that they're severely over-prescribed in the US compared to other nations.

They are still severely under prescribed in nations across the world. To the point that they are not available at all in many countries due to puritanical lobbying. Which means people across the globe are still suffering an absolute horrible fate, despite how easy it is even for a developing country to produce pain medication. The world still hasnt recovered from the last US crusade against pain medication, so i am more then a bit worried about what happens in the US right now. The fact that large parts of the world today have worse pain management options available to their population then what was available in the middle ages should scare you a lot more then some guy having fun with his medication.

People misusing pain medication is a small price to pay to have pain medication available for people who need it. There wont be an optimal solution by pushing down on pharma companies and doctors, it will be quite a lot worse then today.

To put it simply, if you are lobbying to combat the so called "opioid crisis" you should think damn hard about the consequences of your actions. Because if or better when there is another backlash peoples suffering caused by a lack of pain medication will be on your hands.

At least my view from living in Europe is that medical care is at least partly cultural. In the US we put a lot more faith in technology (devices, surgery, etc) than you see elsewhere. Also the the approach of optimization is different. In Sweden when I injured my shoulder, I was given a conversation on over the counter remedies first, and if these were not sufficient would have had a conversation with a physical therapist, and eventually when these fail maybe stronger medicines would have been used. As it was the NSAIDs recommended (which were strong NSAIDs, much stronger than ibuprofen) worked for me.

I don't think it is fair to criticize medical practices across cultures. Every culture has a different view on these and optimizes for different things.

> some guy having fun with his medication.

You don't think that's a bit disingenuous?

We all are making choices in our life. Abusing pain medication is also a choice. If it was problem born only out of lack of information, we wouldnt have this discussion about the necessity of tighter restrictions. You only need restrictions if you want stop people making choices you dont like. Otherwise education would be sufficient.


Yes, and as he said, the majority of the impact is from illegal opioids, not the ones being prescribed.


The largest meta-study to date found that among long-term opiate pain patients without a prior history of abuse, only 0.19% developed any sort of addiction or abuse.

I do agree with you that many heroin users start with prescription opiates. But the vast majority are not themselves prescribed the drug. Surveys show that they're either getting the drugs from friends or relatives or buying it from the black market.

There's no evidence that doctors are "handing out oxycodone like candy", as demonstrated by the vanishingly small addiction rate among actual pain patients. If a kid raids his grandma's medicine cabinet and steals her pain medicine, how is that an indictment of the doctor or pharmaceutical company?

[1] https://www.ncbi.nlm.nih.gov/pubmed/18489635 [2] http://sci-hub.tw/https://www.tandfonline.com/doi/abs/10.108...

As someone who avoids pain medication for medical diagnostic reasons, I have had FAR too many prescriptions for opiates in my 20s and 30s. They were unnecessary 75% of the time that had automatic refills! There was no oversight or followup beyond what you get asked for a medical marijuana prescription (which is a joke). Oh, you have had some pain anywhere for anything? Here's your refill.

What did I do with the ones I didn't need, which I was originally sent home with? Sold them or gave them away for recreational use after my recovery was over.

Opiates, in general, were poorly managed for decades. Vicodin just happened to be the most popular product and the producer never bothered to be responsible about the use of it's own medicinal product, despite being in the business of medicine. I'm sure J&J aren't special, as a company that would end up being willfully negligent in the face of a successful pain medication empire, but they were.

And once you are hooked on the legal opioids, where to you go once your prescriptions run out? or your insurance? or your job. One does not start out shooting heroin laced with fentynal - one ends up there.

When you are encouraging doctors to prescribe oxycotin like it is tylenol, hiding research about the addictiveness and makeing sure its on the formulary of all insurance companies all the while making huge profits; then maybe there is smidge of responsibility to be shared by the corporations.

Most people addicted to opioids started with legally prescribed meds. Those meds may not have been prescribed to them, but that's the problem with the fucking stupidly large numbers of opioids being prescribed in the US: there are very many meds lying around to be diverted to recreational use.

So far almost every point you've made in this thread can be directly sourced to Purdue propaganda. Doesn't that worry you?

There was "The Letter that Started it all": https://www.bbc.co.uk/news/world-us-canada-40136881

That caused the VA to say "pain meds aren't addictive if used to treat pain": https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital...

Here's the paper that rebuts this: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/ (and note this is more than 10 years old)

Here's Purdue Pharma saying, as you are here, that pain meds aren't that addictive and don't we need to use opioids to treat pain (they are addictive, and they don't work for many types of pain): https://www.feinberg.northwestern.edu/sites/ipham/conference...

You're comparing the use and trafficking of illegal drugs with the (alleged) mis-marketing of a legal product.

Of course the punishment isn't the same.

What if the product was both ineffective and dangerous, and it therefore shouldn't have been legal? And what if the studies showing that were buried by the manufacturer?

You could actually argue that someone selling heroin to an addict is doing something consensual, where both parties know what they're getting into. You can't say the same of opioid manufacturers, who intentionally buried vital info and muddied the waters of public perception.

The intention was to make money, knowing that millions of people would be harmed. Who cares if the method was "just marketing"?

Opioids are ineffective and dangerous? Not according to the government body called the FDA.

The FDA isn't infallible, and it relies on data from industry.

Yes, ineffective and dangerous.

> "Opioids are ineffective in the treatment of chronic pain, and the dangerous risks associated with using and abusing opioids have led to America's most deadly drug epidemic."

-- National Safety Council[1]

> "Ibuprofen Plus Acetaminophen Equals Opioid Plus Acetaminophen for Acute Severe Extremity Pain"

-- Govt-funded trial at UVA[2]

> "Ibuprofen, acetaminophen more effective than opioids in treating dental pain"

-- Case Western Reserve University[3]

> "In summary, reliable conclusions about the effectiveness of long-term opioid therapy for chronic pain are not possible due to the paucity of research to date. Accumulating evidence supports the increased risk for serious harms associated with long-term opioid therapy, including overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction; for some harms, the risk seems to be dose-dependent."

-- NIH[4]

And after that, you're welcome to look at examples where pharma execs admitted to misleading doctors about both safety and efficacy[5].

1. https://www.nsc.org/home-safety/safety-topics/opioids/treati...

2. https://www.aafp.org/afp/2018/0301/p348.html

3. https://annals.org/aim/fullarticle/2089370/effectiveness-ris...

4. https://www.sciencedaily.com/releases/2018/04/180417181101.h...

5. https://www.wbur.org/npr/690556552/lawsuit-details-how-the-s...

Your first quote is a mis-representation of the last one - there is no solid clinical data on the treatment of chronic pain using opioids. That doesn't mean they are ineffective and there are plenty of anecdotal stories to suggest they are.

Your other two sources are just subsets of pain and ignores many other uses of opioids.

The first and last are different conclusions by different researchers.

If there's no evidence something is effective, it should be considered ineffective. I've found sources that say there's incomplete evidence and sources that say opioids aren't significantly better than placebo, but no unbiased reviewer says that they're more effective than OTC and generic painkillers.

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