Fuck the Sackler family, and fuck the DOJ for letting them skate without jail time

The BBQ Pit
41

It was, BTW, a 9-0 ruling.

No one involved was acting in good faith. Not Purdue, who promoted their product as being non-addictive. Not the distributors who sent millions of pills each year to small rural pharmacies. Not the pharmacies, who filled thousands of prescriptions a month. And the pill mill doctors weren’t either, but most of them put on a veneer, requiring an exam, consultation and sometimes an MRI.

And the doctors had been told the product had a low potential for addiction. It was a ridiculously blatant lie, the addictive potential of opiates has been known for centuries and historically, every new formulation promoted as being less addictive turned out to be more addictive than its predecessor.

The pharmaceutical companies had also been whipping up a lot of concern about patients in pain who faced barriers in accessing their medication, through astroturf patient groups and lobbying dollars, convincing congresspeople to weaken regulations around their medications, to the point where some doctors felt they might be sued for NOT prescribing.

It all should’ve been criminal but very little of it actually was, unless they could prove that no one really believed the lie they were all pretending to believe.

It was truly a massive systemic failure, the result of capitalistic profit motives gone wild in an economic sector that should be highly regulated if not completely socialized, and the fact that this was mostly legal is a large part of that failure.

It’s also a testament to how easy it is for some people to believe something that they know isn’t true, despite all evidence, if that believe is highly profitable or otherwise advantageous.

42

I personally know three doctors in my area who have done federal prison time in recent years who were sketchy with their opiate prescribing. But all three of them did the actual time for financial crimes, such as defrauding Medicare/Medicaid, or for falsifying records. They certainly got investigated because they were running pill mills, but as others have said, it’s very hard to prove criminality for inappropriate prescribing alone. It’s like getting Capone on tax evasion.

In all of these cases it was clear that the feds were trying to make an example of the defendant. They made big public shows of the investigations and arrests, and in at least one case pushed some relatively minor offenses harder than they generally do.

The more common route for overzealous prescribers is to get in trouble with their state medical board, which usually involves going through some remediation training and being closely monitored for a while. One of my side gigs is interviewing docs as part of their monitoring. My impression is that most of the ones I’ve interviewed really weren’t malicious; they had patients who were in pain and really were trying to help them, and they just made bad choices and got stuck in bad patterns.

I can certainly see how that happens. When I first started we were post-Oxycontin but there were tons of people coming in desperate to get pain pills–some with real pain, some with addictions to feed, some in bad need of money, many with some combination of the three. I had to say no to the overwhelming majority of them, and it was hard. The patients would make me feel like the worst person in the world, and my bosses wouldn’t tell me outright that I should write more but they passed along every patient complaint and really wished that I could find a way to keep the patients (and, more to the point, their Medicaid dollars) coming in. With so many factors pushing docs toward writing the damn meds, it’s easy to see why even well-meaning ones can get in trouble.

43

In the 90s, I was taught in a graduate level pharmacology class that people in pain did not get addicted to opiates. This was a lie being pushed by Purdue, and certainly some people in some places knew it was a lie, but it wasn’t common knowledge. As a student, I had no reason to doubt the professor or whatever text books backed it up.

At the time, in the 90s, the story I learned was that opiates were too difficult to prescribe all because they were addictive and bad for people who used them recreationally. Doctors want to help people in pain, but they can’t because the doctors get in trouble for prescribing too many opiates. Laws should change to make it easier to prescribe them.

Of course that is all built on a foundation of lies. Pushing lies like that is one of the reasons the Sacklers and others involved at Purdue should be stripped of all assets and do real jail time.

A higher order effect of all of the lies about the safety of opiates is that it probably stifled research into non-addictive analgesics. Why sink billions into developing and trialing a new class of pain killers, if the existing ones are safe and effective?

44

The other common “truism” was that when you’re in pain in the hospital, it’s important to “stay ahead of the pain”, so you could get your next dose of opioids before you were even in pain yet.

45

How was it not common knowledge? Morphine addiction among wounded military veterans has been a problem since the Civil War.

46

Damned if i know, but i heard that, too, from lots of legitimate (medical) sources. And i made the same observation at the time.

According to my pcp, another factor that pushed doctors to prescribe more opiates is that patient satisfaction surveys started to be used. Both patients and groups that employed doctors started to rely on patient satisfaction surveys around the time Purdue was pushing oxycontin. And patients who walk away with a prescription that makes them feel good are a lot more satisfied when they fill out that survey than patients who are in pain and told to juggle acetaminophen.

47

So fucking true! My wife was struck by a car while walking and had many injuries. She was in the ICU for a few days, then the regular hospital for another 1.5 weeks, then in a recovery center for a couple weeks. Their goal was to keep her drugged to the max and they explained that she had to stay ahead of the pain to me many times. You know how hard it is to do PT, OT, or cognitive sessions when you can’t stay awake? I had to FIGHT them to start lowering her dosages and I was talked down to like I was making a grave mistake. It was so sad to see my wife in that state, but a vegetative patient is easier to deal with.

Note: This was in 2020. Not a decade+ ago. I would’ve come out of those facilities absolutely addicted. Luckily, my wife steered clear of that, but I did help ensure that she wasn’t being overtreated and made sure there was a tapered retreat. I feel sorry for the millions that end up addicted.

48

I was getting the “stay ahead of the pain” mantra after rotator cuff surgery in 2021, even though I complained about feeling queasy and lethargic. I stopped the oxycodone of my own accord when my heart rate was in the low 30s. Yes, my shoulder hurt like hell, but at least my heart was still beating.

49

I had a bike crash last week and have a minor tear in my rotator cuff. The pain from this tear is pretty bad…trying to sleep is awful since you need your arms to do anything like sitting up or rolling over, but I’m also stuck sleeping in one position. Having surgery sounds like it would be awful! I’m barely managing it with Aleve so I can see the need for opioids.

50

If I recall correctly, and it’s been a long time, and the one standout thing I remember from that class is a known lie… “Some small fraction of unfortunate people do become addicted, but for the majority of patients the use is completely safe. This is why opiates should be prescription drugs, only used under the care of a doctor.”

Ironically? The class would have spent a large amount of time on addiction: nicotine, alcohol, etc., as that was the primary field of study of the professor.

When I broke my leg they gave me a prescription for one of the oxy drugs, with the instructions to take it even if I wasn’t in pain, to keep the pain from coming. I took one pill, but then didn’t take anymore because if I didn’t move there was zero pain, and if I moved wrong the pain was strong enough to break through the drugs. The only thing the drug did was let me really enjoy the Battleship movie. I knew it was stupid while watching it, but I really liked it.

51

No argument there

52

I remember too the mid/late 80s “concern” about pain management being too cautious and forcing patients to suffer needlessly (briefly worked in an ancillary capacity in health care then also very briefly in utilization review).

This, kids, is why you should say no to drugs.

53

I remember being told to stay ahead of the pain train with my migraines. I tried fiorinal for a little while because a friend leant me some of his when we were on a trip together, and the pain was putting down for the count. But I didn’t want to take it on a regular basis. Until the triptans were developed, I just suffered. OTC meds never helped.

54

There is something to this, though not that extreme. As an example I suffer from kidney stones, about one (thankfully small) every few years for the last couple of decades. The start of the pain is somewhat tell-tale and initially slow-building. If I jump on it with painkillers while it is still revving up, medication absolutely helps mitigate the discomfort. If I don’t and let it fully mature into the mind-numbing agony stage, no prescription pill I have ever tried has done a damn thing (but somewhat weirdly since it is just ibuprofen, Toradol at the ER is a fucking miracle drug for kidney stone pain).

The tricky thing is prescription meds are scarce and valuable if, like me, you don’t want to come off as a drug-seeker badgering their doctor for happy pills. So I try and husband them and you can get symptoms of incipient kidney stone pain that then goes away on its own. Either its a stone that shifts (instant relief) or it was something else mimicking that early stage. Makes for a lot of second-guessing on whether to medicate or not.

55

I find the same with NSAIDs and knee pain. If i pre-medicate, before stressing my knees, i often avoid pain entirely. If i don’t, i can be sore for days. I thought that was about preventing inflammation, but one of the doctors on this board told me it’s actually about avoiding the pain, and the dose i take doesn’t do much for inflammation.

56

Not at all the same as being dosed with opiates continuously before you even know whether you’re going to require them. And being encouraged to do so at home as well - how would one even know when they’re no longer going to be in pain except to continue taking the pain meds continuously until they run out, regardless of need.

57

And completely hooked. Seems like that was the point.

58

I don’t know if it’s wise to take opiates before the pain gets bad. But there may actually be something to taking smaller doses sooner to keep the pain in check.

Morphine pumps, where the patient can self-administer a small dose when they want to, generally result in a lower total amount of morphine taken and also less pain than the offer method of taking pills when the nurse comes around. A friend who did both (once for major surgery when she had cancer, and the other time for major surgery to reconstruct a badly broken leg) said that there were two big benefits to the morphine pump. One was that she didn’t worry about the pain, because she knew she’d be able to do something immediately, and not wait in pain for the nurse to arrive. (Which is a huge disincentive to skipping a dose.) The other was that by taking some morphine as soon as she felt pain, she “kept in front of it”, and it never really got bad.

But it’s not just her, insurance companies pay for them because they work better. (And workers compensation insurance companies were one of the drivers to reduce the amount of opiates given to accident victims. They did the research that found that the more opiates given, the less likely the patient was to ever return to work. It was some of the first really clear evidence that mainstream medical practice was over-prescribing opiates.)

59

Bolding mine. I love the self-administered pumps. As I keep saying, there’s quite a difference between dosing yourself when you know it’s needed versus being dosed before you even have the pain. I’ve been on self-administered morphine pumps several times and every time, I didn’t even think to push the button until I felt the pain. After awhile, I noticed I no longer needed it, sooner than I was approved for. I wouldn’t have noticed I didn’t need it anymore if it were being administered pre-emptively for longer than I needed it.

60

My mom is in the hospital right now. She just had knee replacement surgery and is in recovery. They had some weird thing that I’ve never seen before… It looked like a weird high tech ball with a tube connected to it, and it’s in a cloth bag.

I’m pretty sure it was one of these things.

https://avanospainmanagement.com/solutions/acute-pain/on-q-pain-relief-system/

It wasn’t hanging up like an IV bag, it was sitting next to her. It looked like something from Star Trek, it was so unfamiliar.

I don’t know if this is the kind of pump you are talking about. It sure looked cool to me.