Article argues that OxyContin caused strong withdrawal symptoms when used as directed. Important, imo, because at a societal level we substantially blame addiction on "drug abuse" which is not always an adequate model.
As withdrawal becomes more severe and patients develop tolerance to these medications, they need to take increasing doses to get the same effects, leading to more severe withdrawal - aka. a vicious cycle.
The crux of this article was that Purdue knew their dosing schedule was problematic but pursued it despite growing evidence it was reducing efficacy and increasing addiction. Then they hid behind their FDA certification as if that exempts them from acting on evidence that their shitty drug doesn't work right.
In general, no drug for acute _anything_ will last as long as the manufacturer advertises. They are incentivized to push an idealized dosing schedule, even when that makes the drug less effective for a significant number of patients. This is kind of a big deal when a drug causes severe physical withdrawal symptoms.
> at a societal level we substantially blame addiction on "drug abuse" which is not always an adequate model.
While I agree that this model is not accurate, I'd also point out that just because you're taking a drug as directed doesn't mean you're not abusing it.
For whatever reason most people in the U.S. seem to have a wildly unjustifiable level of faith in western medicine, either way too much or way too little. Belief and disbelief in various forms of medicine have been successfully marketed as personal identities, which is easy to see from reading most HN comment threads on health issues.
Feed anyone sufficient doctor prescribed heroin and they will start to act like the people Attorney General Jeff Sessions wants mandatory sentencing for
Tldr: Oxycontin doesn't last for 12-hours unless doage levels exceed thresholds known to induce addiction and higher risks of death. The 12-hour claim is a marketing gimmick that the company will go to war over regardless of the collateral damage. Moreover, the US court system has repeatedly permitted the company to continue, and works with the company to seal these findings.
Doctors should be more skeptical of pharma companies' marketing claims, right? Who believes everything they read? There's probably a case to be made that the FDA should have been more involved, too.
The data on how fast OC released its drug would have been available to the FDA, if not doctors.
Every time one of these articles comes out, people say that the FDA should have been more involved. Every time we hear about some new drug that Europe, India, or China has that is still being cleared in the US, people say that the FDA needs to step back and let pharma companies innovate.
Which is it? I honestly don't think the FDA is culpable in this. They're there to ensure that the manufacturer is meeting a minimum standard of proof, and if the manufacturer is falsifying that proof and ignoring clinical feedback then the manufacturer is solely responsible and needs to be held accountable. But to say that the FDA isn't doing its job here isn't particularly accurate, because they're doing their best to apply the law and ensure that the claims being made are accurate.
Search "kratom" (Mitragyna speciosa). It helps people kick their opiate addiction every day. It's not a magic bullet by any means, but it helps by mitigating the withdrawals to a tolerable point. Good luck - I know how you feel.
I feel the same way. I watched my dad go from Vicodin to Oxy to dead by age 50. All for a neck injury + surgery. It is a painful thing to watch the man who taught you everything reduced to crying on the floor because his prescription ran out early and it would a couple days until it could be refilled.
I'm sure this is an easy question to answer, but it was bugging me during the whole article.
What's preventing a pill that releases a dose immediately and one after 6 hours? Or something like a diabetic pump that dispenses medication continuously? Surely such systems have the potential to be safer and more effective for patients?
Concerta ER does something like that, I'm curious why it isn't more widely used.
"The system, which resembles a conventional tablet in appearance, comprises an osmotically active trilayer core surrounded by a semipermeable membrane with an immediate-release drug overcoat.
The trilayer core is composed of two drug layers containing the drug and excipients, and a push layer containing osmotically active components. There
is a precision-laser drilled orifice on the drug-layer end of the tablet.
In an aqueous environment, such as the gastrointestinal tract, the drug overcoat dissolves within one hour, providing an initial dose of methylphenidate. Water permeates through the membrane into the tablet core. As the osmotically active polymer excipients expand, methylphenidate is released through the orifice. The membrane controls the rate at which water enters the tablet core, which in turn controls drug delivery."
> What's preventing a pill that releases a dose immediately and one after 6 hours? Or something like a diabetic pump that dispenses medication continuously? Surely such systems have the potential to be safer and more effective for patients?
Nothing. There are such pills for stuff like Adderall and Ritalin already, on the mass market.
This is a dupe but Pursue should be prosecuted and held accountable for the total fucking disaster Oxycontin has wrought on our country. They should be considered enemies of the state. This shit is worse than any drug lord in Mexico or any ISIS leader as far as impact to US citizens and they knowingly perpetrated it.
Can somebody give some context on the root cause of the problem - the chronic pain epidemic in US. What caused it, why it is more than in other parts of the world and why so many painkillers?
>What caused it, why it is more than in other parts of the world and why so many painkillers?
>Is it cultural?
That's actually a really common misconception on HN. The United States ranks 27th among countries which abuse opiates, [1] behind many first-world countries like the UK, Italy, Spain, Switzerland, Ireland, and Russia, to name a few.
What's the cause? A lot of HNers like to pin it on unemployment and low-wage, low-skill jobs. I think that's narrowing the field in the right direction, but it isn't quite right; I know many very happy people who just make ends meet. There's something more that no one has been able to pinpoint quite yet.
People take painkillers because they can't afford surgery.
Say you have a messed up disk in your spine. Surgery is tens of thousands of dollars. Getting a prescription for opioids from a primary care physician is a bit cheaper.
You don't see doctors in europe routinely prescribing hard pain killers because they try to fix the problem instead.
Healthcare in america is set up in such a way that hospitals just bill whatever and then have the lawyers argue over whats reasonable. That kinda works when youre part of the medicare system and their lawyers represent your side, but when youre on your own, you're suddenly in hospital recovering from major surgery, facing bankruptcy and have to hire a lawyer to tell the hospital to suck it.
So you just take the painkillers and hope for the best.
There's no "chronic pain epidemic". As is often the case, the pharma market created (or rather, in this case, reshaped) a problem for a particular kind of product to solve.
Obviously, ceteris paribus, less pain is much better than more pain, and there will probably always be acute and chronic pain for therapeutic innovation to tackle. There's no virtue in the experience of chronic pain. But the evidence strongly suggests that patients are worse off with casual access to powerful opiates, and that these products are packaged and sold irresponsibly.
No legitimate underlying medical phenomenon spurred the uptake in opiates.
The root cause is Purdue Pharma, who successfully marketed the drug to primary care physicians by lying about the risk of addiction:
Perhaps knowing that doctors would be vigilant against prescribing drugs with the potential for abuse, Purdue set out to distinguish OxyContin from rivals as soon as it dropped. The cornerstone of its marketing campaign was the drug's incredibly low risk of addiction, an enviable characteristic made possible by its patented time-release formula. Through an array of promotional materials, including literature, brochures, videotapes, and Web content, Purdue proudly asserted that the potential for addiction was very small, at one point stating it to be "less than 1 percent."
(http://theweek.com/articles/541564/how-american-opiate-epide...)
Overeagerness to prescribe. Other countries have similar problems too.
Conversely, the country I live has a benzo problem. Hell, go into any doctor complaining you haven't been sleeping properly and he'll happily prescribe you clonazepam to help you with that. You have just been prescribed an addictive and strong psychoactive drug, just like that. He won't care if you have been working too much, or not eating or sleeping well, he will not care at all about possible factors that may be causing your current insomnia.
"take this and come back to reassess in 2 months", the doctor will say, and ofc, in 2 months you will come back saying this helped immensely, and from that there's a whole slew of problems that everyone knows: try to wane off it, insomnia comes back, sometimes worse. or maybe some new anxiety gets thrown in....
They want money, because if they wanted you to get well they you'd be treating the cause of your symptoms and not your symptoms :D
I certainly know people here (Denmark) who are hooked on prescribed opiates for no real good reasons at all. They are, in all but their own perception, addicts.
Seems to me it comes down to competence and ethics of individual doctors, as well as to preferences and susceptability of individual patients, of course.
We are not experiencing quite the epidemic proportions of the US, presumably owing to a different structure of health services, and probably a higher general level of scepticism towards medical authority, but the mechanisms and the potential are clearly in place.
Hospitals are funded based on patient satisfaction and pain was added to patient satisfaction scores. To boost their ratings and funding hospitals and their doctors started heavily prescribing pain killers - in a way that pushes the problem from their hospital.
Something I've noticed: in the US people generally have an aversion to being even mildly uncomfortable.
And, it's culturally acceptable to be on medication so people take it for basically any inconvenience.
Sweating a little? Crank the AC. Small headache? take a pill. Bad day? Have a drink. Workout left muscles sore? Another pill. Sprained ankle? Obviously you need pain medication!
It's easy to see how there is a low threshold to abusing pain medication.
We found enormous unmet need for pain treatment. Fourteen countries reported no
consumption of opioid pain medicines between 2006 and 2008, meaning that there are no
medicines to treat moderate to severe pain available through legitimate medical channels in
those countries.
These countries are concentrated in Sub-Saharan Africa, but are also found in Asia, the
Middle East and North Africa, and Central America
My takeaway was that opiates were incorrectly classified as a non-addictive way to treat pain, so doctors started dolling them out far too liberally. Hospitals also started employing pain specialists who's sole job was to treat pain in patients. It's pretty easy to find people in any sort of "pain" if that's all you're looking for.
Read the article. It's economic - the makers of these opiate drugs have large marketing budgets they employ to encourage physicians to prescribe these addictive drugs and there has been essentially no governmental oversight on these marketing efforts because these marketing budgets also fund lobbying activities.
There have been a few prosecutions of individual sales/marketing people for knowingly supplying pill mills, but it's just a cost of business expense for large pharma companies.
Article argues that patent evergreening necessitated dishonest marketing and resulted in a "created market" type of strategy.
The patent for OxyContin was predicated on the claim that each dose lasted longer than older poducts. When that didn't work they raised the dose instead of shortening dosing intervals, which caused a reward/withdrawal cycle in patients.
I just got ACL surgery and am doing the entire recovery (day 11) without any painkillers stronger than ibuprofin. This is not because I'm so brave, but because I know the pain associated with opioids to be so much than the physical pain in my knee. We've got to aggressively pursue alternatives.
Sensible doctors do not believe drug company marketing.
I get large amounts of ad-junk from drug companies that ends up unread in the bin. I refuse to meet with drug company representatives. I smile politely at them if I bump into them in the corridor and suggest that they leave their ad-junk with my secretary. My staff then file their ad-junk in the trash bin.
On Friday, I had a drug company representative attempt to tell me ( he was hanging around my coffee area ) about the joys of Targin, a fixed-dose combination of oxycodone and naloxone. I gently shook him off, and directed him to my secretary.
Drug company representatives are usually decent human beings with lives and families. However they are poorly educated, poorly informed salesmen and women with sales targets to meet and product managers to keep happy. Even worse, they and the drug company have no accountability if a patient dies because of their recommendations. If avoidable death supervenes or if there are non-lethal complications or even just therapeutic failure, I am accountable.
Instead of relying on marketing, I rely on information from good, well performed randomised controlled studies published in reputable peer reviewed journals ( I like the NEJM ) and on meta-analyses of these. I view the results of these through a filter of scepticism, cynicism, pragmatism and a modicum of hope.
Many of my colleagues do likewise. I trust that you do the same in your respective vocations. Regrettably, there is a bell curve. I am sure that the drug companies find enough gullible prescribers out in the wild for their purposes.
That sounds like a good, responsible, doctor. I probably wouldn't believe them if they were my doctor. I've been through a repaired Achilles and knee surgery and haven't gone to get the prescriptions filled for any of it. I don't trust any doctor anymore to give me something that is actually good for me - I suspect they're giving me something that's good for them.
I happen to have direct exposure to the medical industry at the practice level. I can tell you unequivocally that entire industry is compromised. Maybe you're a good doctor, and you have my best interests at heart, but you're in the minority, and your peers have ensured I won't be trusting you.
merraksh|8 years ago
elipsey|8 years ago
Article argues that OxyContin caused strong withdrawal symptoms when used as directed. Important, imo, because at a societal level we substantially blame addiction on "drug abuse" which is not always an adequate model.
rubbingalcohol|8 years ago
The crux of this article was that Purdue knew their dosing schedule was problematic but pursued it despite growing evidence it was reducing efficacy and increasing addiction. Then they hid behind their FDA certification as if that exempts them from acting on evidence that their shitty drug doesn't work right.
In general, no drug for acute _anything_ will last as long as the manufacturer advertises. They are incentivized to push an idealized dosing schedule, even when that makes the drug less effective for a significant number of patients. This is kind of a big deal when a drug causes severe physical withdrawal symptoms.
Alex3917|8 years ago
While I agree that this model is not accurate, I'd also point out that just because you're taking a drug as directed doesn't mean you're not abusing it.
For whatever reason most people in the U.S. seem to have a wildly unjustifiable level of faith in western medicine, either way too much or way too little. Belief and disbelief in various forms of medicine have been successfully marketed as personal identities, which is easy to see from reading most HN comment threads on health issues.
billions|8 years ago
unknown|8 years ago
[deleted]
waterside81|8 years ago
There are a multitude of reasons to explain how this happened but to quickly sum up an excellent book:
- Purdue created the whole "sell-direct-to-doctor" phenomena that is now the norm in the US medical profession
- One bad study that showed opiates for pain relief are NOT addictive and this study kept being cited by sales people
- Mexican drug dealers from a very tiny area in Mexico importing black tar heroin
- A prevailing idea in the US that people should never be in pain and managing it through lifestyle changes is not acceptable; a quick fix is needed
- economic depression in the Midwest and Appalachia regions
But really, read the book. It's eye opening and well written.
politician|8 years ago
Good to know.
mtdewcmu|8 years ago
The data on how fast OC released its drug would have been available to the FDA, if not doctors.
jschwartzi|8 years ago
Which is it? I honestly don't think the FDA is culpable in this. They're there to ensure that the manufacturer is meeting a minimum standard of proof, and if the manufacturer is falsifying that proof and ignoring clinical feedback then the manufacturer is solely responsible and needs to be held accountable. But to say that the FDA isn't doing its job here isn't particularly accurate, because they're doing their best to apply the law and ensure that the claims being made are accurate.
racl101|8 years ago
Watching how dependent my mom has become on this has been painful to watch.
stronglikedan|8 years ago
heywire|8 years ago
passivepinetree|8 years ago
As noted elsewhere, this isn't new content.
Spivak|8 years ago
What's preventing a pill that releases a dose immediately and one after 6 hours? Or something like a diabetic pump that dispenses medication continuously? Surely such systems have the potential to be safer and more effective for patients?
sloppycee|8 years ago
"The system, which resembles a conventional tablet in appearance, comprises an osmotically active trilayer core surrounded by a semipermeable membrane with an immediate-release drug overcoat.
The trilayer core is composed of two drug layers containing the drug and excipients, and a push layer containing osmotically active components. There is a precision-laser drilled orifice on the drug-layer end of the tablet.
In an aqueous environment, such as the gastrointestinal tract, the drug overcoat dissolves within one hour, providing an initial dose of methylphenidate. Water permeates through the membrane into the tablet core. As the osmotically active polymer excipients expand, methylphenidate is released through the orifice. The membrane controls the rate at which water enters the tablet core, which in turn controls drug delivery."
eropple|8 years ago
Being plopped into a bath of hydrochloric acid makes this a little tricky, I am led to understand.
> Or something like a diabetic pump that dispenses medication continuously?
And this led me down a brief Google walk for what these are, and...huh, that's a really good question...
kuschku|8 years ago
Nothing. There are such pills for stuff like Adderall and Ritalin already, on the mass market.
mhb|8 years ago
slackingoff2017|8 years ago
slackingoff2017|8 years ago
[deleted]
siliconc0w|8 years ago
panzer_wyrm|8 years ago
Is it cultural?
gragas|8 years ago
>Is it cultural?
That's actually a really common misconception on HN. The United States ranks 27th among countries which abuse opiates, [1] behind many first-world countries like the UK, Italy, Spain, Switzerland, Ireland, and Russia, to name a few.
What's the cause? A lot of HNers like to pin it on unemployment and low-wage, low-skill jobs. I think that's narrowing the field in the right direction, but it isn't quite right; I know many very happy people who just make ends meet. There's something more that no one has been able to pinpoint quite yet.
1. https://en.wikipedia.org/wiki/List_of_countries_by_prevalenc...
wayn3|8 years ago
Say you have a messed up disk in your spine. Surgery is tens of thousands of dollars. Getting a prescription for opioids from a primary care physician is a bit cheaper.
You don't see doctors in europe routinely prescribing hard pain killers because they try to fix the problem instead.
Healthcare in america is set up in such a way that hospitals just bill whatever and then have the lawyers argue over whats reasonable. That kinda works when youre part of the medicare system and their lawyers represent your side, but when youre on your own, you're suddenly in hospital recovering from major surgery, facing bankruptcy and have to hire a lawyer to tell the hospital to suck it.
So you just take the painkillers and hope for the best.
tptacek|8 years ago
Obviously, ceteris paribus, less pain is much better than more pain, and there will probably always be acute and chronic pain for therapeutic innovation to tackle. There's no virtue in the experience of chronic pain. But the evidence strongly suggests that patients are worse off with casual access to powerful opiates, and that these products are packaged and sold irresponsibly.
No legitimate underlying medical phenomenon spurred the uptake in opiates.
panic|8 years ago
Perhaps knowing that doctors would be vigilant against prescribing drugs with the potential for abuse, Purdue set out to distinguish OxyContin from rivals as soon as it dropped. The cornerstone of its marketing campaign was the drug's incredibly low risk of addiction, an enviable characteristic made possible by its patented time-release formula. Through an array of promotional materials, including literature, brochures, videotapes, and Web content, Purdue proudly asserted that the potential for addiction was very small, at one point stating it to be "less than 1 percent." (http://theweek.com/articles/541564/how-american-opiate-epide...)
fb03|8 years ago
Conversely, the country I live has a benzo problem. Hell, go into any doctor complaining you haven't been sleeping properly and he'll happily prescribe you clonazepam to help you with that. You have just been prescribed an addictive and strong psychoactive drug, just like that. He won't care if you have been working too much, or not eating or sleeping well, he will not care at all about possible factors that may be causing your current insomnia.
"take this and come back to reassess in 2 months", the doctor will say, and ofc, in 2 months you will come back saying this helped immensely, and from that there's a whole slew of problems that everyone knows: try to wane off it, insomnia comes back, sometimes worse. or maybe some new anxiety gets thrown in....
They want money, because if they wanted you to get well they you'd be treating the cause of your symptoms and not your symptoms :D
interfixus|8 years ago
Seems to me it comes down to competence and ethics of individual doctors, as well as to preferences and susceptability of individual patients, of course.
We are not experiencing quite the epidemic proportions of the US, presumably owing to a different structure of health services, and probably a higher general level of scepticism towards medical authority, but the mechanisms and the potential are clearly in place.
snissn|8 years ago
https://www.medpagetoday.com/publichealthpolicy/publichealth...
notburnt|8 years ago
And, it's culturally acceptable to be on medication so people take it for basically any inconvenience.
Sweating a little? Crank the AC. Small headache? take a pill. Bad day? Have a drink. Workout left muscles sore? Another pill. Sprained ankle? Obviously you need pain medication!
It's easy to see how there is a low threshold to abusing pain medication.
GFischer|8 years ago
What we don't have is the drug culture, people look for alternative ways to mitigate the pain.
A quick googling gave me this WHO paper:
https://www.hrw.org/sites/default/files/reports/hhr0511W.pdf
We found enormous unmet need for pain treatment. Fourteen countries reported no consumption of opioid pain medicines between 2006 and 2008, meaning that there are no medicines to treat moderate to severe pain available through legitimate medical channels in those countries.
These countries are concentrated in Sub-Saharan Africa, but are also found in Asia, the Middle East and North Africa, and Central America
blawson|8 years ago
https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidem...
My takeaway was that opiates were incorrectly classified as a non-addictive way to treat pain, so doctors started dolling them out far too liberally. Hospitals also started employing pain specialists who's sole job was to treat pain in patients. It's pretty easy to find people in any sort of "pain" if that's all you're looking for.
yborg|8 years ago
There have been a few prosecutions of individual sales/marketing people for knowingly supplying pill mills, but it's just a cost of business expense for large pharma companies.
elipsey|8 years ago
The patent for OxyContin was predicated on the claim that each dose lasted longer than older poducts. When that didn't work they raised the dose instead of shortening dosing intervals, which caused a reward/withdrawal cycle in patients.
mowenz|8 years ago
hammock|8 years ago
tommynicholas|8 years ago
mhb|8 years ago
unknown|8 years ago
[deleted]
thriftwy|8 years ago
Can we please fix something to add dynamic compression to pain signals? log(x) will be a good idea past some pain level.
unknown|8 years ago
[deleted]
merraksh|8 years ago
Sensible doctors do not believe drug company marketing.
I get large amounts of ad-junk from drug companies that ends up unread in the bin. I refuse to meet with drug company representatives. I smile politely at them if I bump into them in the corridor and suggest that they leave their ad-junk with my secretary. My staff then file their ad-junk in the trash bin.
On Friday, I had a drug company representative attempt to tell me ( he was hanging around my coffee area ) about the joys of Targin, a fixed-dose combination of oxycodone and naloxone. I gently shook him off, and directed him to my secretary.
Drug company representatives are usually decent human beings with lives and families. However they are poorly educated, poorly informed salesmen and women with sales targets to meet and product managers to keep happy. Even worse, they and the drug company have no accountability if a patient dies because of their recommendations. If avoidable death supervenes or if there are non-lethal complications or even just therapeutic failure, I am accountable.
Instead of relying on marketing, I rely on information from good, well performed randomised controlled studies published in reputable peer reviewed journals ( I like the NEJM ) and on meta-analyses of these. I view the results of these through a filter of scepticism, cynicism, pragmatism and a modicum of hope.
Many of my colleagues do likewise. I trust that you do the same in your respective vocations. Regrettably, there is a bell curve. I am sure that the drug companies find enough gullible prescribers out in the wild for their purposes.
redleggedfrog|8 years ago
I happen to have direct exposure to the medical industry at the practice level. I can tell you unequivocally that entire industry is compromised. Maybe you're a good doctor, and you have my best interests at heart, but you're in the minority, and your peers have ensured I won't be trusting you.
venning|8 years ago
Also, this should probably have a "[2016]" tag in the title.
acover|8 years ago
pvg|8 years ago
unknown|8 years ago
[deleted]
unknown|8 years ago
[deleted]