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Purdue Pharma files for bankruptcy with $10B plan to settle claims (bloomberg.com)
216 points by dingdongding 30 days ago | hide | past | web | favorite | 182 comments



If anyone doesn't know what's going on here exactly.

The Sackler Family – A Secretive Billion Dollar Opioid Empire - https://www.youtube.com/watch?v=zGcKURD_osM


I have a high level question; a lot of want to legalize drugs. Ending the war on drugs and all that. This is a drug that was legal and a lot of people got on it and now we're angry. Why? I don't like that people got hurt. I also recognize that bad drugs are bad. But I can't find a way out of "tell people drugs are bad and they have to make their own choices." Is the problem here the doctors told them the bad drugs were good drugs?


OxyContin isn’t a bad drug, it’s a highly addictive drug and the company knew it was highly addictive & not only didn’t do enough due diligence to make sure prescribers didn’t over prescribe it but also intentionally encourage that behavior which has led to an epidemic.

However, food for thought on that same subject is the over prescribing of amoxicillin and other similar class of drugs for viruses. The doctor is operating a business and his/her clients want a solution to their problem, so they write a script as they want to keep their customer happy and it “can’t be too bad”.

There’s a case to be made that a certain amount of immediate gratification expected on the part of the consumer is a large contributing factor to overprescribing in general.

However, in this case, Purdue was very much in the wrong and should not have been encouraging over prescription of a highly addictive drug.


Yeah. I think the underlying story is that doctors used to be more apprehensive about prescribing opioid painkillers, and when they did they prescribed lortabs or something like that for acute cases and they wouldn't put refills on or rewrite the scripts when asked. Then, along comes Purdue with a claim that OxyContin, because of its unique formulation, is a big addiction concern and is safe to prescribe for chronic pain. Then they (and a couple other manufacturers) basically conducted a successful campaign to convince doctors that undertreatment of chronic pain was widespread and they were basically letting their patients suffer, strongly suggesting that this may be considered malpractice in the future if they do not start prescribing more opioids. This campaign was very smart and even reached the doctors who refuse to take incentives from drug manufacturers. Essentially, in the way that Pfizer created a new category of concern in the mind of patients with Viagra, Purdue did the same in the mind of doctors with OxyContin.

Lo and behold, people are addicted to OxyContin, some start looking for more immediate-relase formulations of opioids because they don't feel right even on 80mg Oxy tablets, and hundreds of thousands who otherwise would have been alive with chronic pain are now dead of overdose. Meanwhile, research is showing that opioids are not very good for chronic pain and other approaches, usually multimodal approaches, are better, including NSAIDs, gaba-ergic drugs like gabapentin and pregabalin, ketamine, physical therapy, psychological retraining, meditation, acupuncture, etc.


> Then they (and a couple other manufacturers) basically conducted a successful campaign to convince doctors that undertreatment of chronic pain was widespread and they were basically letting their patients suffer, strongly suggesting that this may be considered malpractice in the future if they do not start prescribing more opioids.

That was/is the position of the IOM though. Was Purdue involved with convincing the IOM to adopt that position?


Yes, when ideas become fashionable, they become the conventional wisdom.


Oops, I meant is not a big addiction concern.


can you explain the issue with Amoxicillin and viral use? Is it that amox does nothing for viral infections, and was prescribed anyways?


Bacterial co-infection is a risk with viral infections, the problem is that antibiotics have been prescribed as a first line script when it isn't indicated.


Yeah, that’s the point I was trying to make.

Lots of times Doctors are providing a service and the expectation is “I feel bad, give me some pills to help” when in reality many cases are rest & recover but as a client can you imagine paying your social media person $500 for them to say “doing nothing is the right move”? Not really, no.


Much of the legality argument for drugs stems from not punishing the user. Nobody is really interested in protecting the dealer. Manufacturing, selling, and marketing highly addictive substances at the cost of society isn't where people are interested in relaxing laws. Purdue (and others) have been operating as legal cartels. Shutting them down is a net benefit to society.


From my understanding, this company lied about the effects of the drug. That is the problem. If they would have said "hey we have a great drug that completely dopes a patient up and works like magic to block pain, BUT only give it for one or two days OR ELSE they will become addicted" then we would not be here now debating this. Instead what they told doctors was that the drug was safe at the recommended prescription levels which was not true.


A direct comparison is to the tobacco industry. Tobacco sales still remain legal in most of the country, but for multiple reasons there's been huge restrictions on how and where and to whom (no marketing to minors/kids) tobacco companies can market. Tobacco products have to be marked with big addiction warnings, and very visible reminders of side effects. Tobacco products also generally have taxes collected specifically to directly finance anti-addiction resources in many states.

Legally selling the drug is orthogonal from morally/ethically dealing with the consequences of the drug, including regulating how it is sold, how it is marketed, how it deals with its own consequences.


> a lot of want to legalize drugs. Ending the war on drugs and all that

There are a lot of different drugs. You can't lump them all together!


>>You can't lump them all together!

Actually some of us do. Just open the floodgates when it comes to what you're able to have access to.

Spending money enforcing prohibition feels less helpful than spending that same money on treatment of underlying issues or addressing other social problems that lead to drug use in the first place. Rather than criminalize the use behavior, which doesn't do anything to save lives in any real way, try to fix the actual problem rather than just sweep it under the rug of the criminal justice system.


Problem here is that doctors pushed highly addictive painkillers on anyone and anything, while Purdue did everything they could to increase sales and disguise the risks associated with opioids.


Yes, and in some cases actively pushed them, as did the manufacturers.


The problem is complicated. Here are some abridged points from an OECD document linked below.

1. Overprescription, in the US, there were 240 million opioid prescriptions in the US in 2015, enough for one for every adult in the general population.[1]

2. Poor mental health treatment, "in the United States, 18.7% of all patients with mental health conditions receive 51.4% of the total opioid prescriptions distributed each year, meaning that having a mental health disorder was associated with a two-fold greater use of prescription opioids"[1]

3. Greater availability + lower cost and higher purity of opioids sold by criminal orsg. Mexican criminal orgs have been pushing much greater amounts of opioids in the last ten years, probably due to profits from marijuana being undercut. Prescription drug OD deaths have actually decreased as people switch from controlled substances to heroin/other opiates.[2]

4. Lack of access to effective treatment procedures. The US is woefully inadequate in this regard. "n the United States and Canada, rehabilitation programmes are still mainly abstinence based (Annan et al., 2017[75]). More specifically, in the United States only 8-9% of all substance treatment facilities between 2006 and 2016 had MAT programmes certified by SAMHSA...This happens despite evidence showing that opioid users who are treated only with psychological support are at twice greater overdose death risk than those who receive opioid agonist pharmacotherapy (Pierce et al., 2016[77])"

5. Stigmatization causing addicts not to seek treatment. "Research indicates that stigma contributes to individuals poor mental and physical health, non‐completion of substance use treatment, delayed recovery and reintegration processes, and increased involvement in risky behaviour (e.g. needle sharing)"

OxyContin is a controlled substance, so it's not actually legal. Here is an excerpt from an OECD publication on the opioid crisis on a specific case of decriminalization of opioids:

In 2001, Portugal decriminalised the possession and consumption of all narcotics and psychotropic substances for personal use, intended as the quantity required for an average individual consumption during a period of ten days. Exceeding this quantity, criminal procedures apply. Portugal’s decriminalisation reform has been particularly influential, since by introducing a de jure decriminalisation (changes in the law instead of changes in the daily practice), it has been a pioneer of the explicit decriminalisation of all drugs. Some of the main benefits of decriminalisation mentioned by Portuguese authorities can be summarised as follows:

Changes in the mind-set of the general population, contributing to consider drug use disorders as a medical condition rather than a criminal offence.

Creation of supplementary entrance doors to the public health system, particularly, through the Commissions for the Dissuasion of Drug Dependence.

Coherence enhancement between the health and judicial systems, markedly, to provide and expand access to public health interventions.

...

The decriminalisation of drugs is controversial in nature. However, empirical evidence shows that following decriminalization, Portugal has not witnessed major increases in drug use, but has experienced reductions in problematic use, drug-related harms (e.g. HIV-AIDS, hepatitis, overdose deaths) and criminal justice overcrowding (EMCDDA, 2018[223]; Hughes and Stevens, 2010[224]; Greenwald, 2009[225]). In addition, decriminalisation seems to have caused no harm through lower illicit drugs prices, which would lead to higher drug usage and dependence (Félix and Portugal, 2017[226]).[1]

I recommend checking out the sources I've linked, there's a lot of interesting information in them.

1. https://www.oecd-ilibrary.org/social-issues-migration-health...

2. https://www.overdosefreepa.pitt.edu/wp-content/uploads/2017/...


Looks like they got a golden escape hatch.

Sounds like this arm of the company will end up controlled by a government trust. The best outcome would probably be the government running the operation at break even, lowering costs, and heavily regulating how much product it could give to hospitals.


Pierce the veil and go after the family.


Not sure why this is downvoted. Shuffling assets and liabilities to protect from bankruptcy proceedings is a common crime and happens every day to companies large and small. The veil can be pierced if it can be established that key people were aware of the situation. Unfortunately it just means this process will be dragged on for years and it is unlikely to recover much from the Sacklers


After all they are responsible for thousands of deaths. And they knew it. I don't know why they aren't in jail already.


That's because of the "limited" of private limited.

(Under capitalism) many costs of having PtLds are externalized.


"limited" limits the amount of money investors can lose. It doesn't protect from criminal liability.


sorry have non-managing owners ever been targeted for crimes committed by their PtLds? nope they have not. and how about "personal business", yes, they are always targeted.

this is a big differences... I think tomp is explaining this difference somewhere in this thread.


I think it all comes down to proving personal involvement with the crimes.


>(Under capitalism) many costs of having PtLds are externalized.

I'd wager that at a societal level we roughly break even +/- a little bit in either direction. For every mega-corp abusing their legal status there's a few thousand small and medium businesses that do not have to worry (as much) about being sued into oblivion by some ambulance chaser over something that is not the result of malice. (I'm speaking about various private liability limiting corporate structures in general here.)


So you think the climate going to shits is "roughly break even". Some have benefitted a lot from externalized costs wrt climate impact (made billions). And some have benefitted a little (fast transport modes becoming afordable for personal enjoyment).


is that inherent? i haven't read Capital, but this doesn't seem so much of an inherent problem with capitalism than it seems like a very dumb implementation liability protection.


what capital says is that under capitalism, the ruling class will continually set up dumb rules, such as this one, in their favor, and they have a structural advantage in doing so, so are increasingly successful at it until it provokes revolt.


They'll do that under any system (you can find examples in basically all of recorded history). The people on top always try to use their power to put in rules to stay on top. I'm not convinced they somehow do it more or are more capable of doing it under capitalism than they were under the 18th century monarchies or socialism of the USSR and its satellite states or any of the other societal structures that have come and gone.


you're right that they will do it under any system of class society, with a minority expropriating class and a majority producing class, such as have existed since the invention of written history. that's why marx called for abolishing classes, absorbing everyone into the working class, replacing the structure with an egalitarian, democratic structure to decide how to invest all resources, as the only way out.

russia didn't have the economic basis to get rid of basic material scarcity in 1917, and also was constantly under attack by capitalism, and so it devolved into an undemocratic mess until it reverted (now everything is even worse there).


That isn't a characteristic of "capitalism". Sounds more like a characteristic of any power structure.


Sure, this would also have been true under feudalism.

The important thing to recognize is that the ruling class - whoever owns property and is able to use that to exploit workers - will control the government and make laws that benefit them.


What do you suggest instead?

The possibility to bankrupt a company without losing more than you put into the venture is in my eyes a feature of capitalism, not a bug.


It's a feature when it's good faith efforts. It's very clearly a bug when it's used to evade no end of abuse, illegality and fraud, or to avoid paying the pollution cleanup.

There probably needs to be some exceptional way in law to pierce the shell of limited liability and go after officers, perhaps even claw back from investors and shareholders.


Limited liability only protects the capital of the shareholders, it doesn't protect the management of the company against criminal prosecution.

(In practice, however, managers are only rarely put in jail, both because it's notoriously difficult to prove white-collar crime (except in few cases, like insider trading, which are the pursued with extra vigor), and because CEOs are generally rich and well connected... but the problem there is corruption, not some inherent feature/bug of the idea of limited liability company.)


Perhaps I could have expressed it better. I meant to go for the financials. There are countless cases where the factory or mine has declined and instead of cleaning it up, as promised, they shutter the company. Then there's the countless cases where the company is doing something illegal. Take the proceeds back.

We take money earned from theft and drug dealing, we take the stolen car from the person who innocently bought it. There's an offence of receiving stolen property. We don't take the millions from the execs who made millions pushing pharmaceuticals illegally, or the nuclear plant CEO and shareholder that has now, by dint of closure, given the job of decommissioning to the state - i.e. all of us. Once in a blue moon there's a criminal prosecution, but they just about always manage to stay wealthy.

We need to rethink the limits of limited liability as it's become a convenient shield to hide all sorts of unethical, shitty and outright illegal behaviour behind.


I have always thought there should be a law that funds for things like mine clearup and pensions should be paid as the debt is incurred, and locked up so there's no way for the company to get at it.


Comparing a PtLd to a "personal business" the PtLd shields the owners from criminal liability for crimes committed by the PtLd, while the "personal biz" provides no such protection.

> Limited liability only protects the capital of the shareholders,

No, it also protects shareholders from crimes the PtLd commits in order to "serve them". This is a main problem with PtLds imho.


see my sibling comment


i suggest that, when a PtLd or publicly traded company gets under criminal investigation, that all trade in shares gets suspended. when a fine/settlement is determined the trade is resumed but the fine is --for the part that cannot be paid in cash-- paid in equity while considering an adjusted valuation (post fine) of the company. This means the shareholders dilute to pay the fine/settlement.

1) the fine needs to be fair to the society (often we see these "slap on the wrist" fines for big corps, that's just disgusting and shows how much our democracies are disfunctional)

2) i suggest this because i want the shareholders to be pushing their companies to ethical behavior.

3) it is very important that companies are also held liable for unethical behavior in other countries, and/or even for unethical behavior of subsidiaries (the foxcons and the likes).


The company is going bankrupt, so the effective "fine" to the shareholders is 100% of their equity. That's the point - "limited liability" just means it can't be more than 100% of equity.


Good point. I should have added:

4) When the fine is larger than the company's worth, collect it from the shareholders.


Then noone would invest. Don't forget that often "shareholders" are index funds, pensioners, school endowments...

No, the correct solution already exists - the criminal justice system going after criminals that did crime - it just doesn't work very well (especially when criminals are rich - e.g. Epstein - no need for "limited liability company").


there are so many ways a huge corp can commit crimes while individuals can all use the "plausible deniability" card. also often the crime is committed by the company as a whole, while no individual did something wrong.

> Then noone would invest.

i disagree, you just only invest in ethically sound endeavours. and thats exactly what im trying to achieve by my suggestions. starve bad-business from investment and/or people willing to take ownership. and make investors also do dilligence on the ethical side, instead of only an assessment of books+team+product+market.


How is any investor supposed to be able to do any level of research approaching that depth, much less a college kid or your grandparents?

"Sorry Grandpa, I know you thought that company was on the up and up, but we're gonna have to take your retirement."


exactly. no boundless protection for your capital/investments. you can do all kinds of other investments! but this kind of structure pushes corps to become "walk over dead bodies" evil, and investors not giving a shit.


i thought limited liabilites are a recent invention associated with neoliberalization of the 80s.


They have been a thing here in Sweden since the mid 1800's, and probably even earlier elsewhere.


> (Under capitalism) many costs of having PtLds are externalized.

This is why I think the argument that a corporation only has a duty to it's stockholders is rank bullshit.


This is why that arguments holds out! They do not have duty to anyone else because of this. And I'm okay with that as long as the stockholders are punished (no silly slap on the wrist style punishments) for crimes of their PtLds, as then the owners will force toe PtLds to have serious ethical standards.


> (Under capitalism) many costs of having PtLds are externalized

Limited liability is directly as and exactly an externalization of costs; that's all that it is.

It's one that evolved hand in hand with capitalism, sure, but if it exists in a non-capitalist system it has the same effect.


[flagged]


This is not true, the Sackler families have already put up $4 billion dollars of their own money as part of one settlement in this and they're still being sued by others not part of the settlement. There's also a criminal investigation into members of the Sackler family.


There was a criminal investigation into Epstien as well. Look what happened to him. They even got his dead mans switch.


Assuming Epstein was killed, he was killed while he was in prison, both things hardly make him seem untouchable.


The Epstein affair was not just Epstein the single individual. He could not have operated alone all these years in the way that he did. He got lenient sentences whenever he was brought to justice. The people who supported him remain untouchable.


Ok, but he was rich. And he got "touched". Therefore the rich are not untouchable, which was the original point under discussion. Just like the Sackler family does not appear to be immune from prosecution and confiscation of their property.


We don't know that he got touched. We have a press story with some unlikely events that strongly suggests he got touched.

There's a between-the-wars novel by English author Evelyn Waugh called Decline and Fall. The main character gets involved in all kinds of unspeakable crimes, more out of naivety than inherent criminality, and at the end is "disappeared" out of jail and given a new identity.

Waugh was an Establishment insider and knew how the upper classes operated. It's a very interesting novel.

I'm not suggesting Epstein was naive - far from it.

But if you're in a position to bribe prison guards and authorities to cover up murder-by-fake-suicide, I suspect it's not significantly harder or more expensive to bribe prison guards and authorities to cover up an escape.

It's debatable if it would more expedient to remove the evidence permanently or have it moved to another location where some of its skills might continue to be useful. But I would be surprised if option 2 wasn't at least a possibility.

As for the Sacklers - we'll see if any of them do jail time.


> But if you're in a position to bribe prison guards and authorities to cover up murder-by-fake-suicide, I suspect it's not significantly harder or more expensive to bribe prison guards and authorities to cover up an escape.

> It's debatable if it would more expedient to remove the evidence permanently or have it moved to another location where some of its skills might continue to be useful. But I would be surprised if option 2 wasn't at least a possibility.

To think any of this is plausible given the context requires an unwell mind.


Epstein’s brother identified the body.


The rich are touchable if and only if they harm other rich people. See also: Bernie Madoff.


Did Epstein harm other rich people?


Yes. He involved a lot of other rich people in his crimes. This was OK as long as he kept it under wraps, but once people started really looking into his activities there was a major risk of the fallout affecting others.


Ok, but his crime was not hurting other rich people. He got in trouble because he did something that hurt non-rich people, and then other rich people got wrapped up in that. This is not an example of rich people only getting in trouble by hurting other rich people.


> This is not true

It is true. The Sacklers will never see the inside of a prison and will remain billionaires after the lawsuits and settlements.


I bet we could easily figure out where they live.


How about we stay away from nasty mob tactics?


I'm suggesting we launch a mental warfare campaign on the guilty.

The system is bought by folks like these. If you think the system will punish them, then I suggest taking a look at precedence for folks like them. It's not in the favor of the general public.


The best outcome would be directing resources at preventing and treating opioid addiction, not at punishing the drug manufacturer.


That just sends the message that the rich can get rich by ruining the lives of however many thousands of people and will just seek new ways to get rich by ruining the lives of however many thousands of people.


I agree with you both.


that is, the important thing is directing resources at preventing and treating opioid addictions and ODs, and if there's any justice the entire Sackler family fortune would be used to do so. Fortunately, these two goals are not in conflict, the Sackler's have a net worth upwards of $13 billion, which would be quite helpful resources to direct at preventing and treating opioid addiction and health effects.


13 billion won't be nearly enough. The damage to people, to families, and to communities has been extensive. And it's a big problem in most counties across all 50 states.

But also the Sacklers are only like 8% of the problem. All the rest of the opioids, (92%), came from other companies. So, theoretically, if we confiscated all of the wealth of all of the owners and stockholders in all of these companies we'd get the money we need to at least ameliorate some of the carnage. Because we'd have at least 90% more than we'd have by just confiscating the Sackler wealth alone.

All that's just theory though. I don't even know if it's possible to hold ownership responsible? Because wouldn't that put people who buy stock in whatever company at risk if the company was doing something sufficiently untoward?


Purdue never prescribed opioids to anyone. They only sold them to hospitals and doctors, after the FDA let them do it. Not sure what message punishing them is supposed to send?

But I get it. Someone dies and it’s the drug dealers fault, and punishing them will make everyone feel better. Except it doesn’t do anything about the actual problem (opioid addiction).

It feels to me like the elation here is because the Sacklers are rich and people really don’t like that, rather than any sort of victory in combating opiate addiction.


Please remember that Purdue were the ones who marketed Oxycontin on the premise of one dose for 12-hour pain relief.

When they learned doctors were prescribing it for eight hours, they tried to "re-train" them to use the "proper" (read: their) dosing recommendation, because there were cheaper drugs with six of eight hour doses.

Sure, the doctors made the prescriptions, but you, and I, and everyone who thinks honestly about it for two and a half seconds realizes that no matter what the recommendation is, enough people who are in bad enough pain to be prescribed oxy will take it when they need it, recommendation be damned, that to have issued that recommendation in the first place was an act of bad faith.

They marketed the drug on a lie in order to get doctors to prescribe it, which fueled — if not created — an epidemic, which has killed tens of thousands of people. Their hands are not clean, here.


Actually, this makes me think we should be going after doctors too.


We should be. We should also be going after the distributors who were shipping millions of pills a year to small towns with a population of 6000. This is not an either/or situation, there is plenty of blame to go around.


> that recommendation in the first place was an act of bad faith.

This seems a bit of a stretch to me.

The doctors prescribed it, even given readily available research, the FDA approved it, knowing full well this was a risk. Those are the guilty parties here. Purdue filled their role just fine, they just happened to be making an opiate and so they're getting chased for it now because China is dumping fentanyl. Pretty ridiculous really.


According to the congressional report:

“Purdue Pharma used front organizations and sponsored research to deceive the World Health Organization and corrupt global public health policies”

If that is true and public policy was corruptly manipulated , how can you claim that this is all ok because it was allowed by public policy?


I do not agree with him, but I think you're making a much more salient point indirectly.

Public policy that can be readily manipulated by bad actors (as the drug industry is certainly full of) should not be used as the final say for anything. Systems need to be able to tolerate: corruption, false information, and true but misleading information. Our regulatory systems in general seem to struggle with any of the above. If "health authorities" (to avoid naming any particular organization) can only effectively screen out good actors inadvertently engaged in bad behavior, then they're effectively useless - because bad actors do exist, and they're vastly more dangerous than the former.


WHO is not a regulatory agency and does not have finally authority for anything. https://www.who.int/about/role/en/


It's not just the WHO. The same arguments apply equally to e.g. the FDA who played a similar role in this by rubber stamping the drugs. And similarly it also doesn't just end at the FDA as there are numerous smaller level regulatory agencies and operators involved on the medical side. Even non-regulatory agencies, such as the American Medical Association also showed themselves to be somewhat useless by decisions such as choosing to play into lobbying for consideration of pain as a vital sign.

The same is even true of things such as the FAA and the aviation industry where there were analogous issues. All of this is emphasizing that these organizations, which can be quite the burden on 'good players', are ultimately ineffective at restraining bad players which (I suppose depending on your philosophical view) should be their primary purview.


The FDA does quite a bit to keep both good and bad actors in check. They are not perfect, but for example they regularly track down outbreaks of food born illnesses in ways the producers simply can’t. https://www.fda.gov/safety/recalls-market-withdrawals-safety...

Making wide sweeping statements based on very specific issues simply demonstrates ignorance of how these organizations actually interact with the systems they regulate.

PS: As to FDA ‘rubber stamping’ the drug, using opioids for treatment of end of life cancer pain is perfectly reasonable. OxyContin is just one of a huge list of similar drugs that have been in use long before this outbreak. It’s not the chemical that’s the problem is the other actions by the company.


Oxycontin wasn't just rubber stamped for end of life cancer treatment. You're referring to when the FDA decided to further expand Purdue's drug rights enabling it to be used on 11-16 year olds. Purdue, when seeking this approval, were already facing criminal charges for their marketing of oxycontin. And the FDA's decision in expanding treatment to kids was primarily driven by them asking Purdue to carry out studies evaluating the safety and effectiveness of oxycontin on kids, because they seem like trustworthy guys. Lo, and behold, Purdue's carried out some "studies" and told the FDA it's just awesome. And the FDA said, "Oh okay, cool." [1]

And this story repeats over and over since our entire regulatory system is, when it comes to the big and influential players from Purdue to Boeing, mostly just glorified self regulation. And that leads to a worst of both worlds scenario. We get the lack of oversight inherent in self regulation, yet it's paired with an undue faith in our regulatory systems as many people don't understand the actual regulatory processes, or lack thereof.

[1] - https://www.washingtonpost.com/national/health-science/fda-d...


To be clear doctors could and had already been prescribing OxyContin and other opioids to 11 year olds. The studies where about guidelines for use not ability to prescribe. In this very specific case, the system was working correctly.

Opioids are addictive and become less effective over time. Opioids can also be a valuable tool for relief of severe pain over a short to moderate period. The actual issue is not the drug in this case it’s a drug company pushing for more scales.

PS: I have seen a friend become addicted while in cancer treatment. But, I have also been prescribed opioids after major surgery. So yes they are clearly extremely dangerous, but they can treat levels of pain that are difficult to describe.


You're wrong. Purdue actively misled healthcare professionals and the public about the risks of Oxycontin.

https://arstechnica.com/science/2019/05/world-health-organiz...


They lied about the drugs which they actively marketed to doctors.

That’s far more than just manufacturing and opened them up to significantly increased liability.


After 2001?

The lying in marketing, over the period 1995-2001, was already litigated in 2007.



The Sackler's $13 billion could be used to do quite a lot about the actual problem.


I think you underestimate the size of the problem.

But again, the Sackler's are only 8% of the problem. So if you go after them, and the owners and stockholders of the companies that provided the other 92% of opioids, and the doctors who wrote the prescriptions in bad faith, you probably come up with an amount of money that could make a dent.


I do not believe that Purdue is innocent of anything, and I would love for more evidence to be brought forward to a court of law.

https://www.statnews.com/2016/09/22/abbott-oxycontin-crusade...


The resources from the lawsuits are designated to go toward preventing and treatment of opioid addiction. The purpose of the lawsuits, I think, is not to punish manufacturers but to fund needed health programs.


One naive question - why are doctors who overperscribed opiates still allowed to practice medicine?


A quick google search brings up multiple articles about doctors going to jail. Here’s one where the doc got 13 years for prescribing over 1 million units[1].

[1] https://www.dea.gov/press-releases/2019/05/13/pill-mill-doct...


We spent the better part of decade catching and locking up doctors who prescribed opioids out of guidelines, so much so that doctors are now terrified of prescribing them to people who legitimately need them.

The problem is that the prescribing guidelines, which were written by the pharmaceutical companies themselves, described a regimen that would get pretty much anyone physically addicted to their product.

So you had doctors acting in good faith, prescribing medications only when indicated and following their manufacturer's prescribing guidelines, inadvertently creating new addicts where the manufacturer's literature said there would be none.

Not only that, but we spent several decades treating chronic pain patients with opioids, such that they are completely dependent on that class of drugs to manage their condition. Only very recently have prescribing guidelines adjusted to reflect the reality that opioids are not a good treatment for chronic pain. When those pain patients are driven off of their opioid prescriptions, even if their doctor is well-meaning, some of them turn to heroin/fentanyl to manage their pain.


Shouldn't the FDA be checking whether the guidelines written by the pharmaceutical companies are safe?


The guidelines are almost always on the conservative side of safe because people who died as a result of taking the medication the manufacturer recommended way turn into slam dunk lawsuits. Part of the reason the opioid problem flew under the radar is because people got hooked and weren't dying until they OD'd so it never came back to bite the manufacturer. What are the odds of another opioid type situation? What else could the FDA do with those resources?


Doctors are not researchers. Some doctors might dig deep but others go to work then go home and spend time with their families. They also have bills to pay and school loans.

I can't recall the story exactly but there was a doctor who spoke out against a popular medication. He found that it increased a chance of a heart attack I believe by over 50%. They released a small study in a journal and his existence became a living hell. Eventually, the knowledge became main stream.

I for example had a serious reaction to cipro, left me with chronic pain. This reaction is starting to become common knowledge, yet I have found a single doctor willing to put down possible side effects of cipro in my chart. People have been reporting these side effects to FDA for 15+ years, it is affecting many people but symptoms take up to 12 months to surface and doctors don't want to accept it. I have talked to number of people diagnosed with fibromyalgia for example that later realized they took cipro for UTI right before symptoms began. Plus, the FDA has been making the label more severe almost every year. The European organization EMA suggested doctors use these medication only in life threatening infections.


do you have any suggested reading material?

what kind of chronic pain do you have?

i've had persistent joint issues that started shortly after a round of levaquin, a very similar drug.


There is a subreddit dedicated to it @ reddit.com/r/floxies. There is a facebook page, which I honestly would not recommend, as it is really toxic.

Popping/clicking joints, and not intense pain just dull/achy. These drugs are known to cause peripheral nephropathy and tendinitis. I actually just read an interesting blog about a guy that is insanely fit, recently was given levaquin with prednisone, and continued to lift. Then, tendon in his arm snapped. He is documenting very well how his body is deteriorating and what new symptoms he is experiencing week to week. I think it would be worth posting on HN, I will send you a link when I find it.

Edit: It appears any flouroquinolone can cause these symptoms, this includes levaquin, cipro, avelox. Also, symptoms can develop after a single pill or 150 pills. It is insanely odd. Taking it with a steroid significantly increases chances of having a very negative reaction.


This is a deep question, but the simple answer is they were told repeatedly that it was safe and effective to prescribe for a lot of different ailments.


Seems like an abuse of the limited liability. Does the US have a way to set that aside? I know other countries do


The US indeed has this concept, known as "piercing the corporate veil".

Excess payments to ownership (especially if you think the company is about to face a huge liability) is a classic example of one of the justifications for a judge to do just that: make the owners personally liable rather than just the company.


The smart way is to pay yourself 10% dividends every year into your own holding companies from the start. Sounds like that’s what they did.

Don’t store your gold next to a nuclear reactor and all.


I think in the UK,a judge can rule that two companies constitute a 'group'. Prevents misuse of multiple companies for tax, etc.


In Brazil there is a concept called Business Entity Disregarding (Desconsideração da Personalidade Jurídica) that can get both ways: make partners liable for company debts or companies liable for partner debts. It can be triggered when the plaintiff engaged in some kind of asset hiding fraud or there are substantial confusion regarding company/personal assets.


Are the other manufacturers of oxycontin being sued too? I know that Purdue tried to underplay their role, but from the best #s I've seen they've only sold 20% of the market.

https://www.statnews.com/2019/09/09/purdue-pharma-data-downp...


That's 20% of the whole opioid pill market, not just oxycontin.

As far as I know, generic manufacturers of off-patent drugs usually aren't sued.

On the one side, they don't actively promote/market their products to prescribers or patients, but I'd still think they share some blame by manufacturing it.


> but I'd still think they share some blame by manufacturing it

Nah. Opioids are an essential medication. The problem is not that OxyContin exists, it's the creation of irregular demand for it through the actions that Purdue Pharma are having to settle for.


It’s a question of what extent, if any, vendor liability exists.


Are you of the opinion that opioids have no legitimate medical use? How else could suing generic manufacturers be justified? The issue with Purdue is that they lied about the risks of the drug. Presumably, they lied to the generic manufacturers as well.


> In March, Purdue settled claims brought by the state of Oklahoma for $270 million, and another defendant, Teva Pharmaceutical Industries Ltd., also reached a, $85 million deal to avoid trial. J&J, which refused to settle, was ordered to pay $572 million for creating a public nuisance in the state with its over-promotion of its opioid pain medicines.


With the Sackler family funneling out money prior to this, is there any chance a judge would refuse the bankruptcy?


20 states and D.C. reject the settlement. They think there is a good change to prove fraudulent intent behind those transfers and claw back those funds.

The lawsuit is alleging systematic fraud and requests an order for the Sacklers to return any transferred assets; and to restrain them from disposing of any property. https://ag.ny.gov/sites/default/files/oag_opioid_lawsuit.pdf

Interesting that these decisions are so political. States with republican majority and AGs agreed to settlement, the states with democratic majority did not. Only four AG's favoring the settlement are democrats.


The Purdue PAC is a big donor mainly, though not exclusively to republican campaigns.


It's pretty clear which party listens to their donors better.


> The family has rejected calls by some state attorneys general to boost their guarantee to $4.5 billion, and almost 25 states are opposing the family’s settlement offer.


All the self-payments ("funneling out") the public knows about were years before the lawsuits. Unless you know something the rest of us don't...


That opioids are addictive and that a company that lied about that was probably going to face a bunch of lawsuits.

I'm pretty sure that was obvious to many people. But it was probably especially obvious to the people lying about it to make billions of dollars.


Yes. Clawback.


Last I heard the transfers were several years ago


The transfers, through Swiss banks accounts were happening up until 2018: https://www.cnn.com/2019/09/13/us/sackler-family-purdue-phar...



People keep misreading this, or maybe just looking at the headline and getting the wrong impression.

The news in that piece is that NY discovered the transfers at all. The transfers themselves are a decade old. The payments to the Sacklers from Purdue are from 2008-2016 but the lawsuits only date to 2018. All of this is in the article if you read it.

I.e., no self-payments after lawsuits became material threat.


"Sackler was involved in 137 wire transfers totaling nearly $20 million, and some of those transfers occurred as recently as 2018, the filing indicates."

Who's misreading what now?


mcbain's comment that I am replying to, https://news.ycombinator.com/item?id=20981242 , is referring to the NYTimes story on $1B in transfers.

Those substantial transfers ($1B) were a decade ago.

The sentence you quote does not appear in the NYTimes piece and is, in comparison, peanuts. I do not have access to the Bloomberg piece for full context, but the sentence you quote does not say the movements were self-payments from Purdue rather than just personal transfers between personal accounts. It also does not say all $20M was in 2018; there could be a $1k wire in 2018 for all we know from the single sentence.


And you can find a lot of the trusts on the Panama Papers. Law firm appeared to be Appleby.


Yes, the article points out that the transfers were several years ago


No doubt. I think the peak of patented OxyContin was late 2000s/early 2010s before it all went generic.


No. They will sue the sackler family directly.


26 states already are.


The amazing thing is when I was in legitimate pain in the hospital I couldn't get more than Tylenol. After I was released I drove by a pain clinic and I guarantee I could have scored some oxy that day. I didn't but it's nuts when people that need medication can't get a few pills.

Dont get me started on testorone or ADHD medication hypocrisy.


Just accept that the system is broken and get 'm on the most free market we currently have: the market of stuff that is merely illegal.


I am legal expert but I have a logical question.

Shouldn't they look at the fund the company had on the "day that the lawsuit started".

Where ever they funneled the money, I am sure they are just look at the bank statement.


Without criminal charges, there's no justice.


The Sacklers are running around free, enjoying their wealth, while El Chapo is in jail.


Go To Jail, Go Directly To Jail, Do Not Pass Go. Do Not Collect $200B.


SO what does this mean for non-US litigants, or future non-US litigants?


Well according to the WSJ, what's left of Purdue after the bankruptcy will be owned by a trust who's only purpose is to repay the litigants. So I imagine they'll just be part of that.

Also not all US based litigants are part of the settlement that is being worked out. There are also individuals who are being personally sued that aren't part of this as well.


I guess they’ll have to flog even more pills in order to pay the litigants...


Recommended read: Dopesick from Beth Macy. For a non-American, it reads like a horror script.


Are any of the Sackler family going to face real consequences for this?


It's ok, they've already moved all their billions away.

Their fortune is safe.


How can this be legal?


Welcome to the world run by business. Here’s a warm towel, enjoy your stay.


> Narrator: The towel is made by the lowest bidder, falling apart, it's not warm and you won't.


Bankruptcy? What do you propose as an alternative when liabilities exceed assets?


A Chapter 11 is a filing for reorganization of debt, to keep the business alive and pay creditors over time, often at a discount and privileging some debtors over others.

Even within traditional US Bankruptcy codes, there could instead be a Chapter 7 liquidation bankruptcy. In which the company is simply (or not so simply) liquidated and all assets used to pay creditors. Purdue pharma isn't a public company. I'm not sure how to look up it's net worth.

The Sacklers will of course prefer whichever will lose them the least money.

That's before we start talking about the ways in which a company's owners can indeed legally be liable for the company's fraudulent or criminal behavior, and long before we start talking about the guillotines.


Piercing the veil. This is not a lemonade stand going under. Here, "Liabilities" correspond to dead bodies. In the thousands.


What law permits this now; or are you proposing a new law? If so, how would it work?


https://www.law.cornell.edu/wex/piercing_the_corporate_veil

> "Piercing the corporate veil" refers to a situation in which courts put aside limited liability and hold a corporation's shareholders or directors personally liable for the corporation’s actions or debts.



[flagged]


Yeah this. I really wish there was some way to sentence these billionaires to the middle class for the rest of their lives. Some sort of "external" prison where their net worth is held to that of the median net worth of the OMB's "middle class" range.


Can we do it for everyone?


You mean everyone convicted of criminal misconduct? Or everyone everyone? Feel the latter would do more harm than good. The opportunity to become wealthy it a tremendous motivator.


Yes, it is such a great motivator people will literally kill, die, and destroy the planet for it.


Can poor people get in on this? Being sentenced to a middle class life could be ok.


What does this have to do with "capitalism"? People hiding their ill-gotten assets is hardly a unique characteristic of capitalism.


Luckily, this means the family will be pursued criminally. Bankruptcy doesn’t shed that.


Purdue is already convicted of a felony. You shouldn't be able to declare bankruptcy to dissolve damages from a felony and felony conviction of company should hold directors accountable for damages.


While it’s unfortunate bankruptcy code wasn’t designed for these edge cases, I’m optimistic about how a court will handle this. Even more so about criminal charges that will likely include a prison sentence due to the amounts involved and clear intent.


Bankruptcy exists as a safety net for failed capitalists.


Great now all the opioid production and prescriptions and thus addiction will stop! Oh wait...


Most opiod deaths are from fentanyl. Most fentanyl comes from China, not perscription medication.


75% of opioid/opiate addicts started with pills.

Source: https://www.ncbi.nlm.nih.gov/pubmed/24871348


And if they had continued access to those pills they wouldn't be hitting the black market, getting fentanyl, and dying. Eventually, with support and help, they could start to wean off directly or with methadone or suboxone. But no, we can't have that. Instead our government and society prefers to let people die and then pretends like dismantling one company and taking their money is going to help. It's not going to help a single addict.


True, but I added a little more nuance here: https://news.ycombinator.com/item?id=20981382


Those conversion rates are not low.


They're not zero, but single digit percent times single digit percent is generally considered a small percent. The math works out to 0.32-0.72% total, taking either the low end of both ranges or the high end of both. I think anyone should agree that in an absolute mathematical sense, 0.3-0.7% is a "low percent."

In this specific context? Sure, it's subjective and reasonable people can disagree.


Note, most were not actually prescribed those pills.


Not sure why you're downvoted. Fentanyl is involved in almost 2/3 of opioid-involved overdoses.

https://www.drugabuse.gov/related-topics/trends-statistics/o... Fig 3-5 & descriptions.


How many of those people started on prescription opiates?


Tl;dr: About 80% of heroin users started on prescription opioids. This sounds bad, but actually the conversion rate from opioid on-label use to abuse is pretty low and the conversion from pill abuse to heroin is even lower.

* Rate of conversion from on-label opioid prescription to addiction ("opioid use disorder") is lowish; this metastudy[1] claims 8-12% on average, but the 95% CI is anywhere from 3-17% and I'm not sure what they're measuring the percentage of (i.e., long-term prescriptions might both be more represented in the data and have higher conversion rates) — I doubt 8-12% of people who get 3 days of vicodin for their wisdom teeth extraction develop an opiate use disorder. They also point out that some studies showed misuse rates below 1% and "significant variability remains in this literature." We should expect these rates to fall as tighter prescription quantities from the last several years impact "leftover" pill rates.

* The rate of conversion from prescription opioid addiction to heroin is low; 4-6% per the government.[2]

* Overall opioid-involved overdose annual deaths in the US rose from 8000 in 1999 to 47600 in 2017; of those, the prescription-involved number rose by 13600 deaths (+300%), from 3400. Conversely, the non-prescription-involved deaths rose from by 26000 deaths (+465%), from 4600.[3](Figs 3-4) 26000/39600 = ~66%. (The population has also grown about 17% over that period, but that doesn't change the calculus too much.)

* Therefore: the overall growth pattern in opioid deaths in the last two decades is largely accounted for by heroin and other non-Rx use, which are a tiny population with a very high (and rising) death rate. The rising death rate is mostly due to the surge in black market sale of fentanyl as "heroin."[3] (esp. figures 4-5 and associated text) (Perhaps as a result of DEA and other restriction on the supply of the relatively safer, but less dense, heroin, and restriction on supply of the vastly safer prescription opioids.)

* Notably, the number of non-fentanyl-involved prescription opioid-involved deaths has actually been in decline since 2011![3] (fig. 4.), despite a rising population. Let me echo that since it's really important: prescription opioid-involved overdose, ex fentanyl, both in number and per capita rate, HAS BEEN IN DECLINE SINCE 2011! Why doesn't any news story on opioids in the US headline with that? The primary reason the overall prescription opiate-involved death rate hasn't tracked that decline is rising co-(ab)use with illicit fentanyl, and its relatively higher death rate.

If we could wave a magic wand and wipe (illicit) fentanyl off the earth, our annual opioid death rate would fall by something like half.

[1]: https://www.ncbi.nlm.nih.gov/pubmed/25785523

[2]: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdos...

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


That magic wand is allowing doctors to prescribe safe opiates to addicts, providing safe places they can use, and providing support and means to quit. It's not magic. Many places around the world are doing it. Eliminate the black market and you eliminate those deaths. Our government and society are simply not interested in eliminating those deaths. Places like Portugal, Switzerland, Vancouver bc have been waving that magic wand for decades.


Sure, that's one harm reduction technique that works as long as doctors (and Governments) are willing to prescribe the amount of opioids that addicts want. I touched on the same technique in an earlier, longer form version of the same comment (in response to a slightly different thread the other day):

https://news.ycombinator.com/item?id=20973171

Excerpt:

  Given we don't have a magic wand, what can we do? Obviously we can't stop fentanyl
  from entering our borders or being synthesized illicitly here. We can (and have)
  leaned on illicit fentanyl-producing countries like China and Mexico to make those
  businesses less lucrative. We can do harm reduction things for the vulnerable
  population — which is mostly heroin users. We could legalize heroin with a
  prescription for existing addicts?

  Harm reduction stuff: Provide free/cheap testing for fentanyl adulteration? Make
  naloxone available without prescription, on the shelf, for cheap or free, and
  encourage businesses and residents to keep some around, even if they aren't users and
  don't know any users? Maybe provide monitored, safe injection sites where addicts
  overdosing can be assisted immediately if needed but are not arrested or forced into
  any overbearing programs. Maybe even supply quality- and quantity-controlled heroin 
  to these addicts for use on-site to reduce likelihood of overdose and even allow
  people to taper off if they want to.
It's still nearly equally magical to wishing fentanyl away in that effecting such a policy is incredibly difficult politically (US, anyway).

Pick any level of government. This doesn't really have populist mandate even in Blue states and you can be damn sure Republican Governors are going to reject any "give drugs to addicts" proposal on their desk, if it even makes it through state legislatures. Meanwhile, Congress is stalled with a Democrat-controlled house and a Republican Senate that won't pass any laws. I don't see Trump taking ... positive executive action on this, either.

Maybe some harm reduction can be done at the municipal level, but that probably leaves some of the worst hit parts of the country (rural areas in Red states) without help.


Yeah we're going to continue to kill hundreds of thousands more people before this will even start to be discussed by politicians because our politicians are incredibly stupid and closed minded. But maybe if enough people die, things will change, possibly through voter referendums. I never thought legal marijuana would be a thing, yet it is (federal laws notwithstanding). Once people in states with referendums get tired of their friends and family dying by the thousands, maybe they'll act. Current politicians sure won't. But these primitive morons will eventually die themselves, hopefully sooner rather than later, and hopefully their replacements will be slightly less idiotic, more pragmatic, or perhaps even compassionate. Stranger things have happened. That's why we must continue to advocate for the only solution that has been proven to work despite the challenge of getting it implemented. One day we will look upon the drug war and its perpetrators the way we look at Nazis now. Or our children or grandchildren will. That I'm certain of. How far down the line, no one knows.


> * Rate of conversion from on-label opioid prescription to addiction

And there we already have a problem. Off-label prescribing of opioids are a huge problem.

They’re really not supposed to be used so frequently for chronic non-cancer pain, but they’re used all the time for it.

And that’s a much bigger market than chronic cancer pain patients, because of life expectancy.

Cancer will often kill you, your back pain won’t.


Sorry, that wasn't really the idea I was trying to express at all. The two points are "using opioids as prescribed by Dr" => "using the same opioids in a way that was not prescribed."

I know off-label is specific industry jargon and it doesn't mean the way I tried to use it; sorry for the confusion.

Totally agree that chronic pain is a hard problem and tolerance effects make opioids a non-ideal long term solution. That said, I am neither a Doctor nor a researcher in the pharma industry so I don't have a lot of helpful suggestions for anything better than opioids today.


Too late ... Fentanyl is shipped via mail. Buy stock in the folks who make Narcan.


Unfortunately, it's the same companies.




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