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PaperclipPerfector  2mo ago (text post)   28333 thread views

Culture War Roundup for the week of June 24, 2024

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The Sacklers were ultimately responsible for and made substantial profits from a legal and corporate structure that heavily encouraged and even induced addiction in cases where it wasn't necessary.

How so?

Someone else has already written this up for me, so I'll just quote them.

https://web.archive.org/web/20201004103052/https://www.newyorker.com/news/news-desk/the-sackler-familys-plan-to-keep-its-billions

With the launch of OxyContin, in 1995, Purdue unleashed an unprecedented marketing blitz, pushing the use of powerful opioids for a huge range of ailments and asserting that its product led to addiction in “fewer than one percent” of patients. This strategy was a spectacular commercial success: according to Purdue, OxyContin has since generated approximately thirty billion dollars in revenue, making the Sacklers (whom I wrote about for the magazine, in 2017, and about whom I will publish a book next year) one of America’s richest families.

But OxyContin’s success also sparked a deadly crisis of addiction. Other pharmaceutical companies followed Purdue’s lead, introducing competing products; eventually, millions of Americans were struggling with opioid-use disorders. Many people who were addicted but couldn’t afford or access prescription drugs transitioned to heroin and black-market fentanyl. According to a recent analysis by the Wall Street Journal, the disruptions associated with the coronavirus have only intensified the opioid epidemic, and overdose deaths are accelerating. For all the complexity of this public-health crisis, there is now widespread agreement that its origins are relatively straightforward.

...

Her filing was studded with damning internal company e-mails revealing that, even in the face of a skyrocketing death toll from the opioid crisis, members of the Sackler family pushed Purdue staff to find aggressive new ways to market OxyContin and other opioids, and to persuade doctors to prescribe stronger doses for longer periods of time.

eventually, millions of Americans were struggling with opioid-use disorders.

This is an absolutely magic sentence that tells us nothing about how any of this works. There is no model here. At least, there is no model that can be stated in words, in public. My suspicion for why is because the model that is implicitly being used violates the claims of people who are pro-legalization.

Did you actually click the link? I didn't include the sordid details but they do actually explain what happened and how it worked. A magic sentence like that is totally fine when you include the explanation in another part of the text.

I did click the link. I read the whole thing. They don't explain any sort of model for the intermediate steps. If you need to convince yourself of this, just try. Try on your own to reconstruct a model of how it's supposed to work from the article. Use your own words. See if you can do it.

Uh, sure? They used a variety of financial incentives to encourage doctors to prescribe higher and higher doses of Oxycontin even when it wasn't necessary, because that made them more money. They were directly(and indirectly) paying doctors to hand this stuff out even when it wasn't strictly necessary, taking advantage of the prestige and respect rightfully given to medical professionals in order to generate vast profits while directly fostering opioid addictions.

Maybe I'm missing your point, because I don't know what kind of intermediate steps you need to get from "Inducing doctors to unnecessarily prescribe high doses of opioids" to "Opioid usage epidemic".

prescribe higher and higher doses of Oxycontin even when it wasn't necessary

There is literally only one sentence in the article that refers to dosing, and that's just repeating a claim from a plaintiff. It's pretty weak even from that plaintiff. I guarantee that you, the plaintiff, the FDA, nobody has any sort of rigorous line on when it is "necessary". Their "titration" stuff is basically the same damn thing that Scott talks about doing all the time with other drugs.

But in any event, I don't think the legalization folks have premises that allow saying things like, "Oh, we'll just set it up so that people are magically only allowed to go from having 20mg pills to 40mg pills when it's strictly necessary (according to some magic definition of necessary). That'll totally be a part of how complete legalization will be an utter boon to society and not a disaster!"

Instead, I think the complete legalization folks will say that all that shit is meaningless. We should just make them all legal. The 20mg pill, the 40mg pill, hell the 10mg pill and the 80mg pill, too. That people can just buy whichever one they want. Maybe they'll choose to get a doctor's recommendation. Maybe they'll even use your yet-to-be-published, magic definition of "necessary". But they think that people will somehow be responsible in their usage, substituting away from dangerous street drugs like heroin and fentanyl and toward, I don't know, whichever of the 10mg/20mg Oxy pill your magic chart says is "necessary". They might try a higher dose, like how some people try hard liquor instead of wine or beer, but for the most part, folks will prefer to objectively and responsibly move to a reasonable dose. And it's not like their marketing is ever going to be like, "Hey doctors, you should prescribe a higher dose even when your patient responsibly wants a lower dose," or, "Hey doctors, here is @FirmWeird's objectively correct definition of 'necessary'; don't use that."

But in any event, what does your magic, yet-unknown line of "necessary" have to do with addiction? What's the model connecting this completely unknown thing to rates of opioid addiction?

I guarantee that you, the plaintiff, the FDA, nobody has any sort of rigorous line on when it is "necessary".

As Armin pointed out what counts as "necessary" is dependent upon the situation, patient etc.

But, while it appears you have read the article, you didn't read the links contained within it. I don't blame you for not doing so, legal documents are really long and boring, but that's what you're actually looking for. The meat of the accusations is in fact contained within them. So when you make a comment like

And it's not like their marketing is ever going to be like, "Hey doctors, you should prescribe a higher dose even when your patient responsibly wants a lower dose,"

We can actually turn to the prosecution and see what they were doing.

Together, these drug manufacturers (the “Manufacturer Defendants”) collaborated to falsely deny the serious risks of opioid addiction generally, and high-dose opioid prescriptions specifically. At the same time, they created and promoted the concept of “pseudoaddiction”—a made-up term designed to re-cast familiar symptoms of addiction as signs that patients needed more opioid drugs. They falsely claimed that their opioid drugs could be counted on to improve chronic pain patients’ function and quality of life, and that their extended-release opioid formulations would provide effective pain relief for 12 hours, when they knew there was no scientific support for those claims. And they misleadingly suggested that other pain relief methods were riskier than opioids, while falsely claiming that opioid dependence and withdrawal could be easily managed and effectively prevented with unproven screening tools and management techniques.

Each Manufacturer Defendant spent millions of dollars over the following decade to push these fraudulent messages. They pushed their own name-brand drugs by “detailing” their sales representatives to target susceptible doctors with in-person visits, flooding medical publications with deceptive advertisements, and offering consumers discount cards to entice them to request treatment with their products. And they collaborated to promote the overall expansion of the opioid market by sponsoring misleading Continuing Medical Education (“CME”) seminars and manipulating seemingly independent organizations (“Front Groups”) that the manufacturers funded and disguised as “unbiased” sources of cutting-edge medical research and information. Both the Front Groups and CME seminars depended on co-opted doctors—so-called “Key Opinion Leaders” (“KOLs”)—that the manufacturers recruited and paid.

They were, in fact using aggressive marketing techniques and deception to convince doctors to prescribe higher doses when their patient responsibly wanted a lower dose. They took the symptoms of addiction and claimed that they were actually signs of a condition which required more opioids!

But in any event, what does your magic, yet-unknown line of "necessary" have to do with addiction? What's the model connecting this completely unknown thing to rates of opioid addiction?

There's nothing magic about the opinion of a medical professional. There's nothing unknown or mysterious about the idea that a trained medical professional or doctor would know the appropriate amount of painkillers to give to their patient. Purdue Pharma interfered with this and produced fraudulent research which gave both large financial incentives and a figleaf of justification to encourage inappropriately high doses of opioids (see the Pseudoaddiction concept above). That's the connection, and it is outlined clear as day in the charges against Purdue and the Sacklers.

you didn't read the links contained within it.

I did, indeed, read the links contained within it. I'm a legal nerd, and a voracious consumer of text.

They were, in fact using aggressive marketing techniques and deception to convince doctors to prescribe higher doses when their patient responsibly wanted a lower dose.

The bolded part is nowhere in there. Not in your block quote, either.

There's nothing magic about the opinion of a medical professional. There's nothing unknown or mysterious about the idea that a trained medical professional or doctor would know the appropriate amount of painkillers to give to their patient.

Ok, great! Quick question, though... how come Scott talks about adjusting the dose of various medications up/down, depending on how it's going? He's a doctor, and a trained medical professional to boot. Shouldn't he like, just "know" the appropriate amount of whatever drug to give to his patients?

Purdue Pharma interfered with this

I mean, no? Did they, like, jump into the exam room, and when doc was "just knowing" the "appropriate" amount, they interfered and somehow made him increase it?

produced fraudulent research

I mean, also no? They produced (maybe just promoted?) a concept that may, indeed, be wrong. I don't actually know if it's wrong, and there's not enough information in the indictment to know, either. But they didn't actually produce any fraudulent research. It needs to be a hell of a lot closer to "we made up fake data to put in a paper that we submitted for publication" to be considered 'fraudulent research'.

which gave both large financial incentives

What large financial incentives? Come on, man. Stop hiding the ball.

And remember, the thing you're trying to show is that they "were ultimately responsible for and made substantial profits from a legal and corporate structure that heavily encouraged and even induced addiction in cases where it wasn't necessary". So, I'd definitely like to hear some things about their legal and corporate structure.

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There is literally only one sentence in the article that refers to dosing, and that's just repeating a claim from a plaintiff. It's pretty weak even from that plaintiff. I guarantee that you, the plaintiff, the FDA, nobody has any sort of rigorous line on when it is "necessary". Their "titration" stuff is basically the same damn thing that Scott talks about doing all the time with other drugs.

I, for one, didn't click the link, and I agree with your broader point, but I think you're dodging his argument here.

There doesn't need to be an objective line for "strictly necessary" here. If the doctors don't have any extra rewards dangled before their eyes, I'd say their incentive would imply prescribing the lowest dose possible to get the job done. If you do dangle rewards for how much they prescribe, the incentives shift to "give as much as the patient can take". Different doctors will have different opinions on how much is strictly necessary and how the patient can take, but on the whole incentivising the latter will result in greater prescription rate, and thus more addictions.

How you want to ban that without banning the drugs themselves, or without giving arbitrary power to some goofy bureaucracy, that will end up being corrupted by the pharma industry anyway, is the more appropriate question here, I think.

If the doctors don't have any extra rewards dangled before their eyes, I'd say their incentive would imply prescribing the lowest dose possible to get the job done. If you do dangle rewards for how much they prescribe, the incentives shift to "give as much as the patient can take".

I don't think the click-throughs actually have this, though. The marketing materials they used were not mustache-twirling evil; they used the standard sort of medical language to basically try to say exactly what you're saying - prescribe the dose that gets the job done... but if the current dose is not getting the job done, then titrate up to higher doses. The argument is entirely about what counts as "not getting the job done", which is completely analogous to asking what is "necessary". There's nothing in the click-throughs that can be interpreted as "give as much as the patient can take". There's nothing like "try the highest dose, look for side effects, then reduce if necessary". It's literally the other way around; increase the dose if it seems to be useful. This is obviously presented by plaintiffs as "encouraging them to increase the dose", but you can kinda only make these sorts of jumps if you have a magic metric for what is "necessary" or for what "gets the job done"... and then you sort of close your eyes and imagine that doctors aren't "really" doing that, that they're really just doing something else because of some alternate incentive that isn't even in evidence. It's entirely because we have no such metric that this entire kayfabe is even a plausible discussion.

Frankly, it's probably even more absurd than having hard liquor advertisements that have a little tag at the end saying "drink responsibly". At least in the click-through documents, they paid significantly more lip service to precisely the type of behavior that you're suggesting would be the Good and Right way to do it. They weren't like, "CHECK OUT HOW FUCKING AWESOME OUR HIGHEST DOSE IS! (...btw, try to be responsible with how you prescribe stuff)".

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