site banner
PaperclipPerfector  4mo ago (text post)   28490 thread views

Culture War Roundup for the week of June 24, 2024

This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.

Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.

We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:

  • Shaming.

  • Attempting to 'build consensus' or enforce ideological conformity.

  • Making sweeping generalizations to vilify a group you dislike.

  • Recruiting for a cause.

  • Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.

In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:

  • Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.

  • Be as precise and charitable as you can. Don't paraphrase unflatteringly.

  • Don't imply that someone said something they did not say, even if you think it follows from what they said.

  • Write like everyone is reading and you want them to be included in the discussion.

On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.

10
Top Bottom Old Controversial Comments
Jump in the discussion.

No email address required.

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.

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?

No? Regular supervision and adjustment of the dosage is part and parcel of responsible medical care. If he gets it right on the first go, great, and if he doesn't part of his job is adjusting the dosage or even pulling the patient off the drug. Sometimes the patient's condition can change as a result of medication and they don't need as much of it as they recover - a patient recovering and thus not needing as much of a certain medicine as they did before is not evidence that they were never sick and never needed medication.

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?

And because it covers the same ground...

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

There's no need for scare quotes. Doctors are in fact legitimate medical professionals, and making decisions about dosage is part of their professional responsibility and skillset. There's nothing magical about an anaesthesiologist determining the appropriate level of painkillers for someone based on sex/weight/pre-existing conditions. But yes, they did actually interfere. To quote from one of the legal documents involved...

Purdue’s most powerful tool of deception was sending sales representatives to promote opioids to Massachusetts doctors, nurses, and pharmacists face to face. During sales visits, Purdue reps made false and misleading claims directly to the professionals who care for Massachusetts patients. Purdue assigned reps to specific territories in Massachusetts and gave them lists of Massachusetts doctors to visit.

They sent people out to lie to medical professionals in order to encourage them to sell more Purdue pharmaceuticals.

Each of these in-person sales visits cost Purdue money — on average more than $200 per visit. But Purdue made that money back many times over, because it convinced doctors to prescribe its addictive drugs. When Purdue identified a doctor as a profitable target, Purdue visited the doctor frequently: often weekly, sometimes almost every day. Purdue salespeople asked doctors to list specific patients they were scheduled to see and pressed the doctors to commit to put the patients on Purdue opioids. By the time a patient walked into a clinic, the doctor, in Purdue’s words, had already “guaranteed” that he would prescribe Purdue’s drugs. Purdue rewarded high-prescribing doctors with coffee, ice cream, catered lunches, and cash. Purdue has given meals, money, or other gifts to more than 2,000 Massachusetts prescribers.

And they were actually just paying and bribing doctors who prescribed large doses of opioids. Literal kickbacks! They actually made up fake case profiles and patients in order to convince doctors to hand out oxycontin even when it wasn't necessary or dangerous.

Purdue trained its reps to show doctors charts emphasizing Medicare coverage for its opioids and use profiles of fake elderly patients, complete with staged photographs, to convince doctors to prescribe opioids. As a Massachusetts sales rep observed, a fake patient profile “brings the heart into it” and helps get the doctor to say: “Yes, they need this medication.”

I mean, also no? They produced (maybe just promoted?) a concept that may, indeed, be wrong.

Could it be possible that they made an accurate and true scientific discovery while faking data in order to sell more of their product? I doubt it. The core idea of their marketing was that drug addiction was actually just something that happens to "untrustworthy" people when exposed to drugs, and that "trustworthy" people can be prescribed whatever dose of painkillers you want without any risks. They created numerous bodies to create the misleading impression that pseudoaddiction was a real concept and convince doctors to ignore their actual training. Furthermore, they knew they were lying!

Purdue knew its campaign to push higher doses of opioids was wrong. Doctors on Purdue’s payroll admitted in writing that pseudoaddiction was used to describe “behaviors that are clearly characterized as drug abuse” and put Purdue at risk of “ignoring” addiction and “sanctioning abuse.” But Purdue nevertheless urged doctors to respond to signs of addiction by prescribing higher doses of Purdue’s drugs.

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.

The Massachusetts document is the best source for that.

Regular supervision and adjustment of the dosage is part and parcel of responsible medical care.

Ok, great. So you agree with Purdue's materials.

During sales visits, Purdue reps made false and misleading claims directly to the professionals who care for Massachusetts patients.

What false and misleading claims?

in-person sales visits

...like what is done for literally every other drug out there? You say that this is 'literal kickbacks'. Prosecute that shit for any of the hundreds of other drugs where they do similar in-person sales visits, and then I'll think about believing you.

show doctors charts emphasizing Medicare coverage for its opioids and use profiles of fake elderly patients, complete with staged photographs

So, like, a training mock-up?

Could it be possible that they made an accurate and true scientific discovery while faking data in order to sell more of their product?

Dawg, you skipped the part where you were supposed to show that they faked data in research.

More comments

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)".

So I might need to actually click in order to participate in thus conversation, but for now I'll just ask: this is only about a bunch of marketing materials? There's no mention of any sort of referral program, which would translate higher prescriptions into more cash in doctors' pockets?

Hey, I missed this reply, but the answer to this is actually yes, contra to the reply you received.

Each of these in-person sales visits cost Purdue money — on average more than$200 per visit. But Purdue made that money back many times over, because it convinced doctors to prescribe its addictive drugs. When Purdue identified a doctor as a profitable target, Purdue visited the doctor frequently: often weekly, sometimes almost every day. Purdue salespeople asked doctors to list specific patients they were scheduled to see and pressed the doctors to commit to put the patients on Purdue opioids. By the time a patient walked into a clinic, the doctor, in Purdue’s words, had already “guaranteed” that he would prescribe Purdue’s drugs. Purdue rewarded high-prescribing doctors with coffee, ice cream, catered lunches, and cash. Purdue has given meals, money, or other gifts to more than 2,000 Massachusetts prescribers.

I don't see anything about a referral program along those lines. Closest I can see to having money go back to doctors is that they had the standard sort of "we pay doctors to give speeches promoting our product" that basically every drug company does. Scott has talked about this before with a bunch of other drugs. But yeah, there's nothing that I see in the long documents about any program more directly along the lines of "if you prescribe higher doses or more pills, we, like, kick you back some money or something".

What is this place?

This website is a place for people who want to move past shady thinking and test their ideas in a court of people who don't all share the same biases. Our goal is to optimize for light, not heat; this is a group effort, and all commentators are asked to do their part.

The weekly Culture War threads host the most controversial topics and are the most visible aspect of The Motte. However, many other topics are appropriate here. We encourage people to post anything related to science, politics, or philosophy; if in doubt, post!

Check out The Vault for an archive of old quality posts. You are encouraged to crosspost these elsewhere.


Why are you called The Motte?

A motte is a stone keep on a raised earthwork common in early medieval fortifications. More pertinently, it's an element in a rhetorical move called a "Motte-and-Bailey", originally identified by philosopher Nicholas Shackel. It describes the tendency in discourse for people to move from a controversial but high value claim to a defensible but less exciting one upon any resistance to the former. He likens this to the medieval fortification, where a desirable land (the bailey) is abandoned when in danger for the more easily defended motte. In Shackel's words, "The Motte represents the defensible but undesired propositions to which one retreats when hard pressed."

On The Motte, always attempt to remain inside your defensible territory, even if you are not being pressed.


New post guidelines

If you're posting something that isn't related to the culture war, we encourage you to post a thread for it. A submission statement is highly appreciated, but isn't necessary for text posts or links to largely-text posts such as blogs or news articles; if we're unsure of the value of your post, we might remove it until you add a submission statement. A submission statement is required for non-text sources (videos, podcasts, images).

Culture war posts go in the culture war thread; all links must either include a submission statement or significant commentary. Bare links without those will be removed.

If in doubt, please post it!


Rules


Recommended Posts And Communities

Recommended Realtime Chats